Every finding on record at Maplewood Rehabilitation Center

Based on observation, interview and document review, the facility failed to ensure that care plans were developed and implemented to address the use of blood-thinning medications for 3 of 3 residents (R1, R2 and R3) reviewed.R1 R1's face sheet, printed 1/26/26, identified diagnoses of cerebral vascular accident (stroke) and dysphagia. R1's admission Minimum Data Set (MDS) dated [DATE] identified moderate cognitive impairment, the need for a feeding tube, and receipt of antiplatelet medications. R1's physician's orders dated 1/6/26 identified the resident was to receive clopidogrel 75 mg via G-tube every morning and aspirin 325 mg via J-tube daily with a meal. According to the FDA-approved Plavix (clopidogrel) labeling, clopidogrel is an antiplatelet medication. The FDA-approved labeling warns that Plavix can cause bleeding which can be serious and can sometimes lead to death. The FDA-approved Plavix Medication Guide identifies signs and symptoms of bleeding, including blood in your urine (pink, red or brown urine) and red or black stools (looks like tar). According to the FDA-approved aspirin 325 mg labeling (Drug Facts), aspirin is an antiplatelet medication. The labeling warns that This product contains an NSAID, which may cause severe stomach bleeding, and identifies signs of stomach bleeding, including vomit blood and bloody or black stools. Although Review of R1's January 2026 Treatment Administration Record (TAR) revealed physician ordered monitoring intervention associated with the resident's blood-thinning medications, review of R1's comprehensive care plan (current at the time of the survey) revealed no identified problem, goal, or interventions related to the resident's use of blood-thinning medications. The care plan did not identify the R1 as being at risk for bleeding and did not include interventions addressing management or mitigation of bleeding risk associated with antiplatelet therapy. Review of R1's Kardex, printed 1/27/26, did not identify the use of blood-thinning medications. R1's care guide was requested and not received. R2 R2's face sheet, printed 1/27/26, identified a diagnosis of atrial fibrillation. R2's admission MDS dated [DATE] identified moderate cognitive impairment and receipt of anticoagulant medications. R2's physician's orders dated 1/6/26 identified the resident was to receive apixaban 5 mg twice daily. According to the FDA-approved Eliquis (apixaban) label (Prescribing Information), Eliquis is an anticoagulant medication. The FDA-approved labeling states ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. The labeling further identifies signs and symptoms of blood loss. Although Review of R2's January 2026 Treatment Administration Record (TAR) revealed physician ordered monitoring intervention associated with the resident's blood-thinning medications, Review of R2's comprehensive care plan (current at the time of the survey) revealed no identified problem, goal, or interventions related to the resident's use of blood-thinning medications. The care plan did not identify R2 as being at risk for bleeding and did not include interventions addressing management or mitigation of bleeding risk associated with anticoagulant therapy. Review of R2's Kardex, printed 1/27/26, did not identify the resident's use of blood-thinning medications. R2's care guide was requested and not received. R3 R3's face sheet, printed 1/27/26, identified a diagnosis of infection and inflammatory reaction due to unspecified internal joint prosthesis of the left knee. R3's admission MDS dated [DATE] identified no cognitive impairment and receipt of anticoagulant medications. R3's physician's orders dated 12/30/25 identified the resident was to receive enoxaparin sodium injection 40 mg (0.4 mL) subcutaneously daily. According to the FDA-approved Lovenox (enoxaparin) label (Prescribing Information), Lovenox is an anticoagulant medication and should be used with extreme caution in conditions with increased risk of hemorrhage. Although Review of R3's January 2026 Treatment Administration Record (TAR) revealed physician ordered monitoring intervention associated with the resident's blood-thinning medications, review of R3's comprehensive care plan (current at the time of the survey) revealed no identified problem, goal, or interventions related to the resident's use of blood-thinning medications. The care plan did not identify R3 as being at risk for bleeding and did not include interventions addressing management or mitigation of bleeding risk associated with anticoagulant therapy. Review of R3's Kardex, printed 1/27/26, and review of R3's undated care guide did not identify the resident's use of blood-thinning medications. During an interview on 1/27/26 at 12:54 p.m., R3 was observed lying in bed and stated she receives a daily blood-thinner injection in her abdomen to help prevent blood clots. R3 reported she experiences bruising to her abdomen related to the injections but nowhere else.During an interview on 1/27/26 at 1:37 p.m., Nursing Assistant (NA)-A stated she would want to know if a resident was receiving blood-thinning medications so she could immediately notify the nurse of any signs of bleeding. NA-A reported that she relies on care guides and the resident Kardex to direct resident care; however, she stated these tools did not identify residents receiving blood-thinning medications. NA-A further stated she would need to obtain this information directly from the nurse.During an interview on 1/27/26 at 1:34 p.m., Licensed Practical Nurse (LPN)-A indicated that residents receiving blood-thinning medications should have this risk addressed in their care plans. LPN-A further stated the nurse manager was responsible for ensuring this documentation was completed.During an interview on 1/27/26 at 12:11 p.m., clinical care coordinator (CCC)-A stated she was the nurse manager of the Transitional Care Unit. (TCU). CCC-A verified R1, R2 and R3 had received blood thinning medications that put them at increased risk for bleeding. CCC-A further stated she was unaware that residents receiving blood-thinning medications were required to have this risk addressed in their care plans to monitor for bleeding.During an interview on 1/27/26 at 1:16 p.m., the Director of Nursing (DON) verified R1, R2 and R3 received blood thinning medications. DON was unable to explain the need to include residents receiving blood-thinning medications in the comprehensive care plan and stated that monitoring once weekly would be sufficient. The DON was unable to articulate that residents receiving high-risk medications, including anticoagulants and antiplatelets, require individualized care plan interventions to ensure risks, monitoring, and interventions are communicated to all staff involved in the residents' care, placing residents at risk for unrecognized bleeding.The facility policy, Care Planning, revised 11/2024, lacked specific guidance requiring the identification and care planning of high-risk medications and medication administration routes. As a result, the policy did not ensure that foreseeable risks, such as bleeding related to blood-thinning medications, were addressed through individualized care plan interventions.

Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively sustained ongoing compliance related to repeat citations for past surveys regarding provider notification of changes, care plan revisions, arrangement of hearing appointments, oxygen administration, and infection control practices. This had the potential to affect all 101 residents residing in the facility. Findings include:Review of the facility Certification and Survey Provider Enhanced Reports (CASPER)-3 (assessment data was converted to quality measures [QM] to evaluate nursing home's performance) dated11/25/25, identified the following prior deficiencies by month and year. F580-Notify of Changes (Injury/Decline/Room, etc.) cited on prior survey 11/7/24. Cited at a scope and severity (S&S) of a D. F657-Care Plan Timing and Revision cited on prior surveys 10/2023 and 11/27/24. Cited both times at a scope and severity (S&S) of a D. F685-Treatment/Devices to Maintain Hearing/Vision cited on prior survey 11/7/24. Cited at a scope and severity (S&S) of a D. F695-Respiratory/Tracheostomy Care and Suctioning cited on prior survey 11/7/24. Cited at a scope and severity (S&S) of a D. F880-Infection Prevention & Control cited on prior survey 11/7/24. Cited at a scope and severity (S&S) of a E. See also F580. Based in interview and record review the facility failed to ensure notification was made to the provider and resident representative for concerns of toenail infection and refused podiatry appointments for 1 of 1 resident R83 who required podiatry services. Furthermore, the facility failed to promptly notify the resident's physician and/or practitioner of changes in resident condition for 2 of 2 residents (R53 and R55) reviewed for notification of changes. Specifically, the facility failed to notify the provider of episodes of diarrhea for 1 resident (R53) reviewed for constipation and failed to notify the provider of significant weight gain in accordance with physician-ordered parameters for 1 resident (R55). These deficient practices had the potential to delay medical evaluation and treatment.See also F657. Based on record review and interview, the facility failed to ensure resident-centered care plans were developed, implemented, and revised to accurately reflect residents' current needs for 3 of 3 residents reviewed (R55, R102, and R109). Specifically, the facility failed to include required interventions for edema management for 1 resident, failed to update the care plan to remove discontinued enhanced barrier precautions for 1 resident, and maintained conflicting information regarding the level of assistance required for eating for 1 resident. These deficient practices resulted in the potential for inconsistent care, unmet resident needs, and compromised resident safety and well-being.See also F685. Based on observation, interview, and document review, the facility failed to ensure audiology appointments were available for 1 of 1 resident (R67) who requested audiology services.Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with physician orders and professional standards of practice for 1 of 1 residents reviewed (R109). Specifically, the facility administered oxygen therapy without a physician's order. This deficient practice resulted in the potential for improper oxygen administration, respiratory compromise, and harm to the resident.See also F880. Based on observation, interview, and document review, the facility failed to ensure appropriate infection control measures were in place for maintaining a central line with dressing changes and use of enhanced barrier precautions (EBP) with personal protective equipment (PPE) for 1 of 2 residents (R36) reviewed who had a central line indwelling device.The facility's QAPI committee meeting minutes dated 11/11/25, lacked evidence of ongoing monitoring, tracking or audits to ensure continued compliance from the previous recertification survey. During interview on 12/4/25 at 3:33 p.m., regional operations director (RDO) stated expectation was for QAPI program to continue to ensure compliance through audits, spot checks and mock surveys.

Based on record review, observation, and interview, the facility failed to ensure residents received care and services to maintain or prevent decline in range of motion in accordance with their functional maintenance programs for 7 of 7 residents reviewed (R1, R4, R53, R55, R88, R108, and R109). Specifically, the facility failed to implement prescribed range of motion (ROM) exercises as outlined in residents' functional maintenance programs. In addition, the facility lacked a policy or procedure to ensure functional maintenance programs were implemented, communicated to direct care staff, and consistently monitored for completion. This deficient practice resulted in the potential for decreased mobility, increased contractures, pain, and decline in functional status. Findings include: R1's diagnoses included hemiplegia and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting left non-dominant side, muscle weakness, acute respiratory failure with hypoxia, gout, morbid (severe) obesity with alveolar hypoventilation (respiratory condition characterized by inadequate ventilation). R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. His functional limitations in ROM were upper and lower extremity impairment on one side and mobility device utilized was a wheelchair. R1's required moderate assistance with bed mobility, personal hygiene and upper body dressing. R1 required maximal assist with lower body dressing and putting on/taking off footwear. R1 was dependent for transfers, chair/bed-to-chair transfers and toileting. R1's physician orders included the following: physical therapy (PT) and occupational therapy (OT) to evaluate and treat, On 11/28/25, OT ordered R1 to receive active assistive range of motion (AAROM) on both upper extremities for shoulders, elbows, wrist and hands 10-15 reps one-two sets per the Functional Maintenance Program. R1's care plan dated 11/13/25, indicated self-care deficit. R1 was dependent on assistance from staff with ADL's. Interventions included functional maintenance program- assist with passive range of motion (PROM) to both hips, knees and ankles. R1 was dependent on two staff for boosting up in bed, required supervision with bed mobility, and transferred with assist of two and wheeled walker. R1's treatment administration record (TAR) dated November 2025, lacked functional maintenance documentation, and a schedule for it to be completed. During interview on 12/1/25 at 7:39 p.m., R1 stated he had limited ROM on left side due to a stroke, was not participating in PT or OT. The therapies were discontinued, he had a maintenance program from OT, staff was supposed to help but did not. Associated Clinic of Psychology (ACP) progress note dated 10/30/25, R1 reported being interested in using some hand weights to increase strength. During interview on 12/2/25 at 3:07 p.m., registered nurse (RN)-D reported the cares and treatments for residents were documented in the care plan, care sheets, and treatment administration record (TAR) and tasks. To confirm the cares were being done, she observed and assisted staff in cares, provided additional education and support to the staff, RN-D did not perform ROM with residents. During observation on 12/3/25 at 9:18 a.m. NA-E completed cares for R1 according to care plan. However, no ROM was completed per the functional maintenance program. During interview on 12/3/25 at 9:51 a.m., nursing assistant (NA)-E stated updates to resident care needs was provided during stand-up report, care sheets and tasks. NA-E stated R1 did not receive range of motion cares. During interview on 12/4/25 at 1:20 p.m., Director of Nursing (DON)-A stated ROM was expected to be done as ordered. The facility had a corporate change about 2 years ago, the other system, when information was put in care plan it would automatically populate over to all other areas. However, we just found out that it was not, the functional maintenance program was not getting done. It was important to keep the resident's mobility and strength. The interdisciplinary team (IDT) was reviewing care plans, TAR, care sheets and tasks to confirm all areas were updated and accurate. The staff would be provided ROM education according to recommendations. R4R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R4's diagnoses included multiple sclerosis, anemia, gastroesophageal reflux disease (GERD), non-Alzheimer's dementia, seizure disorder, malnutrition, depression, bipolar disorder, post-traumatic stress disorder (PTSD), dysphagia, and slow transit constipation. The MDS also indicated R4 had a feeding tube. Record review on 12/2/25 revealed R4 had an active functional maintenance program (FMP) dated 6/17/25 that included scheduled passive and active range of motion exercises to both shoulders, elbows, wrists, and hands, consisting of one to two sets of 10 to 15 repetitions. Review of therapy documentation since the start of R4's FMP and nursing notes revealed no documentation indicating the range of motion exercises were carried out as prescribed. Record review revealed no documentation of resident refusal, contraindications, or physician notification regarding the lack of ROM exercises for R4. R53R53's significant change MDS dated [DATE], identified R53 had intact cognition and required assistance with some ADLs. R53's diagnoses included hemiplegia following cerebral infarction affecting the left non-dominant side, hypertension, GERD, renal failure, diabetes mellitus, arthritis, stroke, anxiety disorder, and adjustment disorder with mixed anxiety and depressed mood. The MDS indicated R53 was not experiencing constipation. Record review on 12/2/25 revealed R53 had an active functional maintenance program dated 11/13/25 that included scheduled active range of motion exercises to both shoulders, elbows, wrists, and hands, consisting of one to two sets of 10 to 15 repetitions. Review of therapy documentation and nursing notes since the start of R53's FMP, revealed no documentation indicating the exercises were carried out as prescribed. Record review revealed no documentation of resident refusal, contraindications, or physician notification regarding the lack of ROM exercises for R53. R55R55's quarterly MDS dated [DATE], identified R55 had intact cognition and required assistance with ADLs. R55's diagnoses included heart failure, hypertension, hyperlipidemia, schizophrenia, pulmonary embolism without acute cor pulmonale (enlarged right ventricle of the heart), hypoxemia (low oxygen saturation in the blood), thrombocytopenia (low platelet count in the blood), acute embolism (obstruction of a blood vessel) and thrombosis (blood clot) of deep veins of the left upper extremity, hypothyroidism, and dysthymic disorder (persistent depressive disorder). Record review on 12/2/25 revealed R55 had an active FMP dated 3/10/25 that included scheduled active range of motion exercises to both shoulders, elbows, wrists, and hands, consisting of one to two sets of 10 to 15 repetitions. Review of therapy documentation and nursing notes since the start of R55's FMP revealed no documentation indicating the exercises were carried out as prescribed. Record review revealed no documentation of resident refusal, contraindications, or physician notification regarding the lack of ROM exercises for R55. R88R88's quarterly MDS dated [DATE], identified R88 had moderate cognitive impairment and required assistance with ADLs. R88's diagnoses included cancer, anemia, hypertension, renal failure, obstructive uropathy (blockage in the urinary system), diabetes mellitus, arthritis, non-Alzheimer's dementia, urinary retention, generalized edema, hydronephrosis (stops urine from flowing from the kidney to the bladder), benign prostatic hyperplasia (BPH), and presence of urogenital implants. The MDS indicated R88 had an indwelling urinary catheter and did not exhibit behaviors. Record review on 12/2/25 revealed R88 had an active FMP dated 2/19/25 that included scheduled active range of motion exercises to both shoulders, elbows, wrists, and hands, consisting of one to two sets of 10 to 15 repetitions. Review of therapy documentation and nursing notes since the start of R88's FMP revealed no documentation indicating the exercises were carried out as prescribed. Record review revealed no documentation of resident refusal, contraindications, or physician notification regarding the lack of ROM exercises for R88. R108R108's quarterly MDS dated [DATE], identified R108 had moderate cognitive impairment and required assistance with ADLs. R108's diagnoses included stroke, hemiplegia following cerebral infarction affecting the right dominant side, anemia, hypertension, renal failure, wound infection, diabetes mellitus, hyperlipidemia, arthritis, aphasia (communication disorder), seizure disorder, anxiety disorder, depression, chronic obstructive pulmonary disease (COPD), furuncle (boil) of the buttock, immunodeficiency, and mood disorder due to a known physiological condition. Record review on 12/2/25 revealed R108 had an active FMP dated 6/2/25 that included scheduled passive and active range of motion exercises to both shoulders, elbows, wrists, and hands, consisting of one to two sets of 10 to 15 repetitions, and an additional FMP dated 6/4/25 that included scheduled passive and active range of motion exercises to both hips, knees, and ankles, consisting of two sets of 10 repetitions. Review of therapy documentation and nursing notes since the start of R108's FMP revealed no documentation indicating the exercises were carried out as prescribed. Record review revealed no documentation of resident refusal, contraindications, or physician notification regarding the lack of ROM exercises for R108. R109R109's quarterly MDS dated [DATE], identified R109 had intact cognition and required assistance with ADLs. R109's diagnoses included hemiplegia following cerebral infarction affecting the right dominant side, hypertension, diabetes mellitus, hyperlipidemia, malnutrition, bipolar disorder, dysphagia following cerebral infarction, unspecified protein-calorie malnutrition, and constipation. Record review on 12/2/25 revealed R109 had an active FMP dated 8/8/25 that included scheduled passive and active range of motion exercises to both shoulders, elbows, wrists, and hands, consisting of one to two sets of 10 to 15 repetitions. Review of therapy documentation and nursing notes since the start of R109's FMP revealed no documentation indicating the exercises were carried out as prescribed. Record review revealed no documentation of resident refusal, contraindications, or physician notification regarding the lack of ROM exercises for R109. During an interview on 12/3/25 at 1:23 p.m., nursing assistant (NA)-A stated there were no residents on the third floor with functional maintenance programs. NA-A stated residents who received therapy services completed range of motion exercises during therapy sessions and confirmed range of motion exercises were not completed by nursing staff. During an interview on 12/3/25 at 2:48 p.m., NA-F stated there were no range of motion exercises for any residents that needed to be completed by staff. During an interview on 12/4/25 at 11:45 a.m., the assistant director of nursing (ADON) confirmed residents' functional maintenance programs required ongoing ROM exercises and acknowledged there was no documentation indicating the exercises had been implemented consistently. The ADON stated nursing assistants should have been completing the exercises as ordered. The ADON explained when functional maintenance programs were added to residents' care plans, a required step to pull the program into point-of-care documentation had not been completed, resulting in staff being unaware of the programs. The ADON stated range of motion exercises were important to maintain resident strength and prevent loss of stamina. During an interview on 12/4/25 at 12:18 p.m., the Director of Nursing (DON) confirmed residents with functional maintenance programs were expected to receive ROM exercises as outlined by therapy and acknowledged the exercises were not implemented as ordered. The DON stated the programs were not pulled into point-of-care documentation, and therefore staff were not aware A facility policy for mobility was requested. The interim Administrator stated the facility did not have a generalized mobility policy.

Based on observation, interview and record review the facility failed to ensure toenail care was completed for 1 of 1 resident (R83) who was dependent on staff assistance for activities of daily living (ADLs). Findings include:R83's quarterly Minimum Data Set (MDS) dated [DATE], indicated R83 had severe cognitive impairment and diagnoses of intellectual disabilities, seizure disorder, and personality disorder. R83 had no rejection of cares and was dependent on staff for lower body dressing, including socks and shoes. R83's Therapy ADL communication form dated 10/31/25, indicated R83 was dependent of staff for clothing management.R83's provider order dated 8/16/26. Indicated R83 required a nurse skin check weekly. R83's weekly skin inspection dated 10/27/25, indicated R83 had a shower and R83's toenails did not require trimming. R83's weekly skin inspection dated 11/1/25, indicated R83 had a bed bath and R83's toenails were trimmed.R83's weekly skin inspection dated 11/8/25, indicated R83 had a shower and R83's toenails did not require trimming.R83's weekly skin inspection dated 11/17/25, indicated R83 had a bed bath and R83's toenails were trimmed.R83's care plan revised 8/22/25, indicated R83 required interventions with ADL care. R83 required extensive assist of one person for lower body dressing and two persons assist with bathing. R83's emergency room provider progress note dated 11/25/25, indicated R83 had bad toenail infection and was started on Lamisil 250 milligram (MG) tablet (medication for fungal infection) daily for 28 days. The note further described R83's bilateral feet with significant thickening and discoloration of all the toenails with red non-blanching papules on bilateral feet. R83's diagnosed with fungal infection of the toenails. When interviewed on 12/2/25 at 8:05 a.m., nursing assistant (NA)-A stated nail care was completed on bath days. If the resident was diabetic, the nurse would do them. If there was any concern with toenails, the nurse would be notified.When interviewed on 12/2/25 at 9:06 a.m., registered nurse (RN)-A stated nail care was completed on shower days. The nurses were responsible to complete them if the resident was diabetic. Documentation was completed by the nurses in the weekly skin assessment. RN-A was not aware of any concerns with R83's toenails. When interviewed on 12/2/25 at 10:3 a.m., the assistant director of nursing (ADON) did not recall nail concerns for R83 and further stated if there were any concerns with toenails, podiatry would have seen him. ADON further stated nail care was documented on the weekly skin assessments and verified as indicated in the chart. Pictures of R83's nails were shown and ADON. ADON verified R83's toenails looked overgrown, yellow and thick and R83's toenails could not have been done recently as indicated in the documentation.When interviewed on 12/2/25 at 2:04 p.m., guardian-A stated R83 had discharged recently from the facility to a group home. When arriving at the group home it was noted R83's toenails were in terrible shape. They were all yellow and appeared some were almost falling off. R83 was sent into the emergency room for treatment, and it was determined R83 had a bad toenail infection and was started on some medication. Guardian-A further stated she was unaware of R83's toenail issue as the facility had never discussed it with her. When interviewed on 12/3/25 at 9:10 a.m., physician assistant (PA)-A stated she was the provider for R83 at the group home. PA-A stated the group home called and requested an urgent visit to assess the toenails when R83 had arrived. Unable to complete a visit, staff sent R83 to the ER for evaluation of his feet. R83 was aware of the treatment prescribed for R83 and was due to follow up with him next week. PA-A stated the description of the nails by the emergency room provider would lead her to believe the condition has been going on for a few months. When interviewed on 12/3/25 at 10:47 a.m., the Director of Nursing (DON) expected nails to be looked at and care completed if needed on bath days. Furthermore, any concerns with toenails should be brought to the ADON for evaluation and would contact the provider as needed. A facility policy titled Activities of Daily Living /Maintain Abilities dated 3/31/25, directed staff to provide services to maintain good grooming and personal hygiene to residents who are unable to carry out activities of daily living.

Based on observation, interview, and record review, the facility failed to ensure activities were provided or offered in accordance with resident needs and preferences for 1 of 1 resident reviewed (R109). Specifically, the resident remained in bed for the duration of the survey without activities being offered or provided. This deficient practice resulted in the potential for social isolation, decline in psychosocial well-being, and decreased quality of life.Findings include:R109's quarterly Minimum Data Set (MDS) dated [DATE], identified R109 had intact cognition and required assistance with activities of daily living (ADLs). R109's diagnoses included hemiplegia following cerebral infarction affecting the right dominant side (paralysis or weakness on the right side due to stroke), hypertension (high blood pressure), diabetes mellitus (impaired blood glucose regulation), hyperlipidemia (elevated cholesterol or fats in the blood), malnutrition (insufficient nutrient intake), bipolar disorder (mood disorder with manic and depressive episodes), dysphagia following cerebral infarction (difficulty swallowing after stroke), unspecified protein-calorie malnutrition (general deficiency of protein and calories), and constipation (infrequent or difficult bowel movements).During observation on 12/1/25 at 4:40 p.m., R109 was lying in bed. The room was dark with the curtains drawn, with no activities present. During observation on 12/2/25 at 1:40 p.m., R109 was lying in bed. The room was dark. No activity materials were present, and no staff were observed offering or providing activities to the resident.During observation on 12/3/25 at 10:02 a.m., R109 was lying in bed. The room was dark. No activity materials were present, and no staff were observed offering or providing activities to the resident.During observation on 12/3/25 at 11:27 a.m., R109 was lying in bed in the same position as previous observations. The resident had not been transported to group activities, and no individualized activities were observed to be offered or provided.During observation on 12/3/25 at 1:23 p.m., R109 was lying in bed in the same position as previous observations. The resident had not been transported to group activities, and no individualized activities were observed to be offered or provided.Record review revealed no documentation indicating activities were offered to R109 during the survey period. The activity record did not reflect resident participation or refusal of activities.During an interview on 12/3/25 at 1:23 p.m., nursing assistant (NA)-A stated R109 typically stayed in bed and staff did not routinely offer activities unless the resident requested them.During an interview on 12/4/25 at 12:02 p.m., activity aide (AA)-A stated residents were expected to be offered activities daily, including individualized activities for residents who remained in their rooms. AA-A acknowledged R109 should have been offered activities during the survey period and confirmed one-to-one activities were not occurring due to low staffing in the activities department.During an interview on 12/4/25 at 12:57 p.m., the Director of Nursing (DON) confirmed residents were expected to be encouraged and assisted to participate in activities and acknowledged R109 remaining in bed without activities being offered was not consistent with facility expectations.A facility policy regarding the provision, documentation, and offering of activities for residents, including residents who remained in their rooms or in bed, was requested but was not received.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect anticoagulation status for 1 of 2 residents (R2) reviewed for coding accuracy. Findings include: The Resident Assessment Instrument 3.0 User's Manual version 1.20.1 dated 10/2025, indicated under a heading, Coding Instructions not to code antiplatelet medications such as clopidogrel as N0415E, an anticoagulant. R2's admission MDS dated [DATE], indicated R2 had a stroke, coronary artery disease, and hypertension. Further, a section, N0415 High-Risk Drug Classes: Use and Indication directed staff to check whether a resident took any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. The MDS indicated R2 took an anticoagulant, and the indication was noted. Additionally, the MDS indicated R2 took an antiplatelet. - 10/22/25, clopidogrel bisulfate (an antiplatelet medication used to prevent blood clots) give 75 milligrams (MG) by mouth once daily to prevent a stroke. - 10/22/25, monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle and joint pain, lethargy, bruising, sudden changes in mental status and or vital signs every shift every Monday. The Physician's order form lacked information R2 took an anticoagulant. R2's medication administration record (MAR) and treatment administration record (TAR) dated October 2025, was reviewed and indicated R2 took clopidogrel bisulfate daily starting 10/23/25, through 10/31/25.R2's October 2025 MAR and TAR lacked evidence R2 received an anticoagulant medication.During interview on 12/4/25 at 11:55 a.m., registered nurse (RN)-C stated she was the MDS nurse for the facility and completed all the sections of the MDS with the exceptions of sections C, D, E, and Q. RN-C stated R2's lookback period for the MDS under section N was from 10/22/25 to 10/28/25, and used the MAR to determine whether a medication was administered during the timeframe. RN-C verified R2 was on clopidogrel after viewing the MAR and that the medication was an antiplatelet and stated she did not see where R2 was administered an anticoagulant. RN-C stated she would have to modify the MDS and stated it was important to code the MDS correctly for consistency because R2 did not receive anticoagulants.During interview on 12/4/25 at 2:47 p.m., the director of nursing (DON) stated she expected the MDS to be coded accurately and further stated they reviewed coding and stated she forgot that clopidogrel was an antiplatelet and the MDS RN completed the coding based on the orders. A policy was requested, but the DON was not sure if the facility had one.

Based on observation and interview, the facility failed to ensure a resident's right to privacy and dignity was maintained by ensuring personal medical equipment was not exposed to public view for 1 of 1 residents (R88) reviewed for resident rights. Specifically, the facility failed to ensure a urinary catheter drainage bag was positioned discreetly while the resident was laying in his bed with the door opened to the main hallway. This deficient practice had the potential to compromise the resident's dignity and privacy.Findings include:R88's quarterly Minimum Data Set (MDS) dated [DATE] identified R88 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R88's diagnoses included cancer (abnormal cell growth), anemia (low red blood cells), hypertension (high blood pressure), renal failure (impaired kidney function), obstructive uropathy (blocked urine flow), diabetes mellitus (impaired blood sugar regulation), arthritis (joint inflammation), non-Alzheimer's dementia (cognitive decline not due to Alzheimer's disease), urinary retention (inability to fully empty the bladder), generalized edema (fluid-related swelling), hydronephrosis (kidney swelling from urine backup), benign prostatic hyperplasia (BPH) (enlarged prostate causing urinary obstruction), and presence of urogenital implants (surgically placed urinary devices). The MDS also indicated R88 had an indwelling urinary catheter (continuous bladder drainage) and did not exhibit any behaviors.During observation on 12/2/25 at 9:13 a.m., R88 was observed lying in bed with the door open to the main hallway. R88 had an indwelling urinary catheter, and the catheter drainage bag, which was approximately half full of yellow-amber colored urine, was hanging uncovered on the side of the bed and was visible to other residents, visitors, and staff in the area. During observation on 12/3/25 at 2:22 p.m., R88 was lying in bed with the door open to the main hallway. R88's catheter drainage bag, which was approximately half full of yellow-amber colored urine, was hanging uncovered on the side of the bed and was visible to other residents, visitors, and staff in the area. During an interview on 12/3/25 at 1:42 p.m., nursing assistant (NA)-A stated R88 required assistance with all cares, including transferring the catheter bag from under his wheelchair to the side of his bed. NA-A stated the catheter bag should be covered and confirmed it was not. During an interview on 12/3/25 at 2:33 p.m., registered nurse (RN)-E stated catheter bags should be covered by placing them in a bag to protect the resident's privacy and dignity. RN-E stated staff must assist R88 with moving the catheter bag from under his wheelchair to the side of his bed. RN-E confirmed the catheter bag was hanging uncovered on the side of the bed and was visible to others. Why is it important to have the bag covered? Res dignity? I had indicated this above (bolded area) During an interview on 12/3/25 at 2:44 p.m., licensed practical nurse (LPN)-D stated catheter bags should be covered to respect resident privacy and dignity. LPN-D stated staff must assist R88 with moving the catheter bag from under his wheelchair to the side of his bed. LPN-D confirmed the catheter bag was hanging uncovered on the side of the bed and was visible to others. During an interview on 12/4/25 at 11:23 a.m., the assistant director of nursing (ADON) stated she would expect all catheter bags to be covered at all times to protect resident privacy and dignity. The ADON stated catheter bags should be covered whether positioned under a wheelchair or on the side of the bed. The ADON stated if a catheter bag was not covered and was visible to others, it would be a dignity concern. During an interview on 12/4/25 at 12:22 p.m., the director of nursing (DON) stated she would expect staff to cover residents' catheter bags at all times to maintain privacy and dignity. A facility policy related to catheter care and privacy was requested but was not provided.

Based on observation, interview, and document review, the facility failed to ensure call lights were accessible to 1 of 1 resident (R74) reviewed for call light accessibility. Findings include:R74's annual Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, was able to express ideas and wants, used a wheelchair, was dependent on staff for dressing, hygiene, bathing, and transfers, and required substantial assistance with rolling in bed, sitting to lying in bed and lying to sitting on the side of the bed, and was always incontinent.R74's Falls care area assessment (CAA) dated 10/22/25, indicated R74 had no falls, however, was at risk for falls due to decreased mobility and strength and planned to continue with the care plan.R74's care sheet indicated in a pink banner that all nursing assistants were expected to assist with all call lights. R74's care plan dated 4/11/23, indicated R74 was alert and oriented to person.R74's care plan dated 4/10/23, indicated R74's goal was to have no injuries due to falling with a target date of 1/9/26. Interventions included to make sure the call light was within reach and encourage R74 to use it for assistance as needed and provide prompt response to all requests for assistance.During observation on 12/1/25 between 7:19 p.m. and 7:26 p.m., R74 was in bed sleeping. R74's call light was located on the floor and unidentified staff assisted R74's roommate to bed, walked by R74 and left the room and did not provide R74 with his call light.During observation on 12/3/25 at 7:33 a.m., R74 was in bed and his call light was located under R74's roommate's bed.During observation on 12/3/25 at 8:01 a.m., nursing assistant (NA)-C sanitized his hands in the hallway near the storage closet and looked in R74's room and continued walking past the room and did not pick up R74's call light.During observation on 12/3/25 at 8:05 a.m., NA-C looked inside R74's room and closed the door but did not give R74 his call light and continued down the hall.During interview and observation on 12/3/25 between 8:09 a.m. and 8:12 a.m., NA-C stated R74 required total care and could make his needs known and further stated he asked R74 about getting up, R74 told NA-C he did not want to get up and stated R74 should always have his call light so staff can assist with his needs. At 8:12 a.m., NA-C verified R74 did not have his call light and further stated the call light was supposed to have a clip and the clip would help in case R74 turned. During interview on 12/3/25 at 8:15 a.m., licensed practical nurse (LPN)-B stated R74 required total care and didn't think R74 moved and thought R74 used his call light and viewed R74's care plan and verified R74 was at risk for falls and had an intervention to ensure the call light was in reach and expected staff provide the call light in accordance with the care plan. LPN-B further stated everyone should have a clip for their call light, so they do not end up on the floor.During interview on 12/3/25 at 8:22 a.m., LPN-C stated normally all residents had a clip and did not know why R74 did not have a clip for the call light and would get a new one right away and expected the call light to be in reach and further stated the purpose of the clips is to keep the light secure on the bed. During interview on 12/3/25 at 2:27 p.m., the director of nursing (DON) stated they had call light clips and expected the clip to be closed in bed and that call lights should always be within reach.A policy, Call Light Policy, dated 5/16/23, indicated call cords, buttons, or other communication devices must be placed where they are within reach of each resident.

Based on observation and interview, the facility failed to maintain a clean and sanitary environment for 2 of 2 residents reviewed (R55 and R108) by failing to ensure resident room floors were kept clean and free of visible dirt and debris. This deficient practice resulted in the potential for infection transmission, unpleasant living conditions, and compromised resident comfort and dignity.Findings include:R55R55's quarterly Minimum Data Set (MDS) dated [DATE], identified R55 had intact cognition and required assistance with activities of daily living (ADLs). R55's diagnoses included heart failure (impaired heart pumping function), hypertension (high blood pressure), hyperlipidemia (elevated blood cholesterol), schizophrenia (chronic thought disorder), pulmonary embolism without acute cor pulmonale (blood clot in the lung without acute heart strain), hypoxemia (low blood oxygen levels), thrombocytopenia (low platelet count), acute embolism and thrombosis of deep veins of the left upper extremity (blood clot in a deep vein of the arm), hypothyroidism (underactive thyroid), and dysthymic disorder (chronic low-grade depression).During observation on 12/1/25 at 1:08 p.m., R55's room floor was visibly soiled. The floor contained accumulated dust, darkened residue adhered to the floor surface, and debris beneath the bed and bedside table. The floor appeared sticky in areas near the bed and wheelchair path. No evidence of recent cleaning was observed.During observation on 12/2/25 at 9:40 a.m., R55's room floor was noted to have the same visible dirt and debris as was noted on 12/1/25, indicating the floor had not been cleaned since the prior observation.During observation on 12/3/25 at 12:21 p.m., the surveyor again observed R55's room floor and noted the same visible dirt and debris remained present, indicating the floor had not been cleaned since the prior observation.R108R108's quarterly Minimum Data Set (MDS) dated [DATE] identified R108 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R108's diagnoses included stroke (interrupted blood flow to the brain), hemiplegia following cerebral infarction affecting the right dominant side (right-sided weakness or paralysis after stroke), anemia (low red blood cell count), hypertension (high blood pressure), renal failure (impaired kidney function), wound infection (infection at a wound site), diabetes mellitus (impaired glucose control), hyperlipidemia (elevated blood lipids), arthritis (joint inflammation), aphasia (impaired speech or language), seizure disorder (recurrent seizures), anxiety disorder (persistent excessive anxiety), depression (persistent low mood), chronic obstructive pulmonary disease (COPD) (chronic lung disease affecting airflow), furuncle of the buttock (localized skin abscess), immunodeficiency (reduced immune function), and mood disorder due to a known physiological condition (mood changes caused by a medical condition).During observation on 12/1/25 at 12:57 p.m., the surveyor observed R108's room floor was visibly soiled. The floor contained accumulated dust, darkened residue adhered to the floor surface, and debris beneath the bed and bedside table. No evidence of recent cleaning was observed.During observation on 12/2/25 at 1:36 p.m., R108's room floor was noted with the same visible dirt and debris, indicating the floor had not been cleaned since the prior observation.During observation on 12/3/25 at 7:15 a.m., R108's room floor was noted with the same visible dirt and debris, indicating the floor had not been cleaned since the prior observation.During an interview on 12/4/25 at 10:24 a.m., the environmental Services manager (HSK)-A stated resident room floors were expected to be cleaned daily and acknowledged the observed floors were not in a clean condition.During an interview on 12/4/25 at 12:50 p.m., the Director of Nursing (DON) stated resident rooms were expected to be maintained in a clean and sanitary condition at all times.A facility policy regarding routine cleaning and maintenance of resident room floors was requested but was not received.

Based on record review and interview, the facility failed to ensure resident-centered care plans were developed, implemented, and revised to accurately reflect resident's current needs for 3 of 3 residents reviewed (R55, R102, and R109). Specifically, the facility failed to include required interventions for edema management, failed to update the care plan to remove discontinued enhanced barrier precautions, and contained conflicting information regarding the level of assistance required for eating. These deficient practices resulted in the potential for inconsistent care, unmet resident needs, and compromised resident safety and well-being.Findings include:R55R55's quarterly Minimum Data Set (MDS) dated [DATE] identified R55 had intact cognition and required assistance with activities of daily living (ADLs). R55's diagnoses included heart failure (impaired heart pumping function), hypertension (high blood pressure), hyperlipidemia (elevated blood cholesterol), schizophrenia (chronic thought disorder), pulmonary embolism without acute cor pulmonale (blood clot in the lung without acute heart strain), hypoxemia (low blood oxygen levels), thrombocytopenia (low platelet count), acute embolism and thrombosis of deep veins of the left upper extremity (blood clot in a deep vein of the arm), hypothyroidism (underactive thyroid), and dysthymic disorder (chronic low-grade depression).Record review on 12/3/25, revealed R55 had documented bilateral lower extremity edema noted in nursing progress notes and physician documentation. The medical record indicated R55 had an order for ACE wraps to the lower extremities as part of edema management. Review of R55's care plan revealed no interventions addressing the use of ACE wraps or management of edema.During an interview on 12/3/25 at 1:23 p.m., nursing assistant (NA)-A stated R55 had edema in the lower legs and was supposed to wear ACE wraps during the day.During an interview on 12/3/25 at 2:08 p.m., nurse practitioner (NP)-A stated R55 had edema in the lower extremities and needed staff to encourage R55 to wear ACE wraps, as they were important for edema management.During an interview on 12/4/25 at 11:23 a.m., the assistant director of nursing (ADON) confirmed R55 had orders for ACE wraps related to edema and acknowledged the intervention should have been reflected in the care plan. The ADON stated the care plan had not been updated to include this intervention.During an interview on 12/4/25 at 12:19 p.m., the director of nursing (DON) stated ACE wraps were an intervention for edema management and should have been included in R55's care plan.R102R102's annual Minimum Data Set (MDS) dated [DATE], identified R102 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R102's diagnoses included anemia (low red blood cell count), hypertension (high blood pressure), gastroesophageal reflux disease [GERD] (acid reflux), benign prostatic hyperplasia [BPH] (enlarged prostate causing urinary obstruction), renal failure (impaired kidney function), depression (persistent low mood), malnutrition (insufficient nutritional intake), dehydration (inadequate body fluids), hypovolemia (decreased blood volume), and dysphagia, oropharyngeal phase (difficulty swallowing during the mouth and throat phase). The MDS also indicated R102 required substantial to maximal assistance with eating.Record review on 12/4/25, revealed R102 previously required enhanced barrier precautions (EBP); however, documentation indicated the precautions had been discontinued. Review of R102's current care plan continued to list enhanced barrier precautions as an active intervention.During an interview on 12/4/25 at 11:35 a.m., the ADON confirmed R102 was no longer on enhanced barrier precautions and acknowledged the care plan had not been revised to reflect the current precaution status.During an interview on 12/4/25 at 11:35 a.m., the director of nursing/infection prevention nurse (DON) confirmed R102 was no longer on enhanced barrier precautions and acknowledged the care plan had not been revised to reflect the current precaution status. DON stated enhanced barrier precautions should have been removed from the care plan immediately after the precautions were discontinued.R109R109's quarterly Minimum Data Set (MDS) dated [DATE], identified R109 had intact cognition and required assistance with activities of daily living (ADLs). R109's diagnoses included hemiplegia following cerebral infarction affecting the right dominant side (paralysis or weakness on the right side due to stroke), hypertension (high blood pressure), diabetes mellitus (impaired blood glucose regulation), hyperlipidemia (elevated cholesterol or fats in the blood), malnutrition (insufficient nutrient intake), bipolar disorder (mood disorder with manic and depressive episodes), dysphagia following cerebral infarction (difficulty swallowing after stroke), unspecified protein-calorie malnutrition (general deficiency of protein and calories), and constipation (infrequent or difficult bowel movements).Record review on 12/2/25, revealed conflicting information within R109's care plan regarding the level of assistance required for eating. One section of the care plan indicated the resident required assistance of one person with eating, while another section indicated the resident required set-up assistance only. The inconsistency did not clearly define the appropriate level of assistance staff were expected to provide.During an interview on 12/3/25 at 1:23 p.m., NA-A stated R109 required staff assistance with eating but was able to drink independently.During an interview on 12/3/25 at 2:38 p.m., licensed practical nurse (LPN)-D stated R109 fed himself and did not require assistance.During an interview on 12/3/25 at 2:48 p.m., NA-F stated R109 could feed himself but needed staff present in the room while eating.During an interview on 12/4/25 at 11:45 a.m., the ADON acknowledged the care plan contained conflicting information regarding eating assistance and stated the care plan should have clearly reflected one consistent level of assistance to ensure appropriate care delivery. The ADON acknowledged the identified care plan issues were not consistent with facility expectations.During an interview on 12/4/25 at 12:18 p.m., the DON stated care plans were expected to be accurate, individualized, and updated to reflect current resident needs.A facility policy regarding the development, updating, and revision of resident care plans was requested but was not received.

Based on observation and interview, the facility failed to maintain the confidentiality of resident personal and medical information for 1 of 1 resident observed (R98) by allowing resident-identifiable information to be visible on a computer screen located on a medication cart in a public area. This deficient practice resulted in the potential for unauthorized disclosure of protected health information to residents, staff not involved in care, visitors, and others who walked through the area.Findings include:R98's annual Minimum Data Set (MDS) dated [DATE], identified R98 had intact cognition and was independent with activities of daily living (ADLs). R98's diagnoses included heart failure (impaired heart pumping function), hypertension (high blood pressure), diabetes mellitus (impaired blood glucose regulation), renal failure (impaired kidney function), and anxiety disorder (persistent excessive anxiety).During observation on 12/2/25 from 9:26 a.m. to 9:34 a.m., the surveyor observed a medication cart unattended in the hallway outside resident rooms. The medication cart contained a laptop computer with the screen open and facing outward toward the hallway. The computer screen displayed resident-specific information, including the resident's full name, date of birth , medication list, and diagnoses. The information was clearly visible to anyone walking past the medication cart. At the time of observation, multiple staff members, visitors, and residents passed through the hallway, and no staff member was present to monitor or secure the computer screen.During an interview on 12/2/25 at 9:34 a.m., registered nurse (RN)-A confirmed the laptop on the medication cart was logged into the facility's electronic medical record system and acknowledged the resident information displayed was confidential. RN-A stated staff were expected to log off or close the screen when stepping away from the medication cart but confirmed this was not done at the time of observation.During an interview on 12/4/25 at 12:54 p.m., the Director of Nursing (DON) stated staff were educated on protecting resident privacy and acknowledged the computer screen should not have been left unattended with resident information visible in a public area. The DON confirmed leaving resident information visible on an unattended computer screen was not consistent with facility expectations or resident privacy requirements.A facility policy addressing the protection of resident confidential information, including the secure use of electronic medical records on mobile devices and medication carts, was requested but was not received.

Based on observation, interview, and document review, the facility failed to ensure audiology appointments were available for 1 of 1 resident (R67) who requested audiology services. Findings include:R67's annual Minimum Data Set (MDS) dated [DATE], indicated R67 had adequate hearing and had no difficulty in normal conversation, social interaction, listening to the TV and did not wear a hearing aid. Further, R67 had moderate cognitive impairment, was very important to have family or a close friend involved in discussion about care and was very important to listen to music.R67's quarterly MDS dated [DATE], indicated R67 had adequate hearing and did not use a hearing aid, had moderate cognitive impairment, and had initially been admitted to the facility on [DATE].R67's Medical Diagnosis form, undated, indicated the following diagnoses: Parkinson's disease, dementia, and depression. R67's HealthDrive consent form dated 1/31/24, indicated R67 wanted to be seen for audiology.R67's HealthDrive consent form dated 4/18/25, indicated R67 wanted to be seen for audiology services. R67's Care Conference Forms dated 12/13/24, 3/21/25, 6/13/25, 9/9/25, 10/13/25, indicated a Heading, Exams that included dental and eye exams. The forms lacked information when R67 was seen by audiology.R67's social services note dated 8/2/23 at 10:34 a.m., indicated a consent form for dental, podiatry, vision, and audiology was mailed to R67's family member. R67's social services note dated 8/15/23 at 4:50 p.m., indicated R67 spoke with staff regarding her need for dental, vision, and audiology services and R67's daughter gave verbal consent and R67 was agreeable to sign the form. R67's therapeutic recreation progress notes dated 4/19/23 at 8:48 a.m., indicated R67 reported having difficulty hearing on the phone.R67's therapeutic recreation progress notes dated 10/12/23 at 5:06 p.m., indicated R67 had minimal difficulty in hearing with no hearing appliance used and a hearing plan of care was completed. R67's record was reviewed and lacked information R67 was seen by audiology.During interview and observation on 12/1/25 at 6:51 p.m., R67's hair was covering her ears, no hearing assist devices were visible. R67 required surveyor to speak into her left ear in order for R67 to hear. During interview on 12/2/25 at 8:29 a.m., R67 stated she did not wear hearing aids.During interview on 12/3/25 at 1:50 p.m., family member (FM)-A stated the facility won't bring R67 to an ear doctor. FM-A did not provide information why the facility would not bring R67 to the ear doctor.During interview on 12/4/25 at 8:53 a.m., nursing assistant (NA)-D stated R67 didn't hear well, did not wear hearing aids and staff had to talk closely to R67 for her to hear them.During interview on 12/4/25 at 9:18 a.m., social worker (SW)-B stated HealthDrive covered vision, dental, podiatry, and audiology. If a resident was seen by these specialties, a note was scanned in the Miscellaneous section of the resident's electronic medical record (EMR) along with the consent form. If a resident refused to be seen, the specialties would document the refusals on a note in the Miscellaneous section. SW-B did not know how often audiology came but stated podiatry came monthly, dental came monthly, or every other month and vision came every three months. SW-B stated the health unit coordinator (HUC)-I would know. SW-B stated she did not see a record R67 had been seen by audiology and was not sure how appointments worked. During interview on 12/4/25 at 9:31 a.m., HUC-I stated HealthDrive specialties send the facility dates when they are coming and stated audiology hadn't been out for a while. HUC-I further stated they had not had an audiologist for at least 6 months and would send residents out for appointments. HUC-I stated she could check under the Miscellaneous section for any appointments R67 had and added R67 did not have an appointment set up outside of the facility for audiology. Residents were automatically signed up for audiology appointments when a resident signed a consent form. HUC-I stated the HealthDrive form need to be updated because they did not have audiology any longer. HUC-I verified R67 had not seen audiology in the facility and has not gone out for any hearing appointments.During interview on 12/4/25 at 11:49 a.m., licensed practical nurse (LPN)-C stated if a resident signed a consent form they were placed on a list right away for specialty services and stated they were working on getting someone from audiology.During interview on 12/4/25 at 12:34 p.m., social worker (SW)-A stated the facility was in the process of acquiring a new audiologist and was not sure when an audiologist came to the facility. SW-A was aware staff had to get close for R67 to hear. When R67 was in the day room, she needed to be moved to a quieter location in order for SW-A to talk with R67.During interview on 12/4/25 at 2:39 p.m., the director of nursing (DON) stated they obtained consents and residents were added to a list and further stated HUC-I added R67 to the list in October and contacted HealthDrive who had no audiologist. Residents could see outside providers if they wanted, this was something that could be offered. DON stated R67 did not have an acute concern so it was not brought up again. DON further stated, the goal was to get in contact with another company and did not know what transpired with previous consent for audiology.A policy was requested but was not received.

Based on observation, interview, and record review, the facility failed to ensure prescribed treatment for urinary tract infection (UTI) prevention was administered or reported as refused for 1 of 2 residents (R47) reviewed for recurring UTIs. Findings include:R47's admission Minimum Data Set (MDS) dated [DATE], indicated R47 was cognitively intact, was dependent on staff for toileting and required substantial/maximum assistance for transfers and mobility. The MDS indicated R47 was frequently incontinent of bowel and bladder, did not have any urinary device. R47 did not exhibit rejection of care behavior. R47's diagnoses included chronic kidney disease, diabetes mellitus, and urinary tract infection.R47's care plan dated 1/13/26, indicated alteration in elimination with a goal to be free from signs and symptoms of UTI.R47's October 2025, medication administration record (MAR) indicated, Estradiol Vaginal Cream 0.1 MG/GM (milligrams/gram)[Estradiol Vaginal] Apply to inner vulvar & urethral topically one time a day every Wed, Sat for UTI prevention. Apply 5g to inner vaginal area two times weekly, with a start date of 10/18/25. The MAR indicated three days marked with a 2 (drug refused) and one day with a 9 (other-see nurses note).R47's November 2025, MAR indicated, Estradiol Vaginal Cream 0.1 MG/GM [Estradiol Vaginal] Apply to inner vulvar & urethral topically one time a day every Wed, Sat for UTI prevention. Apply 5g to inner vaginal area two times weekly. The MAR indicated eight days marked with a 2 (drug refused) and one day with a checkmark (administered).Review of R47's December 2025, MAR on 12/3/25, indicated, Estradiol Vaginal Cream 0.1 MG/GM [Estradiol Vaginal] Apply to inner vulvar & urethral topically one time a day every Wed, Sat for UTI prevention. Apply 5g to inner vaginal area two times weekly. The MAR indicated one day (12/3) marked with a 2 (drug refused). R47's MAR further indicated, Macrobid Oral Capsule [an antibiotic commonly used to treat UTIs] Give 100 mg by mouth two times a day related to [UTI] with a start date of 11/20/25.R47's lab result report dated 11/19/25, indicated an abnormal urinalysis/urine culture lab result from a urine sample collected on 11/16/25, indicating a UTI.During interview on 12/2/25 at 8:47 a.m., R47 reported concerns regarding timeliness of medication administration. R47 further stated she had frequent UTIs and had recently finished a round of antibiotics for a UTI. During observation and interview on 12/3/25 at 7:36 a.m., registered nurse (RN)-B entered R47's room with a medicine cup full of pills. R47 was sitting up with bedside table in front of her awaiting breakfast. R47 took all the pills provided and RN-B left the room. RN-B did not offer to administer the Estradiol. R47 stated she had been offered the Estradiol one time that she could remember and refused it at that time. R47 could not remember being offered the Estradiol other than that one time. R47 could not recall when that offer/refusal took place. R47 stated RN-B did not offer the Estradiol yet today.During interview on 12/3/25 at 7:51 a.m., RN-B stated R47 had recently finished antibiotics for a UTI which was her second UTI since admission. RN-B stated R47 had Estradiol ordered, but always refuses it. RN-B further stated she had not offered the Estradiol to R47 yet and was going to offer it later when she was back in bed. RN-B confirmed she had signed off R47's MAR with a 2, indicating refused, even though she had not offered the medication yet. RN-B stated she should not have documented the refusal prior to offering, even if she thinks R47 will end up refusing it. RN-B further stated continued refusals of any treatment by a resident should be reported to the provider so they could re-evaluate and possibly order an alternative medication for UTI prevention. During interview 12/3/25 at 9:36 a.m., nurse practitioner (NP)-A stated would expect to be notified when residents consistently refuse a medication and was not aware that R47 had not been receiving Estradiol as ordered due to consistent refusals. During interview on 12/3/25 at 1:01 p.m., license practical nurse (LPN)-A stated when a resident continuously refused prescribed treatment or medication, the provider should be notified. LPN-A further stated staff should not document a refusal on a MAR without actually offering the treatment or medication.During interview on 12/4/25 at 11:38 a.m., director of nursing (DON) stated staff should not be documenting refusals prior to offering a treatment or medication even if they had a history of refusals. DON further stated would expect staff to notify the provider of consistent refusals.A facility policy on UTIs and nursing documentation was requested but not received.

Based in interview and record review the facility failed to ensure notification was made to the provider and resident representative for concerns of toenail infection and refused podiatry appointments for 1 of 1 resident R83 who required podiatry services. Furthermore, the facility failed to promptly notify the resident's physician and/or practitioner of changes in resident condition for 2 of 2 residents (R53 and R55) reviewed for notification of changes. Specifically, the facility failed to notify the provider of episodes of diarrhea for 1 resident (R53) reviewed for constipation and failed to notify the provider of significant weight gain in accordance with physician-ordered parameters for 1 resident (R55). These deficient practices had the potential to delay medical evaluation and treatment. Findings include: R83's quarterly Minimum Data Set (MDS) dated [DATE], indicated R83 had severe cognitive impairment and diagnoses of intellectual disabilities, seizure disorder, and personality disorder. R83 had no rejection of cares and was dependent on staff for lower body dressing, including socks and shoes. R83's Therapy ADL communication form dated 10/31/25, indicated R83 was dependent of staff for clothing management. R83's provider order dated 8/16/25. Indicated R83 required a nurse skin check weekly. R83's care plan revised 8/22/25, indicated R83 required interventions with ADL care. R83 required extensive assist of one person for lower body dressing and two persons assist with bathing. R83's podiatry progress note dated 8/6/25, indicated R83 was scheduled for treatment today, but R83 refused. R83's podiatry progress note dated 11/13/25, indicated R83 was scheduled for treatment today, but R83 refused. R83's provider discharge summary from the facility dated 11/21/25, lacked indication there was concern or problems with R83's feet or toenails. R83's emergency room provider progress note dated 11/25/25, indicated R83 had bad toenail infection and was started on Lamisil 250 milligram (MG) tablet (medication for fungal infection) daily for 28 days. The note further described R83's bilateral feet with significant thickening and discoloration of all the toenails with red non-blanching papules on bilateral feet. R83's diagnosed with fungal infection of the toenails. R83's electronic medical record (EMR) lacked indication R83's guardian was notified of the condition of R83's toenails or notified of the refused podiatry appointments. R83's EMR further lacked indication R83's provider was aware of the condition of the toenails. When interviewed on 12/2/25 at 8:05 a.m., nursing assistant (NA)-A stated nail care was completed on bath days. If the resident was diabetic, the nurse would do them. If there was any concern with toenails, the nurse would be notified. When interviewed on 12/2/25 at 9:06 a.m., registered nurse (RN)-A stated nail care was completed on shower days. The nurses were responsible to complete if the resident was diabetic. If there were concerns, the resident's provider would be notified. If there was a guardian, they would also be notified. When interviewed on 12/2/25 at 10:3 a.m., the assistant director of nursing (ADON) did not recall toenail concerns for R83 and further stated if there were any concerns with toenails, podiatry would have seen him. If R83 refused to be seen, R83's guardian would be notified by either the social work or the nurse manager. ADON further stated there have been some concerns with the podiatry services that the facility was working on. At times residents would not be seen because they like to stay in bed and didn't get to the room where services were being provided. ADON further stated R83 liked familiar faces and would have agreed if approached by staff. ADON verified R83's refusal of podiatry services and would need to review the chart further to determine if R83's guardian was notified. When interviewed on 12/2/25 at 2:04 p.m., guardian-A stated R83 had discharged recently from the facility to a group home. When arriving at the group home it was noted R83's toenails were in terrible shape. They were all yellow and appeared some were almost falling off. R83 was sent into the emergency room for immediate treatment, and it was determined R83 had a bad toenail infection and was started on some medication. Guardian-A was not aware R83 had refused podiatry and further stated she was unaware of R83's toenail issue as the facility had never discussed it with her. When interviewed on 12/3/25 at 9:57 a.m., nurse practitioner (NP)-A had not been aware if R83's toenails. NP-A further stated she expected staff to notify her if there were concerns with R83's feet. When interviewed on 12/3/25 at 9:10 a.m., physician assistant (PA)-A stated she was the provider for R83 at the group home. PA-A stated the group home called and requested an urgent visit to assess the toenails when R83 had arrived. Unable to complete a visit, staff sent R83 to the ER for evaluation of his feet. PA-A was aware of the treatment prescribed for R83 and was due to follow up with him next week. PA-A stated the description of the nails by the emergency room provider would lead her to believe the condition has been going on for a few months. When interviewed on 12/3/25 at 10:47 a.m., the Director of Nursing (DON) expected staff to notify the provider if there were concerns with R83's toenails. Furthermore, any refusal of appointments should have been communicated to R83's guardian. A facility policy titled Notification of Change Policy dated 3/2024, directed staff to communicate changes in a resident's condition to the resident and/or representative and report to the attending physician or delegate. R53 R53's significant change Minimum Data Set (MDS) dated [DATE] identified R53 had intact cognition and required assistance with some activities of daily living (ADLs). R53's diagnoses included hemiplegia following cerebral infarction affecting the left non-dominant side (left-sided weakness or paralysis after stroke), hypertension (high blood pressure), gastroesophageal reflux disease (GERD) (acid reflux), renal failure (impaired kidney function), diabetes mellitus (impaired glucose regulation), arthritis (joint inflammation), stroke (brain injury from interrupted blood flow), anxiety disorder (excessive anxiety), and adjustment disorder with mixed anxiety and depressed mood (emotional response to stress). The MDS also indicated R53 was not experiencing constipation. Record review on 12/2/25, revealed documentation indicating R53 experienced multiple episodes of diarrhea during the period from 11/4/25 through 12/2/25. The medical record lacked documentation showing the provider was notified of the change in condition. During an interview on 12/3/25 at 1:34 p.m., nursing assistant (NA)-A stated R53 had experienced frequent diarrhea since returning from the hospital approximately one month prior. During an interview on 12/3/25 at 2:08 p.m., nurse practitioner (NP)-A stated R53 had chronic diarrhea. NP-A stated R53's order for Senna (stool softener) should have been written as needed. NP-A stated Senna may have been initiated during R53's hospitalization and continued on the discharge orders when he returned to the facility. NP-A confirmed scheduled Senna was initiated on 10/30/25 and confirmed R53 also had an order for loperamide (anti-diarrheal). NP-A stated she would have expected notification if the resident was experiencing diarrhea and confirmed she had not been made aware of any episodes since the end of October. During an interview on 12/3/25 at 2:36 p.m., licensed practical nurse (LPN)-D stated R53 had been experiencing diarrhea for a while. LPN-D confirmed R53 had an order for scheduled Senna and stated the resident was aware of the medication and refused it at times. LPN-D stated she would not notify the provider of diarrhea episodes and would instead review the resident's orders for an as-needed medication. During an interview on 12/3/25 at 2:25 p.m., registered nurse (RN)-E stated R53 experienced episodes of diarrhea for approximately the past month and occasionally refused the scheduled Senna. RN-E stated R53 had an as-needed medication for diarrhea, which was administered when symptoms occurred. During an interview on 12/4/25 at 11:21 a.m., the assistant director of nursing (ADON) stated R53 had chronic diarrhea and administering both a scheduled laxative and an as-needed anti-diarrheal medication was contraindicated, as neither intervention would be effective. The ADON stated the provider should be notified of any change in condition interfering with the resident's activities of daily living. The ADON confirmed the provider should have been notified of R53's episodes of diarrhea and stated she was unable to provide documentation showing notification occurred. During an interview on 12/4/25 at 12:19 p.m., the director of nursing (DON) confirmed the episodes of diarrhea represented a change in R53's condition and stated the provider should have been notified. R55 R55's quarterly Minimum Data Set (MDS) dated [DATE], identified R55 had intact cognition and required assistance with activities of daily living (ADLs). R55's diagnoses included heart failure (impaired heart pumping function), hypertension (high blood pressure), hyperlipidemia (elevated blood cholesterol), schizophrenia (chronic thought disorder), pulmonary embolism without acute cor pulmonale (blood clot in the lung without acute heart strain), hypoxemia (low blood oxygen levels), thrombocytopenia (low platelet count), acute embolism and thrombosis of deep veins of the left upper extremity (blood clot in a deep vein of the arm), hypothyroidism (underactive thyroid), and dysthymic disorder (chronic low-grade depression). Record review on 12/2/25 revealed R55 had a physician's order dated 8/27/24, to notify the provider of a weight gain greater than two (2) pounds in 24 hours or five (5) pounds in one week. Review of weight records revealed R55 experienced weight gains exceeding two pounds on six separate occasions between 11/1/25 and 12/3/25: On 11/6/25, R55 weighed 287.1 pounds, and on 11/7/25, weighed 290.1 pounds, reflecting a weight gain of 3.0 pounds. On 11/11/25, R55 weighed 284.0 pounds, and on 11/12/25, weighed 287.8 pounds, reflecting a weight gain of 3.8 pounds. On 11/12/25, R55 weighed 287.8 pounds, and on 11/13/25, weighed 291.1 pounds, reflecting a weight gain of 3.3 pounds. On 11/16/25, R55 weighed 279.2 pounds, and on 11/17/25, weighed 283.2 pounds, reflecting a weight gain of 4.0 pounds. On 11/24/25, R55 weighed 280.0 pounds, and on 11/25/25, weighed 282.4 pounds, reflecting a weight gain of 2.4 pounds. On 12/1/25, R55 weighed 281.4 pounds, and on 12/2/25, weighed 288.9 pounds, reflecting a weight gain of 7.5 pounds. R55's medical record lacked documentation showing the provider was notified of the weight gains in accordance with the physician-ordered parameters. During an interview on 12/3/25 at 1:34 p.m., NA-A stated nursing assistants obtained residents' weights and recorded them in a binder located at the nurses' station. During an interview on 12/3/25 at 2:08 p.m., NP-A stated R55 had a history of edema and did not always like to wear TED stockings, but staff needed to encourage their use because they were important for managing edema. NP-A stated she expected staff to notify her when parameters were included in a resident's orders. NP-A stated she could not recall being notified of R55's occurrences of weight gain During an interview on 12/3/25 at 2:25 p.m., RN-E stated R55 had a history of edema and an order for leg wrapping. RN-E stated nursing assistants obtained weights and recorded them in a binder at the nurses' station, after which nurses documented the weights in the electronic medical record (EMR). RN-E confirmed R55 had an order for daily weights and initially stated she was unaware of notification parameters. Upon review of R55's orders, RN-E confirmed parameters were present and stated she did not always notify the provider of weight changes. During an interview on 12/3/25 at 2:25 p.m., LPN-D stated R55 was ordered to have daily weights due to edema. LPN-D stated weights were obtained by nursing assistants, recorded in a binder, and then documented by nursing staff in the EMR. LPN-D confirmed notification parameters were present and stated provider notification would have been documented in the EMR if it had occurred. During an interview on 12/4/25 at 11:21 a.m., the ADON stated R55 had an order for daily weights and initially stated no notification parameters were present. Upon review of R55's orders, the ADON confirmed parameters were present. The ADON stated she expected staff to notify the provider based on the order and stated the order should be revised if the provider did not wish to receive notifications. The ADON reviewed R55's weight records and confirmed the provider should have been notified. The ADON stated she was unable to provide documentation showing notification occurred. During an interview on 12/4/25 at 12:19 p.m., the DON confirmed R55's weight gains met the notification parameters outlined in the physician's order and stated she expected staff to follow the order and notify the provider accordingly. A facility policy related to notification of changes in condition was requested but was not provided.

Based on observation, interview, and document review, the facility failed to ensure appropriate infection control measures were in place for maintaining a central line with dressing changes and use of enhanced barrier precautions (EBP) with personal protective equipment (PPE) for 1 of 2 residents (R36) reviewed who had a central line indwelling device.Findings include:R36's admission Minimum Data Set (MDS) dated [DATE], indicated R36 had moderate cognitive impairment and required substantial/maximal assistance for most activities of daily living (ADL) and transfers. R36's diagnoses include spastic hemiplegia (paralysis on one side of the body) affecting the right, dominant side, osteomyelitis (infection of the bone), and history of traumatic brain injury. R36's care plan (CP) dated 10/8/25, indicated resident was on EPB related to IV (central line). The CP instructed staff to use appropriate PPE when providing high contact cares. R36's CP indicated EBP was resolved 11/3/25. R36's treatment administration record (TAR) for October 2025, indicated, Change dressing Location RIGHT CHEST using sterile technique weekly and as needed. The TAR indicated the dressing was changed four times in October, 2025, with the last time 10/27/25. The TAR further indicated, Staff to follow: Enhanced barrier Precautions every shift for IV. The TAR indicated staff completing three times a day. R36's TAR for November 2025, indicated, Staff to follow: Enhanced Barrier Precautions every shift for IV. The TAR indicated task completion three times a day on 11/1/25 and 11/2/25 and then discontinued on 11/3/25. The TAR further indicated Change dressing Location RIGHT CHEST using sterile technique weekly and as needed. The TAR lacked evidence of completion at all in November, 2025. The TAR further indicated, Remove PICC [peripherally inserted central catheter] line one time only until 11/5/25. The TAR lacked evidence this was completed. During observation and interview on 12/1/25 at 2:13 p.m., R36 stated not sure if still on antibiotics but did not think they were using the central line any longer. The dressing on R36's central line was not dated, and the sides of the dressing were curling up as if pretty old. During interview on 12/2/25 at 3:15 p.m., R36 stated cannot remember the last time they used the central line, flushed it or changed the dressing. R36 further stated they stopped donning gowns a while ago. During observation on 12/3/25 at 8:40 a.m., nursing assistant (NA)-B entered R36's room. NA-B completed hand hygiene with alcohol based hand sanitizer and donned gloves. NA-B did not don a gown. R36 was still in bed when NA-B assisted R36 with a brief change, peri care, and donning new pants. NA-B then assisted R36 into a sitting position on the edge of the bed and changed his shirt. While R36's shirt was off, NA-B confirmed the presence of the central line, stated they were not using it anymore, and agreed the dressing appeared to be curling up on the edges and peeling off. NA-B then transferred R36 into a wheelchair and assisted with washing face and oral and denture care. During interview on 12/3/25 at 1:20 p.m., NA-B stated R36 used to be on EBP due to the presence of a central line and that meant appropriate PPE was required when performing any cares. NA-B stated since the central line was still present, EBP should still be in place for R36 and confirmed she only donned gloves earlier when assisting R36 with morning cares. NA-B stated the PPE was to protect the resident from staff germs. During interview on 12/3/25 at 1:58 p.m., licensed practical nurse (LPN)-A stated EBP should have been continued for R36 since the central line remained in place. During interview on 12/3/25 at 3:00 p.m., medical doctor (MD)-A stated was just made aware that R36's central line had not been pulled last month as ordered. MD-A stated there was some confusion as to who could pull the central line and thought it was now scheduled to be removed next week. MD-A further stated would have expected proper care to continue on the central line like dressing changes and flushes and therefore, would also expect EBP to have been continued. During interview on 12/4/25 at 11:30 a.m., director of nursing (DON) stated the maintenance and care orders for R36's central line catheter should not have been discontinued until the catheter was actually removed and would have expected staff to identify this oversight and continue to follow EBP. Facility policy Enhanced Barrier Precautions dated 4/1/24, indicated EBP referred to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi drug resistant organisms] as well as those at increased risk of MDRO acquisition [e.g., residents with wounds or indwelling medical devices]. The policy further indicated EBP were initiated when a resident had an indwelling medical device such as a central line and continued for the duration of the resident's stay or until the indwelling medical device was removed.

Based on observation and interview, the facility failed to ensure activities of daily living (ADLs) related to hygiene and grooming were provided in accordance with resident needs for 1 of 1 residents reviewed (R88) by failing to ensure the resident wore clean clothing throughout the survey period. This deficient practice resulted in the potential for compromised dignity, discomfort, and negative psychosocial impact to the resident.Findings include:R88's quarterly Minimum Data Set (MDS) dated [DATE], identified R88 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R88's diagnoses included cancer (abnormal cell growth), anemia (low red blood cells), hypertension (high blood pressure), renal failure (impaired kidney function), obstructive uropathy (blocked urine flow), diabetes mellitus (impaired blood sugar regulation), arthritis (joint inflammation), non-Alzheimer's dementia (cognitive decline not due to Alzheimer's disease), urinary retention (inability to fully empty the bladder), generalized edema (fluid-related swelling), hydronephrosis (kidney swelling from urine backup), benign prostatic hyperplasia (BPH) (enlarged prostate causing urinary obstruction), and presence of urogenital implants (surgically placed urinary devices). The MDS also indicated R88 had an indwelling urinary catheter (continuous bladder drainage) and did not exhibit any behaviors.During observation on 12/1/25 at 1:52 p.m., surveyor observed R88 wearing visibly soiled clothing, including a shirt with food stains and pants with darkened areas and debris. During observation on 12/2/25 at 9:13 a.m., surveyor again observed R88 wearing the same clothing with the same visible stains noted on the prior day, indicating the clothing had not been changed.During observation on 12/3/25 at 7:09 a.m., surveyor again observed R88 wearing the same clothing with the same visible stains noted on the prior day, indicating the clothing had not been changed.During observation on 12/3/25 at 1:42 p.m., the surveyor again observed R88 wearing the same visibly soiled clothing. The stains remained present, indicating the resident had worn the same dirty clothing throughout the survey period.During an interview on 12/3/25 at 1:42 p.m., nursing assistant (NA)-A stated R88 required staff assistance with dressing and acknowledged the resident should have been provided clean clothing daily. NA-A confirmed the resident's clothing had not been changed during the observed days.During an interview on 12/3/25 at 2:44 p.m., licensed practical nurse (LPN)-D stated R88 dresses himself and if staff notice his clothing is dirty, staff should remind him to go and change clothing with staff assistance.During an interview on 12/3/25 at 2:48 p.m., NA-F stated R88 dressed himself but if clothing were dirty staff needed to assist him with changing his clothing.During an interview on 12/4/25 at 11:23 a.m., assistant director of nursing (ADON) stated if a resident was wearing visibly dirty clothing, staff should assist resident with changing them immediately even if the resident is independent with grooming and dressing.During an interview on 12/4/25 at 1:05 p.m., the Director of Nursing (DON) stated residents were expected to be dressed in clean clothing daily to maintain hygiene and dignity. The DON stated staff should have offered and attempted to assist the resident with changing clothing at least twice daily. The DON stated if the resident continually refused to change clothing, management should have been updated. The DON acknowledged the condition observed was not consistent with facility expectations.A facility policy regarding the provision of clean clothing and assistance with dressing as part of activities of daily living was requested but was not received.

Based on observation, interview and record review the facility failed to maintain accurately documented medical records for 3 of 3 residents (R47, R68, R83) reviewed who had inaccurate documentation. Findings Include: Findings include: R47 R47's admission Minimum Data Set (MDS) dated [DATE], indicated R47 was cognitively intact, was dependent on staff for toileting and required substantial/maximum assistance for transfers and mobility. The MDS indicated R47 was frequently incontinent of bowel and bladder, did not have any urinary device. R47 did not exhibit rejection of care behavior. R47's diagnoses included dislocation of left patella (kneecap), chronic kidney disease, diabetes mellitus, and urinary tract infection. R47's care plan dated 1/13/26, indicated alteration in elimination with a goal to be free from signs and symptoms of UTI. R47's October 2025, medication administration record (MAR) indicated, Estradiol Vaginal Cream 0.1 mg (milligram)/GM (Gram) [Estradiol Vaginal] Apply to inner vulvar & urethral topically one time a day every Wed, Sat for UTI prevention. Apply 5g to inner vaginal area two times weekly, with a start date of 10/18/25. The MAR indicated three days marked with a 2 (drug refused) and one day with a 9 (other-see nurses note). R47's November 2025, MAR indicated, Estradiol Vaginal Cream 0.1 MG/GM [Estradiol Vaginal] Apply to inner vulvar & urethral topically one time a day every Wed, Sat for UTI prevention. Apply 5g to inner vaginal area two times weekly. The MAR indicated eight days marked with a 2 (drug refused) and one day with a checkmark (administered). R47's December 2025, MAR indicated, Estradiol Vaginal Cream 0.1 MG/GM [Estradiol Vaginal] Apply to inner vulvar & urethral topically one time a day every Wed, Sat for UTI prevention. Apply 5g to inner vaginal area two times weekly. The MAR indicated one day (12/3) marked with a 2 (drug refused). R47's MAR further indicated, Macrobid Oral Capsule [an antibiotic commonly used to treat UTIs].Give 100 mg by mouth two times a day related to [UTI]. with a start date of 11/20/25. During observation and interview on 12/3/25 at 7:36 a.m., registered nurse (RN)-B entered R47's room with a medicine cup full of pills. R47 was sitting up with bedside table in front of her awaiting breakfast. R47 took all the pills provided and RN-B left the room. RN-B did not offer to administer the Estradiol. R47 stated she had been offered the Estradiol one time that she could remember and refused it at that time. R47 could not remember being offered the Estradiol other than that one time. R47 could not recall when that offer/refusal took place. R47 stated RN-B did not offer the Estradiol yet today (12/3). During interview on 12/3/25 at 7:51 a.m., RN-B stated she had not offered the Estradiol to R47 yet and was going to offer it later when she was back in bed. RN-B confirmed she had signed off R47's MAR with a 2, indicating refused, even though she had not offered the medication yet. RN-B stated she should not have documented the refusal prior to offering, even if she thought R47 would end up refusing it. R68 R68's admission MDS dated [DATE], indicated R68 was cognitively intact and required dialysis. R68's diagnosis included end stage renal disease (ESRD). R68's care plan (CP) printed 12/2/25, indicated R68 was at risk for complications related to R external chest port. R68's November 2025 treatment administration record (TAR) indicated, Dialysis-Monitor fisutla [sic] for Bruit and Thrill every shift Bruit [Whooshing sound] and Thrill [a powerful pulse felt at the top of the fistula]. If this is not heard or felt, you must contact MD. The TAR indicated task completed 55 times from 11/12/25 through 11/30/25. R68's progress note (PN) dated 11/14/25 at 18:35 p.m., indicated, Has port for dialysis. Bruit/Thrill present. No complications noted following return from dialysis. R68's PN dated 11/19/25 at 9:37 p.m., indicated, Has port for dialysis. Bruit/Thrill present. No complications noted following return from dialysis. R68's PN dated 11/26/25 at 9:39 p.m., indicated Has port for dialysis. Bruit/Thrill present. No complications noted following return from dialysis. During interview on 12/3/25 at 8:25 a.m., R68 stated went to dialysis three times a week and staff would usually check a set of vital signs (VS) and look at the external port on her chest on days when she returned from dialysis. R68 stated staff did not palpate anything or listen to anything except for her lungs on occasion. R68 further stated she did not have a fistula. During interview on 12/3/25 at 9:37 a.m., nurse practitioner stated would not expect staff to be feeling for thrill or listening for bruit around an external central catheter and would only expect it with a fistula. During interview on 12/3/25 at 1:23 p.m., RN-B stated when R68 returned from dialysis, she would check VS and observe the site for bleeding. RN-B further stated was not really sure about bruit and thrill but thought she could just feel above the port site for thrill. RN-B then stated that bruit and thrill assessment were appropriate in the presence of a fistula and would not be necessary for an external central catheter port site. RN-B stated the order for that assessment was entered automatically with the dialysis orders and that staff were just signing it off. RN-B stated signing items off on the TAR when not really doing the task should not be done. During interview on 12/3/25 at 3:00 p.m., medical doctor (MD)-A stated assessing bruit and thrill was not appropriate with a central line and was only appropriate with a fistula. During interview on 12/3/25 at 1:01 p.m., license practical nurse (LPN)-A stated staff should not document a refusal on a MAR without actually offering the treatment or medication. LPN-A stated documenting task not actually completed would be falsifying a medical record. During interview on 12/4/25 at 11:38 a.m., director of nursing (DON) stated staff should not be documenting refusals prior to offering a treatment or medication even if they had a history of refusals. DON further stated staff should be documenting accurately and documenting things when they were not actually done would be considered an inaccurate entry. R83's quarterly Minimum Data Set (MDS) dated [DATE], indicated R83 had severe cognitive impairment and diagnoses of intellectual disabilities, seizure disorder, and personality disorder. R83 had no rejection of cares and was dependent on staff for lower body dressing, including socks and shoes. R83's Therapy ADL communication form dated 10/31/25, indicated R83 was dependent of staff for clothing management. R83's provider order dated 8/16/26. Indicated R83 required a nurse skin check weekly. R83's weekly skin inspection dated 10/27/25, indicated R83 had a shower and R83's toenails did not require trimming. R83's weekly skin inspection dated 11/1/25, indicated R83 had a bed bath and R83's toenails were trimmed. R83's weekly skin inspection dated 11/8/25, indicated R83 had a shower and R83's toenails did not require trimming. R83's weekly skin inspection dated 11/17/25, indicated R83 had a bed bath and R83's toenails were trimmed. R83's care plan revised 8/22/25, indicated R83 required interventions with ADL care. R83 required extensive assist of one person for lower body dressing and two persons assist with bathing. R83's emergency room provider progress note dated 11/25/25, indicated R83 had bad toenail infection and was started on Lamisil 250 milligram (MG) tablet (medication for fungal infection) daily for 28 days. The note further described R83's bilateral feet with significant thickening and discoloration of all the toenails with red non-blanching papules on bilateral feet. R83's diagnosed with fungal infection of the toenails. When interviewed on 12/2/25 at 9:06 a.m., registered nurse (RN)-A stated nail care was completed on shower days. The NA were responsible to complete them if the resident was diabetic. Documentation was completed by the nurses in the weekly skin assessment. When interviewed on 12/2/25 at 10:3 a.m., the assistant director of nursing (ADON) stated nail care was documented on the weekly skin assessments. ADON verified R83's weekly skin assessments indicated toenail care was not needed or had been completed. Pictures of R83's nails were shown and ADON. ADON verified R83's toenails looked overgrown, yellow and thick and R83's toenails could not have been done as indicated in the documentation. When interviewed on 12/2/25 at 2:04 p.m., guardian-A stated R83 had discharged recently from the facility to a group home. When arriving at the group home it was noted R83's toenails were in terrible shape. They were all yellow and appeared some were almost falling off. R83 was sent into the emergency room for treatment, and it was determined R83 had a bad toenail infection and was started on some medication. When interviewed on 12/3/25 at 9:10 a.m., physician assistant (PA)-A stated she was the provider for R83 at the group home. PA-A stated the group home called and requested an urgent visit to assess the toenails when R83 had arrived, however was not able to. The facility sent R83 in to the emergency room for treatment. PA-A stated the description of the nails by the emergency room provider would lead her to believe the condition has been going on for a few months. When interviewed on 12/3/25 at 10:47 a.m., the Director of Nursing (DON) expected staff to document assessments and care accurately. R83's medical record should have indicated the description of his toenails in the weekly assessments or in a progress note. A facility policy on accuracy of medical records was requested however was not received.

Based on observation, interview, and document review, the facility failed to ensure specific patient centered orders were in place and implemented for colostomy care for 1 of 1 resident (R81) reviewed for colostomy care. Findings include:R81's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have hallucinations or delusions, did not reject care, used a wheelchair, was dependent on staff for toileting hygiene, showering or bathing, and lower body dressing. Additionally, R81 had an colostomy and diagnoses included unspecified dementia, anxiety, depression, and malnutrition and did not have any skin conditions. R81's Physician's Orders form saved on 12/1/25 at 2:05 p.m., indicated the following orders:7/28/23, and discontinued on 8/1/23, left lower quadrant colostomy remove pouch and discard. Cleanse the peristomal skin with only tap water, pat dry. Apply [NAME] number 8664, 1 1/4 inch precut convex drainable pouch. Have the resident hold her hand over the pouch for a few minutes. 7/28/23, and discontinued on 8/1/23, colostomy and fistula pouches need to be changed at the same time every 2 to 3 days depending on the seal. The abscess drain will be secured under the pouch barrier tape, so the drain tube attachment device is removed. Colostomy supplies: [NAME] number 8413 pouches 20/month change three times weekly, [NAME] number 89520 barrier rings 20 per month change 3 times weekly and [NAME] colostomy belt number 7300.10/7/23, Change pouch every other day until follow up appointment or if leakage. Wash stoma and skin with tap water, pat dry, cut opening for stoma in wafer. Apply pouch in the morning every other day.8/9/24, Empty colostomy bag each shift.10/29/24, May use facility standing orders as signed by provider.10/4/25, staff and nursing to ensure the use of non-sting skin preps post cleansing to peristome with tap water with all colostomy bag changes. Do not use regular sting skin preps due to pain and discomfort to the resident. Use enhanced barrier precautions/EBP. The current orders lacked information on what type of colostomy bag to use, or whether to use any barrier rings. R81's Standing Orders for Skilled Nursing Facilities indicated the following:All orders initiated from standing orders should be communicated to the provider. Apply ice and cold pack for 20 minutes four times daily as needed to injuries with inflammation. Under a heading, Skin and Wound Management, assess wound and or dressing daily, and complete wound measurements with dressing changes, indicated directives for stage two or three pressure injuries, however lacked directions what to do with excoriated skin due to leakage from an colostomy.R81's care plan dated 11/14/22, indicated R81 had an alteration in skin integrity related to colostomy bag placement and was at risk for breakdown due to incontinence and R81's goal was to remain free of any breakdown. Interventions included a skin integrity check weekly, notify physician as needed with any changes and deterioration in incision and or need for change in treatment.R81's care plan dated 11/14/22, indicated R81 had a colostomy with a goal of not having complications with the colostomy and interventions included applying appropriate skin barrier before applying adhesive around the stoma with each bag change, clean the area with warm water and pat dry, use soap only, if paste has collected on the skin, let it dry and then peel it off gently, inspect stoma peristomal skin area with each pouch changes. Note irritation, bruises, or rash and report findings to the physician as needed, colostomy emptying and pouch changing per MD orders.The care plan lacked information on the specific colostomy supplies R81 required.R81's medication administration record (MAR) and treatment administration record (TAR) dated November 2025, indicated R81 had her colostomy pouch changed 15 times on 11/1/25, 11/3/25, 11/5/25, 11/7/25, 11/9/25, 11/11/25, 11/13/25, 11/15/25, 11/17/25, 11/19/25, 11/21/25, 11/23/25, 11/25/25, 11/27/25, and 11/29/25. R81's MAR and TAR dated December 2025, indicated R81's pouch was changed on 12/1/25. R81's Weekly Skin Evaluation forms dated 11/10/25, 11/17/25, 11/24/25, and 12/1/25, indicated a bruise to the left outer wrist otherwise skin was intact on 11/10/25, a faint bruise to the left wrist and the rest of the skin was intact on 11/17/25, the bruise on the left wrist was healed and there were no other skin concerns on 11/24/25, and on 12/1/25 at 7:31 a.m., R81's skin remained intact.R81's nursing progress note dated 11/26/25 at 11:07 a.m., indicated R81 reported pain around her colostomy and the bag was removed and her skin was raw. The area was cleansed and dried, an Adapt ring was applied to the surrounding stoma, covering raw area to prevent stool from touching it and a new colostomy bag was applied and R81 was given an ice pack.R81's nursing progress notes dated 11/26/25 at 11:11 a.m., indicated acetaminophen was administered for pain to raw skin surrounding the stoma.R81's nursing progress notes dated 11/26/25 at 12:04 p.m., indicated R81 reported pain at an eight out of ten indicating severe pain, to the area around R81's stoma and the bag was changed, and Tylenol and ice were administered.R81's nursing progress note dated 11/27/25 at 6:19 a.m., indicated R81's colostomy bag was emptied and changed. The note lacked information regarding R81's skin condition around the colostomy area.R81's nursing progress note dated 11/28/25 at 8:02 a.m., indicated R81 reported pain at an eight out of ten indicating severe pain around her stoma site. The note lacked information whether R81's stoma site was assessed.R81's nursing progress notes dated 12/1/25 at 2:02 p.m., indicated R81's colostomy bag was leaking, and stool was resting on the skin. R81's bag was removed and the peristoma (area around the stoma) was cleansed and patted dry and an Adapt ring was applied to create a better seal around the stoma and to keep the stool off of the skin. Further the skin was excoriated and R81 reported burning to the skin rating discomfort a 5 out of 10 and requested an ice pack.R81's nursing progress notes dated 12/3/25 at 7:03 a.m., indicated the surrounding skin to the colostomy was intact. During interview on 12/1/25 between 12:54 p.m., and 12:56 p.m., R81 reported having loose stools from her colostomy and her skin was sore and raw adding she had the wrong bag used, and staff changed the bag whenever it needed to be changed.During interview and observation on 12/1/25 at 1:35 p.m., licensed practical nurse (LPN)-B had a box of Ceraplus Holister CeraRing box number 8805, along with an empty Holister colostomy pouch box numbered 8931 in R81's room. R81 stated she rated her pain an eight because her skin around the stoma was irritated. LPN-B stated she had a new Holister box number 8931 and would have to reorder supplies. During observation, R81's colostomy pouch had brownish liquid stool and LPN-B verified R81 did not have a CeraRing when she removed the colostomy pouch. LPN-B stated that was why R81's skin was excoriated when she removed R81's previous colostomy pouch. R81's skin surrounding her stoma site was excoriated and had opened reddened areas around the stoma approximately 1/2 inch wide with a blotchy, reddened rash. LPN-B stated she sometimes placed two CeraRings to cover the stoma because R81's stool pushed the bag off. LPN-B placed the CeraRing and applied the new pouch. LPN-B stated the purpose of the CeraRing was to create a better seal and to keep the stool off the skin. LPN-B stated the CeraRing was a nursing standard and verified R81's orders did not identify the CeraRing and stated she used the CeraRing since R81 had the stoma. LPN-B stated R81's skin excoriation would come and go and stated the CeraRing prevented the skin from being exposed to the stool. During interview on 12/3/25 at 12:26 p.m., LPN-B stated providers were at the facility today and LPN-B usually called to notify a provider and if there were non-urgent needs LPN-B stated she would write a note for the provider for when they came to the facility and stated she called on most things and documented a note if a provider is contacted. LPN-B stated she updated LPN-C on R81's skin 12/1/25, and LPN-C spoke with nurse practitioner (NP)-A and got an order for specific colostomy supplies. LPN-B stated she took R81's bag off and stated her skin was healed. LPN-B stated knowing which specific bag supplies to use was a contentious topic and the health unit coordinator (HUC) used to order supplies and staff let the HUC know what was needed. LPN-B was not sure how they came to a specific bag number and further stated the care plan and orders lacked information for specific colostomy supplies. LPN-B stated the NP should be updated when skin changes occur and verified she did not document the provider was updated when R81's skin was excoriated on 11/26/25, and stated the provider should have been updated. LPN-B stated she would have updated NP-A and further stated she updated LPN-C regarding R81's skin change from 12/1/25, and LPN-B was going to take care of it. LPN-B stated she looked at the excoriation as tiny areas and did not measure them. LPN-B added she should have, and skin assessments would be documented in the progress notes. LPN-B further stated R81's stoma was depressed, and the stool worked its way under the supplies. During interview on 12/3/25 at 12:58 p.m., LPN-C stated the provider is notified right away of any skin concerns. When the physician is notified, LPN-C expected it to be documented in the resident's record. If a resident had skin changes skin would be assessed on treatment days and further added R81's provider should have been notified when they found the excoriation. LPN-C stated she did not know if she called the provider the same day on 12/2/25. LPN-C thought R81 first had excoriation on 12/1/25, but verified R81 had excoriation on 11/26/25, after viewing R81's record. LPN-C stated she would have expected staff to document if the skin was resolved and verified the progress notes lacked information the provider was notified. LPN-C further stated R81 now had orders for the CeraRing because they thought they should obtain an order if they were using them. LPN-C stated they had wound rounds on Tuesdays; however, ostomies were not looked at. LPN-C stated the ostomies were looked at when they are changed and had weekly skin assessment notes, but staff do not remove an colostomy for the bath. LPN-C stated she expected wounds to be documented when they have resolved because they utilize pool staff and would have to put something in place for pool staff to know. During interview on 12/3/25 at 2:04 p.m., NP-A stated she was at the facility Mondays, Wednesdays, and Thursdays. NP-A stated she had not been notified R81 had excoriation on 11/26/25, and further stated she was notified 12/3/25, for the skin excoriation from 12/1/25.During interview on 12/3/25 at 2:27 p.m., the director of nursing (DON) stated they usually had colostomy orders with specific detailing and what supplies to use. DON expected staff would update the provider and per their standing orders this would be done by the next business day for non-urgent items. DON viewed R81's orders and verified R81's orders lacked specific information for which colostomy supplies R81 required. The DON stated they received their supplies from Gentell and further stated the supply numbers had to be in her orders at some point because that was how Gentell knew what supplies to send. She would go by the most recent order and viewed R81's discontinued orders that indicated to use a [NAME] 8531. Further, the DON stated she expected staff to document the status of skin when issues were present and continue to follow up and assess when they changed the pouch. The DON stated all colostomy supplies were sent specific to each resident and the supply number was important to know because the specific supplies were in place for a reason. Each nurse should know which supplies a resident required in case they ran out and needed to be reordered. DON expected staff document when skin issues were resolved, still present, or if they got worse.On 12/3/25 at 3:46 p.m., the DON sent an email that indicated she included a screen shot from their Gentell order which included R81's order section. The screen shot indicated R81 received [NAME] 8931 colostomy pouches and Adapt 8805 colostomy wafers along with a box of skin preps. An order was later created on 12/3/25 at 5:57 p.m., from the DON that indicated to change the pouch every other day or as needed for leakage. Wash stoma and skin with tap water. Pat dry. Use [NAME] 8931 pouch, cut the opening in the wafer for the stoma, apply adapt 8805 barrier ring, apply the pouch over and document any signs or symptoms of skin breakdown and update the provider as needed. On 12/4/25 at 10:37 a.m., an invoice that included all the supplies ordered for R81 and the date ordered was requested in an email to the DON. At 11:32 a.m., the DON replied in an email and attached R81's delivery tickets for 7/1/25, 8/5/25, 11/3/25. The tickets indicated R81 received [NAME] 8930 pouches, [NAME] 8805 CeraRing, and no sting skin Barrier film for each date listed. During interview on 12/4/25 at 10:41 a.m., the Gentell DME (durable medical equipment) provider program supervisor (GDPPS) stated the last three colostomy supply orders for R81 on 7/1/25, 8/5/25, and 11/3/25, contained the following supplies: [NAME] 8930 which was 20 drainable pouches and a [NAME] 8805, which contained 20 CeraRing and a box of No Sting barrier prep. GDPPS stated the CeraRing prevented drainage around the stoma, so skin did not become excoriated and further stated R81 had these supplied since her first order February 2025. During follow up interview on 12/4/25 at 2:37 p.m., the DON stated she expected staff follow physician orders and if they received barrier rings, expected staff clarify and further stated they could not memorize every resident's order supply numbers. A policy, Skin Assessment and Wound Management, dated 2/2025, indicated the purpose of the policy was to provide guidelines for assessing and managing wounds and to implement appropriate preventative skin measures.

Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with physician orders and professional standards of practice for 1 of 1 residents reviewed (R109). Specifically, the facility administered oxygen therapy without a physician's order. This deficient practice resulted in the potential for improper oxygen administration, respiratory compromise, and harm to the resident.Findings include:R109's quarterly Minimum Data Set (MDS) dated [DATE] identified R109 had intact cognition and required assistance with activities of daily living (ADLs). R109's diagnoses included hemiplegia following cerebral infarction affecting the right dominant side (paralysis or weakness on the right side due to stroke), hypertension (high blood pressure), diabetes mellitus (impaired blood glucose regulation), hyperlipidemia (elevated cholesterol or fats in the blood), malnutrition (insufficient nutrient intake), bipolar disorder (mood disorder with manic and depressive episodes), dysphagia following cerebral infarction (difficulty swallowing after stroke), unspecified protein-calorie malnutrition (general deficiency of protein and calories), and constipation (infrequent or difficult bowel movements).During observation on 12/2/25 at 9:18 a.m., the surveyor observed R109 receiving oxygen via nasal cannula.During observation on 12/2/25 at 2:09 p.m., the surveyor again observed R109 receiving oxygen via nasal cannula.During observation on 12/3/25 at 7:11 a.m., the surveyor again observed R109 receiving oxygen via nasal cannula.Record review on 12/2/25 revealed no physician's order for oxygen therapy for R109. The medical record lacked documentation authorizing oxygen use, including the liter flow rate, route of administration, or parameters for use. There was no documentation indicating oxygen therapy had been initiated per provider order or that the provider had been notified the resident was receiving oxygen.During an interview on 12/3/25 at 1:23 p.m., nursing assistant (NA)-A stated R109 received oxygen via nasal cannula continuously.During an interview on 12/3/25 at 2:38 p.m., licensed practical nurse (LPN)-D stated R109 received oxygen continuously and the oxygen was set at 2 liters per minute. LPN-D reviewed R109's medical record, confirmed R109 was receiving oxygen, and acknowledged there was no active physician's order for oxygen therapy in the medical record.During an interview on 12/4/25 at 11:45 a.m., the assistant director of nursing (ADON) stated R109 had been receiving oxygen since admission on [DATE]. The ADON reviewed R109's electronic medical record and confirmed there were no orders for oxygen. The ADON stated it was important to have an order for oxygen to ensure the correct flow rate was used, for staff to monitor oxygen saturations, and to ensure oxygen equipment was changed on a regular basis.During an interview on 12/4/25 at 12:57 p.m., the Director of Nursing (DON) stated oxygen therapy should only have been initiated with a physician's order specifying the flow rate and parameters for use. The DON acknowledged R109 was receiving oxygen without an order and confirmed this was not consistent with facility expectations or professional standards of practice.A facility policy regarding the initiation, monitoring, and discontinuation of oxygen therapy, including requirements for physician orders and documentation, was requested but was not received.

Based on interview and document review, the facility failed to implement individualized interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who sustained fractures after a fall from bed, and required emergency medical care. Findings include: R1's significant change Minimum Data Set (MDS) Falls CAA (Care Area Assessment) Worksheet, dated 11/6/24, identified R1 was diagnosed with vascular dementia, end stage chronic disease, diabetes, bipolar disorder, and pain syndrome. She required staff assistance and triggered falls related to daily scheduled antianxiety medications. She was free of falls in the past year. She was enrolled in hospice (end of life) care since 6/2022. R1 was non-ambulatory and was bed-bound. At times, R1 lacked verbal responses and was impacted by flexion contracture of the upper extremity. R1's quarterly MDS, dated [DATE], identified severe cognitive impairment. R1 required overall dependence on staff for her activities of daily living (ADLs) with substantial/maximal assistance for rolling from side to side while in bed. R1's diagnoses included, but not limited to, stroke, chronic pain syndrome, and moderate vascular dementia. Additionally, R1 continued with hospice and displayed episodes of bowel and bladder incontinence. R1 was free of falls in the previous three months. R1's admission Record, printed 7/7/25, identified the following additional diagnoses: obsessive-compulsive disorder (mental health condition with unwanted thoughts and repetitive behaviors), fibromyalgia (long-term condition causing widespread body pain, fatigue, etc.), and weakness. R1's comprehensive care plan, identified, on 5/31/24, R1 was determined to have an ADL deficit related to many of the above diagnoses along with back contractures that caused her to lean forward at times. One of the two goals was to remain free of falls/sliding out of bed to the floor. Interventions directed R1 to be laid down around 7:00 p.m. - 7:30 p.m. and if R1 was agitated, she was to be up in the broda chair (specialized chair to help support head, neck, spine) by the nurses' station for observation. R1's comprehensive care plan, identified, on 5/31/24, R1 had a history of falls with risk factors related to morbid obesity, right sided weakness secondary to her history of stroke, gout (form of arthritis), COPD (chronic obstructive pulmonary disease), chronic pain, incontinence, dementia and end state renal disease. [R1] becomes agitated and restless at times. R1's goal was to remain free of falls. On 6/12/25, interventions directed a few of the following: bariatric bed for comfort and to help prevent falls from bed, broda chair for comfort, and Place in staff view when restless. R1's comprehensive care plan, identified on 5/31/24, R1 had a potential for altered mood state due to bipolar disorder with depression and anxiety where she was anxious and/or hot at times and will take blankets off. Additionally, she had episodes of restlessness, asking repetitive questions, and/or yelling out for her brother when he is not there. Goal was for R1 to be less anxious after staff interventions. Interventions directed medications per physician orders, to provide reassurance and TLC (tender loving care), and to remind resident to use distraction strategies when worried such as deep breathing, watching TV, and to assist with re-dressing with encouragement to keep clothing on. R1's June 2025, Medication Administration Record (MAR), identified an order for lorazepam (anti-anxiety) medication every four hours with an evening dose scheduled at 6:00 p.m., along with every four hours as needed (PRN) dosing. The MAR identified no PRN dosing was administered. An Administration Details report printed 7/9/25, identified R1 was administered the scheduled 6:00 p.m. lorazepam at 5:05 p.m. R1's June 2025 Medication Administration Record (TAR), identified staff documentation each shift for Non-Pharmacological Pain Interventions. 6/12/25's, evening section identified a 0 correlating to No interventions needed. Additionally, another section instructed each shift for the nurse to offer pain medication and anti-anxiety medication throughout the shift as R1 would often not ask for these medications. Documentation for this identified a 0. A Found on Floor Risk Management report, dated 6/12/25 at 7:45 p.m., identified the 6/12/25, progress note information, along with information R1's pain level was assessed at a 3 based on R1's negative vocalization (occasional moan or groan, low level of speech with a negative quality), her facial expression (sad, frightened, frown) and her body language (tensed, distressed pacing). The report indicated R1 was Agitated, forgetful, confused, did not always realize her limitations, and had dementia. An immediate interaction initiated was to Check and change after dinner [supper]. A section labeled Predisposing Situation Factors (i.e., rolled out of bed, reaching for something, exhibiting behaviors, toileting needs, responding to hunger/thirst needs, other, etc.,) lacked indication of any such identified factors. The report lacked additional details to R1's agitation and/or any possibly associated behaviors. Additionally, the report lacked identification of potential issues related to care plan intervention implementation concerns. A progress note, dated 6/12/25 at 9:48 p.m., identified R1 was found on the floor (earlier in the shift) after her roommate updated staff to this location. R1 responded to staff she fell after they attempted to question her on fall details. An assessment was free of signs and/or symptoms (s/s) of injury, but she endorsed arm and back pain. The note identified R1 did not hit her head. She was checked and changed (for incontinence) around 7:45 p.m. (after the fall and returned to bed). Daughter, hospice, and on-call (facility) nurse were contacted. A hospice note, dated 6/12/25, indicated R1 was assessed by registered nurse (RN)-B due to an unwitnessed fall from bed while R1 attempted to self-transfer. The assessment was free of fracture s/s. R1 was unable to verbalize pain. She laid in bed comfortably but appeared anxious and pulled at her clothing. A Task Follow Up Question Report, dated 6/12/25, identified a section labeled Behavior. That day, documentation occurred at 12:04 a.m., 12:49 p.m., 9:01 p.m., and 10:54 p.m. Each time frame identified the following questions: Number of times behavior occurred during your shift, Behavior Approaches, Trend. All time-frame responses were charted Not Applicable. The 9:01 p.m. entry was documented by nursing assistant (NA)-A. The report lacked indication of what behavior(s) were monitored or indication of R1's agitation/restlessness that shift. A progress note, dated 6/13/25, indicated the interdisciplinary team (IDT) meet and reviewed the fall. They identified R1 fell from bed after dinner [supper] when she became restless due to needing her brief to be changed and fell. R1 at times had difficulty verbalizing her needs and thus staff anticipated these. R1 was on psychotropic and narcotic medications. No injuries were identified. An intervention was implemented to check and change R1 after dinner (supper). The nurse practitioner (NP) and the daughter were updated. The note lacked evidence there was identification there were care plan implementation concerns. R1's medical record, information dated between 6/12/25 and 6/19/25, lacked evidence R1 showed a significant increase in pain from her baseline, and/or left arm swelling. On 6/20/25, a progress note indicated R1's left arm was painful to touch with facial grimacing that morning. The area was free of redness and swelling. Staff questioned on possible reasons for the pain with no reasons identified. R1 was assessed additionally by a hospice nurse and no s/s of injury were identified. On 6/22/25, a progress note indicated R1's left arm was swollen. After hospice assessed, an x-ray order was placed. A left elbow x-ray Final Report, dated 6/23/25, identified the following: There is a transverse fracture of the distal humerus extending from the medial to the lateral epicondyle. There are no dislocations. There is considerable soft tissue swelling adjacent to the facture. Impression: Distal humeral intra-articular fracture. Emergency Department (ED) Orthopedic Surgery Consultation/H&P progress note, dated 6/23/25, identified repeat x-rays were obtained which identified left supracondylar humerus fracture with mild extension deformity. Additionally, other injuries were noted on post splinting x-rays which included a proximal radial shaft fracture. Due to this, and R1's endorsement of some degree of potential pain, a left forearm and left hip x-rays were ordered; however, despite recommendations to stay for continued assessment, the daughter wished R1 returned to the nursing home and R1 was discharged back to the nursing home against medical advice (AMA). R1's progress notes, and a facility Risk Management Incident Report log, lacked evidence R1 was involved in any additional incidents between her 6/12/25 fall and 6/22/25, which may have contributed to the fracture diagnoses. NAR (nursing assistant) Care Sheets, provided 7/7/25, directed R1 was to be checked and changed after dinner [supper], check, change and reposition every two hours, keep close to the nurses' station, use pillows to position in bed, and when agitated, get up in the wheelchair. Care Sheets for 6/12/25 were requested; however, interviews identified these sheets were not saved. When interviewed via telephone on 7/7/25, at 12:14 p.m., R1's family member (FM)-A expressed significant concerns related to R1's post-fall management and fracture identification. FM-A explained it should not have taken a family assessment of R1's expressed pain to determine there was an issue. FM-A endorsed continued concerns related to R1's status after the fall as R1 appeared heavily sedated and drooling, where she was unable to control her mouth muscles. Additionally, R1 slept more than normal and was not talking. FM-A stated there were conversations R1 was going to graduate from hospice due to her overall stability; however, now R1 needed continued hospice support because of the fall and her associated declines. FM-A explained, prior to the fall, R1 was able to use her left arm to assist herself with eating. Now, due to the fall and the fracture, she was dependent on staff for meals and R1 was barely eating. FM-A reported she visited R1 often, and at times during these visits, R1 moved her legs a little bit, but otherwise stayed where staff placed her. On 7/7/25, at 1:23 p.m., and on 7/8/25, at 10:11 a.m., interactions with R1 were attempted; however, there were no verbal responses elicited. When interviewed via telephone on 7/8/25, at 11:33 a.m., hospice RN-A stated that prior to R1's fall, R1 was able to eat independently with setup, was at baseline, and was free of any significant declines. After the fall, and in response to the fall, R1 displayed more pain and sounds like she is eating less. They are now having to help her eat. During a telephone interview on 7/8/25, at 12:08 p.m., RN-B stated that on 6/12/25, during her assessment, she identified contractures to R1's left arm but did not identify any fracture concerns, nor did R1 show any increased pain. However, R1 pulled on her clothing and appeared anxious. RN-B indicated she questioned staff on this, as she had not worked with R1 before, to which staff reported this was typical for R1. When interviewed via telephone on 7/8/25, at 1:13 p.m., R1's nurse practitioner (NP)-A stated R1's status fluctuated based on the day and time and R1 was so difficult to read; however, prior to the fall, R1 was overall stable, where hospice contemplated discharging her, but due to the fall, this did not occur. NP-A stated R1 overall looks about the same. but maybe [she was] not eating as much. NP-A identified she had not assessed R1 after her fall and/or after she was alerted to the x-ray results. NP-A indicated pain management was the main goal for R1 which was primarily managed by hospice. NP-A stated fracture associated swelling could show up basically any time after a fall which was dependent on each patient individually. She was unable to estimate when she would expect such swelling to show up with R1. During an interview on 7/8/25, at 2:28 p.m., licensed practical nurse (LPN)-B stated, other than the fall on 6/12/25, she was unaware of any additional incidents/events related to R1. LPN-B explained R1 fell during the evening medication pass and R1's only complaints during the fall assessment were arm and back pain, which were not new complaints for R1 due to generalized pain. LPN-B indicated R1 had episodes where R1 took off her gown and staff had to keep putting it back on: It was one of those nights. LPN-B further explained that evening, R1 also attempted to get her legs off the bed which prompted multiple encounters of repositioning R1 to her back. Due to R1 being provided her bedtime medication, she was unable to give R1 any additional medications for the gown removal and leg actions. It was approximately 10 to 15 minutes after staff last repositioned R1 due to these actions that she was found on the floor: [the fall] happened quick. LPN-B indicated R1's intake after the fall had lessened due to no longer being able to use her left hand to help herself eat, and she was more quiet, and sleeping more, but overall, she did not feel R1 showed any additional declines. When interviewed via telephone on 7/9/25, at 10:56 a.m., NA-A stated she reviewed the NAR group sheets for resident fall interventions and was expected to ensure these were implemented. NA-A identified she was R1's primary NA on 6/12/25 and placed R1 into bed for the night after evening cares, about 30 minutes after R1 finished supper: Maybe around 6:30 p.m. NA-A explained, that evening, R1 was restless the whole shift, and she had not witnessed such restlessness from R1 before. Typically, R1 was restless in the evening, but typically only removed her gown; however, that shift, R1 kicked out the pillows they used for positioning which was abnormal for [R1]. Additionally, R1 took off her gown, the blankets, pillows, everything. Both herself and the nurse had to replace the gown, the pillows, and reposition R1 multiple times when they checked on her. NA-A was unsure as to why R1 was restless, as when she attempted communication with R1, R1 would just look at her. In response, NA-A identified she told R1 to calm down and to tell her if she needed anything. NA-A stated, despite R1's restlessness, R1 remained in bed. NA-A reported, at the time of R1's fall, she was on break; however, identified there were times before that when R1 was not in view of staff. NA-A indicated that on 6/12/25 she was unaware R1's care plan directed R1 to be kept in view of staff when she was restless or a designated bedtime. During a follow-up telephone call on 7/9/25, at 11:08 p.m., LPN-B stated she was expected to follow fall interventions identified in the care plan, on the group sheets, and on the treatment administration record (TAR). She was unaware during the interview of what these interventions were for R1 on 6/12/25, but she stated all R1's fall interventions were followed that shift prior to the fall. Since the fall, R1 now had a fall mat on the one side that she tries to swing herself off of. LPN-B indicated R1 had shifts where she was more agitated with attempts to take her clothing off and thus when R1 was out of bed, she was placed in the hallway and visible by the nurse's medication cart unless engaged in activities. LPN-B expressed that R1's care plan, as directed on 6/12/25, should have specified what to do with her after she was placed into bed for the evening, and she became restless versus just the direction of place in staff view when restless. LPN-B indicated she would have known how to interpret this intervention if it were day hours; however, was unsure what that would have meant during bedtime. LPN-B explained R1 started to become restless once staff put her into bed on 6/12/25, which she suspected was around 7:00 p.m. or so. LPN-B identified R1 remained in bed that evening, despite her restlessness, and there were periods of time R1 was not within view of staff prior to her fall. When interviewed on 7/9/25, at 12:41 p.m., the assistant director of nursing (ADON) identified herself as R1's unit manager and stated she expected staff to follow the care plan, the Kardex (care plan driven summarization of designated interventions), and NAR group sheets at all times. The ADON explained that typically R1 was outside of her room and was expected to be by the nurse's station and/or medication cart to be within view of staff; however, she followed up with R1 did not require 24-hour supervision. The ADON stated staff put [R1] to bed too early right after dinner [supper], as R1 normally stays up for a bit, at least until after 7:00 p.m. Additionally, she stated, if [R1] is restless, that means she probably does not want to lay down. The ADON was questioned on her understanding of R1's 6/12/25, intervention to keep in line of site of staff when restless and indicated this was open to interpretation and was unable to comment further on this intervention expectation. In follow-up however, she indicated this was one of the reasons this was adjusted after the fall. If R1 was restless, she expected the NA would have alerted the nurse, the nurse would have assessed and hopefully determined R1 did not want to lay down as it was too early. Additionally, non-pharmacological interventions should have been utilized such as ensuring the fan was on as maybe she was hot, and if those such interventions were not effective, utilization of as needed medication(s) would be tried. If those still did not decrease the restlessness, provider contact was to be completed. During this, staff should have reviewed the NAR group sheets to which they would have noted the fall interventions and maybe one of them would have made a difference. During an interview on 7/9/25, at 2:23 p.m., the director of nursing (DON) stated she expected staff to follow the care planned fall interventions: Simple as that. Potential risk factors of not following these increased fall risk, and thus, injury risk. When questioned on the expectation for R1's fall intervention of in view of staff when restless, she indicated this was vague; however, identified this meant in a public space where staff are commonly stationed and can easily turn their head and view her.out of her room. Due to this, when R1 was restless, she should have been placed in her chair and brought out of her room. When interviewed on 7/9/25, at 3:14 p.m., the administrator expected staff to follow the care plan and NAR group sheets as these identified fall interventions in which both sources were expected to match each other. Due to this, the group sheets were printed daily, or when changes were made during the shift. She indicated staff did not use the Kardex due to this process. If staff questioned information on these, she stated she expected they referred to the nurse or the nurse manager. The administrator explained, after R1's fall, they initiated an internal investigation; however, information provided to them at that time, compared to information received from staff after the surveyor entered the facility, differed slightly. This difference centered overall on R1's restless behaviors prior to the fall and staffs' response to her restlessness. It was her understanding, once LPN-B contacted the on-call nurse manager, it was identified the care plan was followed that evening. If care plan issues would have been identified that evening, or during their investigation, the course of their investigation would have looked different. The administrator explained R1 was typically outside of her room by the nurse's station, and if she was restless, staff were expected to monitor R1 and additionally expected staff followed the intervention at that time for place her in view of staff. Due to some confusion about this intervention, this intervention was updated to provide more details to staff. Based on their investigation, the administrator indicated the fracture resulted from the fall on 6/12/25, especially as she was found on her left side. During a follow-up telephone interview on 7/9/25, at 4:30 p.m., NP-A stated she expected the fall care plan interventions to be followed and explained R1's care plan intervention for staff viewing when restless meant bringing R1 closer to the nurse's station that included getting her up out of bed. NP-A indicated she was not aware of concerns surrounding R1's fall and care plan interventions not being followed. A Care Planning policy, dated 1/6/22, identified interventions where derived from a thorough analysis of the information gathered as part of the comprehensive assessment (significant change MDS process) with a goal to identify problem areas and their causes and for the interventions to be targeted and meaningful to the resident. This was then used to develop the resident's daily care routines and was to be utilized by staff for the purposes of providing care or services to the resident. A Fall Prevention and Management policy, dated 2/2024, identified as part of its policy statement that one purpose of the protocol was to implement fall prevention interventions. The policy directed staff to identify interventions related to the resident's specific risks and causes to assist in fall prevention and fall complication minimization.

Based on interview and document review, the facility failed to initiate cardiopulmonary resuscitation (CPR) in accordance with Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) when R3 was found absent of pulse and respirations, CPR was not initiated and R3 died . The facility implemented corrective action, so the deficient practice is being issued at past non-compliance. The IJ began on [DATE], when R1 was found unresponsive without a pulse or respirations, CPR was not initiated. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 4:29 p.m. The facility implemented corrective action on [DATE], prior to the start of the survey and was issued at past non-compliance. Findings include: R3's Face Sheet printed [DATE], indicated R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated he was cognitively intact. R3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 1:36 a.m. a progress note indicated nursing assistant (NA)-A reported to registered nurse (RN)-A R3 was having chest pain, nausea, and trouble breathing. On [DATE], at 1:43 a.m. a progress note indicated RN-A went into R3's room. R3's oxygen level was low, and he had increased respirations. RN-A told R3 she would be sending him to the hospital. On [DATE], at 1:47 a.m. a progress note indicated RN-A left R3's room to call 911. The progress note indicated RN-A went downstairs to make copies of paperwork which would go with EMS when they arrived to take R3 to the hospital. Review of the facility investigation that included camera footage indicated on [DATE], at 1:43 a.m. RN-A entered R3's room. At 1:47 a.m. RN-A left R3's room, grabbed paperwork, then went downstairs. At 1:57 a.m. RN-A placed a call (presumably to 911). At 2:05 a.m. RN-A returned to R3's room. At 2:06 a.m. RN-A exited R3's room. At 2:06 a.m. emergency medical services (EMS) arrived on the unit, and RN-A greeted them at the elevator door. At 2:07 a.m. RN-A and EMS went into R3's room. On [DATE], at 11:09 a.m. RN-A was interviewed. RN-A stated when she had left R3's room at 1:47 a.m., R3 was still breathing and had a pulse. RN-A stated she began multitasking, which included making copies of R3's paperwork which would be sent with EMS and calling 911. RN-A stated she looked at R3's code status and saw he was full code status, which meant he should have CPR. RN-A stated she reentered R3's room at 2:05 a.m. RN-A stated she believed R3 had died , and she left the room, and did not initiate CPR, because R3 was dead. RN-A stated she went back into R3's room with EMS at 2:07 a.m. and she told EMS she believed R3 was dead. RN-A stated EMS contacted their Medical Patrol who advised no lifesaving interventions. R3 had died . On [DATE], at 12:50 p.m. the director of nursing (DON) was interviewed and stated RN-A should have initiated CPR immediately when she went back into R3's room and found him without a pulse and respirations. The facility policy Cardiopulmonary Resuscitation dated ,d+[DATE], directed basic life support (BLS), including CPR, will be provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The IJ was removed and the deficient practice corrected by [DATE], when the facility implemented a systemic plan that included the following actions: Review of their CPR policy on [DATE], re-education of all nursing staff on the CPR policy on [DATE], and [DATE], review of all resident's code status for accuracy [DATE], and conducting mock code drills for for CPR on [DATE], and [DATE]. This was verifed through staff interviews on [DATE], from approximately 12:00 p.m. through 1:00 p.m. and policy review on [DATE], at approximately 1:10 p.m.

Based on interview and document review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) in accordance with Provider Orders for Life-Sustaining Treatment (POLST) for 1 of 3 residents, found without a pulse or respirations. CPR was not immediately initiated and R1 died . This deficient practice had the potential to affect 34 of 81 residents who resided at the facility and who had orders for CPR to be performed. The Immediate Jeopardy (IJ) began on [DATE], at 10:55 a.m. when R1 was found without a pulse or respirations, and CPR was not immediately initiated. The administrator and director of nursing (DON) were informed of the IJ on [DATE], at 4:43 p.m. The facility implemented corrective action as of [DATE], therefore the deficiency is being cited as past non-compliance. Findings include: R1's admission record dated [DATE], indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 12. This score is indicative of moderate memory impairment. R1's Provider Orders for Life Sustaining Treatment (POLST) dated [DATE], indicated R1 wished to have cardiopulmonary resuscitation (CPR) attempts performed if he was found to be without a pulse or respirations. R1's progress note dated [DATE], indicated on [DATE], at 9:30 a.m., R1 was given medication at 9:30 a.m. R1 received assistance to sit up on the side of the bed. A tray table was placed in front of R1 and R1 proceeded to take his medication without any issues. Facility internal investigation document entitled, Witness/Observer Statement dated [DATE], indicated nursing assistant (NA)-A observed R1 sitting on his bed at about 10:00 a.m. At about 10:30 a.m., NA-A entered R1's room and found R1 lying across the bed. NA-A further stated, I called out to [R1] and [R1] didn't respond, so I went closer to [R1] and touched [R1] and tried to shake him awake and [R1] didn't wake up so I went to get the nurse. R1's progress notes dated [DATE], indicated on [DATE], at 10:50 a.m., licensed practical nurse (LPN)-A was distributing medications to residents when NA-A asked LPN-A to come to R1's room. NA-A stated she believed R1 was dead. During interview on [DATE], at 1:41 p.m., LPN-A stated NA-A reported R1 was lying crosswise on the bed and did not respond to verbal or physical prompts. NA-A stated R1 had died . LPN-A responded to R1's room at about 10:55 a.m. LPN-A stated, I found [R1] lying across the bed, he was not dressed. I helped [NA-A] get him into the bed and covered him. R1's extremities were cool to the touch, arms were cold. [R1] was pulseless. [R1] was probably down 5 to 10 minutes. I left the room to get my stethoscope. [R1] had no heart tones or breath sounds. I left and went downstairs to get the DON. The DON saw the resident and called coroner. During interview on [DATE], at 2:10 p.m., DON stated, I was working in the transitional care until and was summoned by [LPN-A] who needed me to come upstairs. [LPN-A] told her everything was OK an hour and a half ago. [NA-A] found [R1] lying across the bed, eyes open and cool to the touch. DON stated, I came in with a stethoscope, R1 was cool to the touch. [R1] was African American so I could not see pallor or lividity. [R1] was down for an unknown amount of time. [R1's] core was warm, but extremities were cold, eyes were glassy, and pupils were fixed. There was no way CPR would bring [R1] back. After examining [R1] I called the coroner. The coroner said CPR would not have helped him. DON stated she did not check R1's code status. In a publication by The American Heart Association (AHA), the organization established all potential rescuers to initiate cardiopulmonary resuscitation (CPR) with the following exceptions. Withholding and Withdrawing CPR (Termination of Resuscitative Efforts) Related to Out-of- Hospital [CONDITION(S)], Criteria for Not Starting CPR. While the general rule is to provide emergency treatment to a victim of [CONDITION(S)], there are a few exceptions where withholding CPR would be considered appropriate: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril (e.g., exposure to infectious diseases). Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, decomposition). A valid advance directive, a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .polst.org) indicating that resuscitation is not desired, or a valid Do Not Attempt Resuscitation (DNAR) order. [NAME] ME, [NAME] DS, [NAME] TA, [NAME] KD, [NAME] MH, [NAME] JE, Munkwitz MM, [NAME] AR, [NAME] MR, [NAME] EH. Part 3: ethical issues: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.2015;132(suppl):S383-S396. (Circulation.2015;132[suppl 2]:S,d+[DATE].DOI: 10.1161/CIRXXX 4.) The facility policy entitled F,d+[DATE].24 Cardio-Pulmonary Resuscitation (CPR), revised ,d+[DATE], indicated: 6. When a resident if found breathless or pulseless, CPR is to be immediately initiated and prior to the arrival of emergency medical services unless any of the following apply: a. A valid Do Not Resuscitate (DNR) order is in place, advanced directive, and any related physician order b. Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividly, decapitation, transection, decomposition) are present. c. Initiating CPR could cause injury or peril to the rescuer. The IJ that began on [DATE], was corrected on [DATE] when the facility took action to correct the noncompliance and the removal was verified on [DATE]. The facility action included: chart review was done to ensure appropriate notifications had been made, nurse's CPR certification status and nurses license were verified, new and agency staff orientation checklist was reviewed, an initial record audit was conducted comparing the scanned POLST document in Point Click Care (PCC) with the banner of PCC and documented results, any code status issues for residents identified during audit were corrected, CPR policies were reviewed with the Interdisciplinary Team and nursing staff), all licensed nursing staff scheduled to work in the building were trained on code status policy, CPR certification status was verified for all nursing staff. Continuing measures included conducting code simulation drills and offering additional CPR classes.

Based on observation, interview and document review, the facility failed to notify physician and responsible party of refusal of medications for 2 of 3 residents (R1, R2) reviewed for significant change in condition. R1 sustained actual harm after missing 19 of 25 doses of [MEDICATION NAME] and was hospitalized for [REDACTED]. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], identified R1 had indicated it was Very Important to have family or a close friend to be involved in discussions about his cares. In addition, the admission MDS dated [DATE], identified R1 was cognitively intact, was not depressed and was not experiencing hallucinations, delusions or behaviors including, R1 was not refusing medications. R1's MDS indicated R1's guardian did not participate in the assessment process. R1's psychoactive medication care plan dated [DATE], identified R1 received antipsychotic medication for [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type (a mental health disorder including hallucinations or delusions,[MEDICAL CONDITIONS]) and instructed staff to monitor and document target behaviors/symptoms and evaluate for causes and contributing factors. R1's care plan dated [DATE], indicated R1 was oriented to person, place and time and desired facility staff to involve/family/responsible party in decision making. Care plan did not identify R1 had a guardian. Facility Order Listing report dated [DATE], indicated R1 had an order dated [DATE], for [MEDICATION NAME] ([MEDICATION NAME]) with instructions to give 15 milligrams (mg) by mouth at bedtime for [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type. R1's [DATE], Medication Administration Record [REDACTED]. Incident report dated [DATE], identified R1 had been refusing [MEDICATION NAME] since admission on [DATE], and had only taken it twice in the previous month. Report indicated R1 had been hospitalized on [DATE], due to behaviors. Incident report indicated no notifications R1's Clinical Resident Profile printed [DATE], indicated R1 had a guardian. Review of Order Appointing Successor Guardian dated [DATE], indicated R1 was a protected person and that The Ward (R1) remains an incapacitated person in need of assistance. The Ward lacks sufficient understanding to make or communicate responsible decisions. Guardianship order did not contain a specific order requiring R1 to take medications. Late Entry Progress Note (PN) dated [DATE], indicated that at approximately 8 a.m., R1 became increasingly more agitated when licensed practical nurse (LPN)-A was unable to locate a specific lotion and was not able to be redirected. When LPN-A brought R1's medication, R1 refused medications and yelled at LPN-A to get that slop referring to the breakfast tray away. R1 became more agitated when LPN-A asked if she could get something different. The progress note indicated R1 stated, Get away from me you f***ing [***] . R1 then stood up from recliner and lunged at LPN-A stating, I'm going to kill you. Progress note indicated 911 was called and R1 was transferred to the hospital. Review of progress notes (PN) from [DATE] until [DATE], revealed an increase in refusal of [MEDICATION NAME], delusions and escalating behaviors without clear communication of changes to medical provider or guardian. Progress note dated [DATE], indicated R1 had refused [MEDICATION NAME] and been up all night waiting for a car to arrive from Germany. R1's PN dated [DATE], indicated R1 stated he had not slept well for the last few nights, because his platoon leader has told him to watch for this car to be delivered from Germany. R1 was checking the parking lot frequently for the car. R1's PN dated [DATE], indicated R1 stated it was causing tremors. R1's PN, dated [DATE], indicated R1 refused his evening medications. Registered nurse (RN)-A wrote a note regarding medication refusal in the facility communication book for the nurse practitioner. R1's PN dated [DATE], indicated social worker (SW)-B spoke with R1's guardian regarding mail R1 had received. R1's guardian gave permission for R1 to have his expired ID card. The PN lacked documentation that SW-B informed R1's guardian that he was refusing medications or stating he had a car coming from Germany. R1's Care Conference Summary dated [DATE], indicated, nursing staff had discussed R1's medications, and indicated there were no nursing concerns. R1's refusal of medications was not addressed. Guardian was not notified of missed medications or behaviors. R1's PN, dated [DATE], indicated the SW-A spoke with R1's Veterans Administration social worker, guardian and foster home staff, regarding upcoming discharge back to foster home. There was no indication the SW-A, told them of R1's refusal [MEDICATION NAME] or increasing behaviors. R1's PN, dated [DATE], indicated R1 refused all evening medications, throwing them on the floor and stepping on them. There was no documentation of notifying medical provider or guardian of R1's actions. R1's PN, dated [DATE], at 1:33 p.m. the on call nurse practitioner (NP-A) was informed resident had refused his morning medications and was hanging out by the door. The progress note did not indicate if NP-A was informed of total number of missed doses and what medications were missed. NP-A instructed the nurse to reoffer the medications after R1 had eaten. R1's PN, dated [DATE] at 6:06 p.m. indicated R1 ordered RN-A out of his room, refusing his medications and blood sugar checks. The progress note also indicated R1 was constantly pacing. TCU (transitional care unit) Health East Communication Log (communication book for TCU staff to leave messages for NP-B) entry dated [DATE], indicated R1 had refused all medications except insulin and [MEDICATION NAME] for two day shifts stating they were making him crazy and tremor. Nurse Practitioner-B wrote back to the TCU nursing staff, Not our Pt (patient). TCU Health East Communication Log entry dated [DATE], regarding R1 indicated, staff had explained to R1 he needed to take medications and requested [MEDICATION NAME] be discontinued or change to as needed because R1 did not like how it made him feel. NP-B wrote back to the TCU nursing staff, Not our Pt During interview on [DATE], at 1:55 p.m. the director of nurses (DON) stated the staff had left a message in NP-B book twice instead of in NP-C's book. The DON stated NP-B just crossed out the information and wrote not our patient. During a follow up interview at 2:31 p.m., the DON stated the communication books were to be used for non life threatening issues. The DON stated staff assumed information put in the book was taken care of, but that there had been no system in place to ensure follow up had occurred. During interview on [DATE], at 3:03 pm RN-B, evening supervisor, stated residents have right to refuse medications. RN-B stated after three refusals, staff were to inform the doctor. If the medication was a high risk medication or resident was displaying a change in behaviors, the doctor should be immediately notified. RN-B stated he had never used the communication book, and would not use it for medication refusals. During interview on [DATE], at 3:11 p.m. RN-C stated she had noticed a significant change in R1. She was not his normal nurse but he liked to stop and talk with her. RN-C stated she had overheard R1 was refusing meds. RN-C stated she told one of the night nurses that R1 seemed to be getting more and more delirious. RN-C stated if a patient refused their medication, she would call the provider or write it in the communication book. RN-C verified she did not inform R1's guardian or physician of changes in behaviors. During interview on [DATE], at 9:17 a.m. VA care coordinator stated R1 was still at Regions Hospital and they were pursuing a court order for committal and a(NAME)(a court order allowing the giving of antipsychotic medications to a patient without their consent). She verified she had not been informed of missed medications or behaviors until the day after he was admitted to the hospital During interview on [DATE], at 9:27 a.m. VA social worker (VA SW) stated the facility social worker (SW)-A initially stated R1 missed two days of medications. The VA SW stated, when the VA care coordinator looked into R1's care, she found out R1 had missed most of his [MEDICATION NAME] during his stay. VA SW stated R1 has not had any issues in the two and a half years she had known him and had not required a(NAME)order during that time. On [DATE] at 9:33 a.m., NP-C returned phone call and verified facility had not told her R1 had been refusing [MEDICATION NAME] for the majority of his stay. NP-C was surprised to learn R1 had refused more than 10 dose. RN-C stated no one at facility told her. NP-C stated she saw R1 once on [DATE], and at that time, she was not aware of missed medications or behaviors. NP-C stated she would have expected to be notified in person or by phone of a patient on [MEDICATION NAME] refusing medication, because that would have been a significant medication concern that would cause the patient to suffer a mental collapse. NP-C verified NP-B was not R1's medical provider. During interview on [DATE], at 9:38 a.m. R1's guardian stated R1 was in Regions Hospital, trying to be stabilized. R1's guardian said, This was a big setback for (R1), it took them [AGE] years to get him stable and one month at Maplewood to destabilize him. R1's guardian indicated no one told her R1 was refusing medication. Guardian stated she expected to be called the first time R1 refused medications. R1's guardian stated she was not notified he was hospitalized until the next day. Guardian stated R1 was not able to make his own decisions. R2 R2's significant change MDS dated [DATE], indicated [DIAGNOSES REDACTED]. The MDS indicated R2 was unaware of season, staff faces, location of room or that he was in a nursing home. R2 has no indicators of depression but refused cares four to six days during the seven-day observation period. R2 required assistance with all ADLS including eating. MDS indicated R2 was on hospice. R2's sleep care plan dated [DATE], instructed staff to encourage activities during day. R2's [MEDICAL CONDITION] medication care plan dated [DATE], instructed staff to evaluate medical cause for changes in behavior, mood or anxiety level prior to use of or dose change for psychoactive medication, monitor for adverse effects of medication and report symptoms to medical provider. R2's mood care plan dated [DATE], indicated R2 was experiencing alteration in feelings of well being related to depression and R2 had expressed having thoughts of being better off dead. R2's care plan indicated he was on hospice. R2, was observed on [DATE], at 11:54 a.m. to be sitting in the day room, awake, appearing to be watching television. An Incident report dated [DATE], indicated R2 had missed antidepressant and antipsychotic medications seven times in the month of October due to R2 being asleep. Staff notified nurse practitioner and family of the incident on [DATE] at 9:00 a.m. R2's [DATE], Medication Administration Record [REDACTED]. R2 also had an order for [REDACTED]. During interview on [DATE], RN-D stated R2 was very hard to awaken. RN-D stated if R2 was sleeping she did not give him any medications. If R2 awoke more than an hour after the scheduled time for the medication, she did not offer it. RN-D stated she felt it would not be right to give a sedative to someone who was sleeping so soundly. RN-D stated she did not inform nurse practitioner, physician, hospice or family that she held R2's medications because he was sleeping. During interview on [DATE], at 2:23 p.m. the DON stated R2's medications were once a day medications, they could have been given later that day. The DON stated stopping those medications suddenly could have caused problems for the patient. The DON stated once issue was identified during audit notifications were completed. Verified the nurse had not notified anyone. The DON stated R2 was examined and nurse practitioner stated he suffered no harm. During interview on [DATE], at 1:20 p.m. NP-B stated she expected to be informed if a patient was not receiving medications due to not being able to awakened multiple days in a row.

Based on interview and document review, the facility failed to prevent an injury during transfer for 1 of 3 residents (R[AGE]6) reviewed for accidents. R[AGE]6 sustained harm when R[AGE]6 was inappropriately transferred without the use of a mechanical device and sustained a fracture to the right ankle. Although a deficient practice occurred, the provider had implemented corrective action on 7/29/19 therefore, this finding is being issued at past non-compliance. Findings include: R[AGE]6's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R[AGE]6 had severe cognitive impairment with a [DIAGNOSES REDACTED]. R[AGE]6's progress notes dated 7/26/19, at 4:15 p.m. included, NA (nursing assistant) called writer into the room to report right ankle discoloration to the skin. The right foot was inspected and there was discoloration. On lateral and medial aspect of ankle with a 2 inch linear red mark in the center of both, slight swelling to the top of the foot with pain when foot touched. The note indicated R[AGE]6 had called out, Ow my foot. Ice was applied for comfort. R[AGE]6's physician orders [REDACTED]. R[AGE]6's Portable X-Ray results obtained 7/26/20, at 10:40 p.m. included: Impression: 1. Acute to subacute mildly displaced fracture distal fibular metaphysis (narrow portion of a long bone). Acute to subacute mildly displaced fracture distal tibial metaphysis. 2. Mild osteopenia (reduced bone mass). 3. Mild degree of [MEDICAL CONDITION] (degeneration of cartilage). Facility documents indicated an incident was reported 7/27/19 included: Resident (R[AGE]6)noted to have swelling to right ankle. X-ray ordered with results as follows; acute to subacute mildly displaced fracture to distal fibular metaphysis and distal tibial metaphysis. Mild osteopenia. The facility follow up investigation dated 7/31/19, indicated, nursing assistant (NA)-F stated her and NA-G had transferred R[AGE]6 with a mechanical lift on 7/26/19, during the transfer the up button was accidentally pushed instead of the lower button and this caused R[AGE]6's foot to get stuck and push against the mechanical lift. When interviewed on [DATE], at 2:00 p.m. the director of nursing (DON) verified there was also a witness statement from 7/27/19, at 11:30 a.m. from NA-F who explained that they (she and NA-G) transferred (R[AGE]6) in the mechanical lift when (R[AGE]6's) foot got caught between the handle and the battery pack on the lift. The lift was pushed by NA-F to go up by accident and (R[AGE]6) foot got pinched between the battery pack and the bar. A facility document showed when interviewed by the DON on 7/29/19, no time specified, NA-G verified the total lift was used for the transfer with (R[AGE]6) and stated, I was the one pulling the sling back. I did hear (R[AGE]6) whimper. I think the mistake was when (NA-F) went up instead of down, foot got caught. The DON had NA-G perform a return demonstration using the mechanical device with (R[AGE]6) and explained to NA-G that something traumatic had to have occurred for (R[AGE]6) to have a fractured right ankle. They were unable to recreate the potential for R[AGE]6's foot to have been injured in this manner. A facility document dated 7/29/19, at 1:19 p.m. NA-G stated she, lied to the DON. NA-G stated with the help of NA-F, they transferred (R[AGE]6) by grabbing under the resident's arms, and used the back of (R[AGE]6's) pants to lift (R[AGE]6) up into the bed. A facility document dated 7/29/19, at 1:40 p.m. the DON called NA-F on the phone and verified they (NA-F and NA-G) lifted (R[AGE]6) up by the arms and transferred (R[AGE]6). They had (R[AGE]6) on the side of the bed and then plopped (R[AGE]6) into the chair. (R[AGE]6) legs were twisted, but neither NA could recall if (R[AGE]6) was able to bear any body weight or if (R[AGE]6's) right ankle touched the floor at all. When interviewed on 2/12/19, at 12:53 p.m. the DON verified NA-F and NA-G were initially suspended following the discovery of the right ankle fracture for R[AGE]6 pending investigation on 7/26/19, and were terminated 7/29/19, for failure to follow the care plan for R[AGE]6, failure to use the mechanical device for transfer as assessed, and failure to truthfully report what had occurred with the transfer on 7/26/19. A progress note from 7/29/19 included, Resident transported to St. John's hospital due to increased pain and internal rotation of the right ankle. While at the hospital, (R[AGE]6) underwent a conscious sedation for reduction of a right tib-fib fracture. Family notified of resident's condition. (R[AGE]6) returned to MCC (Maplewood Care Center) at 10:00 p.m. by E[CONDITION] (emergency medical services) (R[AGE]6) took all of (R[AGE]6) scheduled medications. (R[AGE]6) has no s/sx (sign/symptoms) of pain noted. Will continue to monitor. The facility policy for Investigation revised 12/19 indicated the investigation process is used to try and identify what happened. The nurse begins the investigation immediately and will include who was involved, resident participants, statements, involved staff and witness statements of event, a description of the environment at the time of the incident, injuries present and observation of resident and staff behaviors during the investigation. Corrective action for the past non-compliance that began on 7/26/19, was verified during the onsite visit 2/12/20 and 2/13/210, as having been implemented 7/29/19. Verification of the corrective action was accomplished by interview, chart review and review of educational documents and audits completed by the facility. Residents had been interviewed, nursing staff had been interviewed, and nursing staff were re-educated to the facility's accident reporting and investigation policies. Nursing staff were re-educated on the importance of proper transfer according to resident assessments.

Based on interview and document review, the facility failed to ensure documentation of a resident's cardio [MEDICAL CONDITION] resuscitation (CPR) code status was consistent throughout the medical record to ensure the resuscitation code status reflected the resident's current resuscitation preference. This resulted in an immediate jeopardy (IJ) finding for 1 of 1 resident (R1) who had changed her resuscitation preference to do not rescusitate (DNR), stopped breathing and had no pulse, but staff initiated CPR. The immediate jeopardy began on [DATE], after R1's resuscitation preference had changed from CPR to DNR and the change was not consistently documented throughout R1's medical record. R1 became unresponsive without a pulse or breathing and staff performed CPR for the resident who desired DNR code status. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE], at 6:03 p.m. The immediate jeopardy was removed on [DATE], but remained at a lower scope and severity level of D, no actual harm with potential for more than minimal harm at an isolated scope. Findings include: R1's PPS (prospective payment system) 5-day Minimum Data Set (MDS) assessment indicated R1 had been admitted from an acute hospital on [DATE], required extensive assistance with dressing and total assist with transfers, received oxygen, and was cognitively intact. R1's Admission Record identified [DIAGNOSES REDACTED]. R1's [DATE] hospital discharge paperwork, indicated a code status of DNR. R1's [DATE] electronic admission physician orders [REDACTED]. R1's hard copy (paper) Provider Orders for Life-Sustaining Treatment (POLST), was prepared by licensed practical nurse LPN-(A) and signed by R1. The date prepared was blank. The POLST directed staff to attempt CPR if patient had no pulse and was not breathing. The nurse practitioner (NP) signed the form on [DATE]. Although the date the POLST was prepared was blank, a review of the facility's schedule identified LPN-A had worked on [DATE] but had not worked any other days prior to the NP's signature. Although R1's resuscitation code status preference changed based on the POLST prepared [DATE], from DNR to CPR, the resident's electronic medical record was not modified, and continued to identify R1's code status as DNR in the physician's orders [REDACTED]. A review of R1's progress notes indicated R1 had been hospitalized on [DATE] for wheezing and difficulty breathing, and had returned to the facility on [DATE]. R1's [DATE] hospital discharge summary, indicated a code status of DNR. The summary included: Hospice was discussed during last hospitalization with patient deferred. She subsequently requested for hospice evaluation although her respiratory status returned to baseline. She reports depression. Psychiatry referral made for after discharge to rule out mood disorder prior to hospice. R1's [DATE] hospital discharge orders indicated her code status was: DNR Following hospital return, R1's electronic medical record (EMR) continued to identify R1's current resuscitation code status preference as DNR. The [DATE] admission physician order [REDACTED]. R1's electronic PCC profile identified R1's code preference as DNR. R1's electronic MAR indicated [REDACTED]. R1's [DATE] progress notes indicated on [DATE] at 10:40 p.m., a nursing assistant (unidentified) had reported to registered nurse (RN)-A, R1 was having a hard time breathing. The note indicated upon RN-A entering R1's room, R1 complained of difficulty breathing. R1 had oxygen on via nasal cannula. RN-A attempted, but was unable to get vital signs due to R1 flailing her arms. The documentation indicated RN-A had decided to transfer R1 to the hospital, and the nursing assistant remained in R1's room while RN-A obtained paperwork for the transfer, and an oxymask (oxygen delivery covering nose and mouth). RN-A also documented having informed the transitional care unit (TCU) staff paramedics were on the way prior to returning to R1's room. Once back in R1's room, while applying the oxymask, R1 went limp. At that time, RN-A reviewed R1's POLST which directed full code (CPR). RN-A started CPR and directed a nursing assistant to get the TCU nurse. The TCU nurse (unidentified) arrived stating R1 was gone. Paramedics arrived, followed by the police. The resident's time of death was identified as 11:10 p.m. The note lacked when and who determined to discontinue the CPR. During an interview on [DATE], at 2:26 p.m. RN-A stated a resident's resuscitation code status is to be consistent throughout a resident's medical record. RN-A stated there had been a system breakdown over the past couple of months, and stated she'd noticed each resident's POLST and electronic computer code status orders do not always match. RN-A stated she has spoken to a floor manager about the concern but could not remember when, or to whom, she spoken with. RN-A stated normally she would look for a resident's code status in the electronic EMR, but the POLST can also be used. RN-A stated when R1 became unresponsive, she reviewed the POLST in the envelope she had just copied for the hospital transport. RN-A stated the POLST indicated CPR so she'd initiated CPR. RN-A stated she sent nursing assistant (NA)-A to get the TCU nurse and registered nurse (RN)-B. RN-A stated she was exhausted when RN-B arrived. RN-A stated she continued with CPR even though RN-B stated she's (R1) gone. RN-A stated she stopped CPR when she was too exhausted to continue. RN-A stated she was focused on R1 and did not know for sure how long she'd performed CPR. RN-A stated the paramedics arrived a short time later, followed by the police. RN-A stated in reviewing R1's electronic record with the police, it was discovered R1's most recent resuscitation code status was not CPR, but was instead DNR. RN-A confirmed the hospital discharge orders from [DATE], indicated DNR. RN-A stated when a resident returns from the hospital a new POLST is to be completed, but this had not been done, and the POLST in R1's medical record had been determined to be outdated. During an interview on [DATE], at 10:17 a.m. RN-B stated in an emergency, if a resident was hospitalized in the last ,[DATE] days, she would look in the hospital discharge paperwork to find the resident's code status. RN-B stated for residents who have been at the facility over 2 days, she would refer to a resident's POLST for code status. RN-B stated upon admission or re-admission a nurse discusses the POLST with a resident, and stated the resident and nurse then sign the POLST. RN-B stated if a resident is unable to sign the POLST, the POLST is not completed until discussed with family or the power of attorney (POA). RN-B stated when discussing the POLST, if a resident has expressed a different resuscitation code status preference from the admission orders [REDACTED]. RN-B stated she would not call the MD for a code status order change. During the interview [DATE] at 10:17 a.m., RN-B also stated when she entered R1's room on [DATE], RN-A was performing CPR on R1. RN-B stated RN-A had stated she was exhausted and had asked RN-B to take over. RN-B stated she did not assist with CPR as there was no backboard or CPR mouth mask in the room. I did not feel comfortable stepping in and not doing it right. RN-B stated she watched RN-A perform CPR for approximately ,[DATE] minutes and did not attempt or direct staff to get a backboard or mouth mask. When RN-A stopped compressions, RN-B stated she assessed for vital signs. R1 was pulseless and was not breathing. RN-B stated at that time, she left the room to call family. During an interview on [DATE], at 11:09 a.m. LPN-A stated when R1 was originally admitted on [DATE], R1's admission orders [REDACTED]. LPN-A stated when discussing the POLST with R1, R1 had expressed a desire to change her resuscitation status to CPR. LPN-A stated she filled out the POLST to indicate the resident's wish for CPR to be conducted, and both she and R1 signed the form. LPN-A stated she had turned the paperwork into the heath unit coordinator (HUC) who was then to scan the paperwork into the medical record. LPN-A stated she believed the nurse manager also received the paperwork. LPN-A stated she was unsure whether the physician needed to sign the POLST. LPN-A stated she does not call the MD to get an order for [REDACTED]. During an interview on [DATE], at 9:40 a.m. registered nurse (RN)-C, a nurse manager, stated physician orders [REDACTED]. RN-C stated staff verify with the resident and family if the code status is the resident's current preference. In addition, at the time of admission, staff discuss the POLST with the resident. RN-C stated a resident's code status wishes should be honored, and stated if a resident wants to change their code status at any time, a new paper POLST form is completed and kept for the physician to sign. RN-C stated the electronic code status orders are not changed until the physician signs the POLST. RN-C stated the POLST and electronic orders may not match while the POLST awaits a physician's signature. RN-C further stated the physician was not called for a code status order change. RN-C stated staff are directed to look at the resident's electronic MAR indicated [REDACTED]. During an interview on [DATE], at 4:24 p.m. the director of nursing (DON) stated code status orders are obtained upon admission and entered into the electronic medical record. The DON stated the paper POLST is initiated by the floor nurse or nurse manager, having a conversation with the resident regarding code status wishes. If the resident's wishes are different than the orders, staff are to call the physician and obtain a new order that correlates with the resident's wishes. The DON reiterated a resident can change their code status wishes at any time, and stated a resident's electronic medical record and POLST are suppose to match. The DON stated when a resident is readmitted from the hospital, staff are to ensure the order and POLST match. The DON further added when a resident wants to receive CPR, CPR is to continue until the paramedics or physician give the order to stop. The DON stated re-education had been initiated after R1's code, but stated she was not confident everyone had received the re-education yet. The facility's [DATE] policy, Cardiopulmonary Resuscitation, included: The facility will have protocols in place to document and communicate throughout the facility, the resident's choices regarding: a. CPR Physician orders [REDACTED]. A change in resident preference or condition, c. Facilitation of how staff will honor resident choices. d. addressing how resident preferences and physician orders [REDACTED]. The policy lacked specific process directions and/or where to locate the resident's current code status. The facility's ,[DATE] policy Determination of Code Status, physician's orders [REDACTED]. -upon admission an explanation of CPR and DNR (do not resuscitate) are provided to resident and resident representative -Inform resident /representative of the need to obtain a choice regarding CPR or DNR in the event of a [MEDICAL CONDITION]. -Obtain a physician's orders [REDACTED]. -Follow facility/agency protocols to obtain physician signature on original document. Copy of document signed by resident/resident representative will be kept in the medical record, until original document is received and placed in medical record. -Resuscitation status will be reviewed upon readmission, with quarterly care conference and with a significant change. -With any change in resuscitation status, a new form will be completed with resident/resident representative and physician signatures. -If the resident is hospitalized or discharged to another facility, a copy of the form will accompany the resident. The immediate jeopardy that began on [DATE], was removed on [DATE] at 4:15 p.m., but non-compliance remained at the lower scope and severity level of a D, which indicated no actual harm with potential for more than minimum harm, isolated. The facility developed and implemented a removal plan which included the following interventions verified through interview and document review: -Audited all residents' medical records to ensure all residents current physician orders [REDACTED]. -Nurses were trained on location of code status in electronic record. On the resident's electronic Medication Administration Record, [REDACTED]. This in an immediate location for nurses to reference. On the dashboard in electronic medical record, under clinical alerts. -HUC's were trained to check that the POLST is filled out entirely, check orders and POLST reflect same information prior to scanning. Report discrepancy to licensed nurse immediately. -Nurse training initiated regarding the correct procedure for changes to the POLST and getting updated physician orders [REDACTED]. Nurses were educated on not only updating the POLST, but immediately calling the physician or nurse practitioner to obtain updated orders for resident's code status so that the resident's most current wishes are reflected in the electronic medical record. All nurse working received training and to ensure all nurses have training prior to working daily schedule will be crossed referenced to master nurse list for training needs. -Policy for CPR was reviewed and updated.

Based on observation, interview, and document review, the facility failed to complete a comprehensive fall risk assessment and implement fall interventions to assist in preventing further falls for 1 of 1 residents (R97) who sustained multiple falls, which resulted in actual harm to R97 who sustained a [MEDICAL CONDITION]; failed to ensure staff followed facility policy during a mechanical lift transfer for 1 of 1 residents (R25) who was transferred with one assist and began to fall from the lift, which resulted in actual harm to R25 who sustained a large hematoma (bruise) and skin blister; and failed to ensure residents were as free from accident hazards as possible for 1 of 7 residents (R32) whose oxygen tank was refilled in a resident room. Findings include: R97 stated on 1/7/19, at 1:15 p.m. that she had a broken right hip. When asked how R97 had broken the hip, R97 stated the fracture had happened when R97 tripped over her feet in the elevator, when going out to smoke. R97 stated no staff were present when she tripped. At 5:25 p.m. R97 was interviewed again regarding the fall, which resulted in R97's right [MEDICAL CONDITION]. This time R97 stated she had fallen in front of the elevator when going to smoke. R97 again stated no staff were present when the fall occurred. R97's care plan revision dated 10/11/18, indicated R97 had become a fall risk due to the following: incontinence, [MEDICAL CONDITION] and narcotic medication use, and impaired cognition. Staff were to make sure R97 was wearing gripper socks or appropriate footwear when ambulating or when in a wheelchair. The care plan lacked direction regarding strategies to use to ensure R97 was wearing appropriate footwear, as well as other interventions or strategies after a pattern of falls. Record review of fall incidents from 10/10/18 to 12/28/18 revealed: - On 10/10/18, R97 reported to a dietary aide at 4:20 p.m. R97 had fallen that morning. R97 told the dietary aide she had tripped and fallen to her knees on the sidewalk. R97 was able to get up and did not tell anyone until telling the dietary aide. The report indicated a night nursing assistant was interviewed and indicated R97 had been up twice during the night. The report noted R97's shoes were falling apart and R97 could have tripped on an uneven sidewalk, as R97 was known to shuffle her feet when walking. The report indicated there had been a recent rain, as the ground was wet and it was dark at the time of the fall. There was no indication in the report that R97's shoes were replaced, but an intervention identified on the report was to encourage R97 to wear proper fitting shoes. The report addressed R97's mental status, indicating R97 knew the limits of her abilities to ambulate safely. Record review revealed R97's care plan was updated to include intervention to encourage appropriate footwear. - On 11/4/18, R97 was found outside at 4:30 a.m. smoking and lying on the ground. R97 reported having gone outside to smoke and denied being hurt. The report indicated there were no slippery surfaces and R97 may have fallen from dizziness, as R97 was going outside to smoke more frequently and sleeping less. The report also indicated R97 was wearing slippers at the time of the fall, and had potentially lost her footing when walking and fell . Fall report lacked evidence of a root cause analysis (identified pattern, time of falls, sleeping concerns, etc.) and additionally did not include a recognition the care plan was not followed or retraining occurred with responsible staff. - On 12/6/18, R97 went out to smoke as R97 usually did every morning around 4:30 - 5:00 a.m. The report indicated that on the way back to R97's room on the third floor R97 had fallen on the first floor and was found sitting on the floor. According to the report R97 stated I just fell I'm alright, I went to smoke a cigarette. R97 was advised not to go down to the first floor to go outside by herself to smoke. R97 then requested pain medication and went back down to the first floor to smoke. Staff tried, but were unable to stop R97 from going outside again. Fall report lacked evidence the care plan was implemented or a root cause analysis was completed and as a result, no additional intervention were considered to reduce R97's potential to fall while independently smoking. - On 12/24/18, the night nurse reported R97 had fallen outside while going to smoke at 5:45 a.m. and was witnessed by a phlebotomist. The report indicated R97 had a recent hospitalization for pneumonia, was weaker, shuffled when walking, and overstated or forgot her limitations regarding the ability to ambulate safely. A decline was expected due to a [DIAGNOSES REDACTED]. Fall report lacked evidence of a root cause analysis, implementation of interventions based on change in condition nor evidence of a smoking re-assessment due to change in care needs. - On 12/28/18 at 6:00 a.m. R97 fell in the elevator on the first floor, on the way outside for a cigarette and was found by two nursing assistants. R97 was unable to get up on her own and the two nursing assistants assisted R97 off the floor and into a wheelchair. R97 at the time was refusing to go to the hospital and was exhibiting facial grimacing. R97 was given [MEDICATION NAME] and the anti-anxiety medication [MEDICATION NAME] for the pain. A progress note dated 12/28/18, at 9:02 a.m. indicated R97 did agree to go to the hospital; and at 11:01 a.m. a progress note indicated R97 had a fractured right hip and was scheduled for surgery that afternoon. A smoking assessment for R97 was found in a 10/3/18, document titled Social Service Data Collection-V4. The assessment indicated R97 smoked daily, displayed cognitive deficits, and when observed smoking there were no issues with safe handling of cigarettes/lighters, there were no holes in clothing and [MEDICAL CONDITION] the fingers. R97 was determined to be independent with smoking. No other smoking assessment had been completed until after the [MEDICAL CONDITION]. The smoking assessment completed on 1/4/19, indicated R97 had not smoked since the 12/28/18, hospitalization . A document titled Smoking Policy, Effective (MONTH) (YEAR), was signed by R97 on 7/4/18. The policy indicated smoking times were from 5:00 a.m. to 11:00 p.m. That due to safety, no resident was to be outside smoking between the hours of 11:00 p.m. and 5:00 a.m. The policy indicated that if a resident could not smoke independently, the resident would only be allowed to smoke with family or visitors in the designated smoking area at the South of the building. The policy also indicated Staff will not be required to supervise smoking. A Berg Balance Scale assessment dated [DATE], indicated R97's total score was 42 indicating R97 was at risk for falls as a score equal to or less than 50/56 indicated a risk of falls. R97 started physical therapy six times a week for the period dated 7/2-9/28/18. The assessment indicated R97 was identified as requiring partial to moderate assist with lying to sitting on the side of bed; sitting to lying; rolling left and right; chair or bed to chair transfer and toileting; supervision with sit to stand and was able to walk with assist 10-49 feet. There was no indication R97's ability to safely ambulate or attempt interventions to reduce risk of falls outside while smoking had been reassessed after any of the falls. On 1/7/19, at 5:19 p.m. licensed practical nurse (LPN)-E stated R97 had a history of [REDACTED]. LPN-E stated staff did not go out to the smoking gazebo with residents and did not take residents out to smoke. Residents were required to be able to smoke safely. On 1/7/19, at 5:33 p.m. registered nurse (RN)-B stated that at the time of the falls R97 had a shuffling gait and a tendency to wear tennis shoes that didn't fit well. RN-B stated the tennis shoes had holes in the sides, but wasn't wearing those shoes at the time of the 12/28/18, fall. RN-B stated being unaware of what type of shoes R97 was wearing at the time of the 12/28/18 fall. RN-B stated that R97 preferred to go outside at around 5:00 a.m. to smoke and the 12/28/18 fall happened around 6:00 a.m. When asked for clarification as to R97's interview regarding where R97 was found, RN-B stated R97 was found on the first floor and R97 had already fallen when staff found her. RN-B stated R97 may have been found outside the elevator and may have tripped coming out of the elevator. R25's report titled IDT/Fall Team First Post Investigative Review dated 1/6/19, revealed R25 had an incident which required R25's evaluation at the emergency department on 1/4/19. The report revealed nursing assistant (NA)-F had used a mesh bath sling instead of the required mechanical lift sling; and didn't follow facility policy for a two person transfer which resulted in a fall with injuries. R25's spouse stated during an interview on 1/7/19, at 12:35 p.m. R25 had been sent to the emergency department (ED) on 1/4/19, because of a fall from a mechanical lift. On 1/8/19, at 8:57 a.m. R25's spouse stated R25 had been bruised from the fall and there was an open area on R25's left thigh. On 1/7/19, at 6:15 p.m. R25 stated there was bruising on the left leg and showed the surveyor the bruising. There was an approximate three inch circular, open non-bleeding, but red skin tear/laceration surrounded by deep purple bruising noted on the left upper/inner thigh. R25 expressed surprise and stated the area was bleeding. A review of R25's care plan dated 2/18/18, indicated R25 was a total assist of two for transfers with an EZ-stand lift. At 9:36 a.m. NA-E indicated R25 would be getting out of bed and along with NA-D, a two person mechanical lift was conducted for R25 from the bed to a wheelchair. R25 expressed discomfort when the left leg was lifted and place on the foot rest. On 1/9/19, at 9:38 a.m. NA-D and NA-E stated there was to always be two people when using a mechanical lift. On 1/9/19, at 2:06 p.m. the interim director of nurses (DON) and director of social services (DSS) stated NA-F was interviewed immediately following the incident and described the incident in the following manner: R25's incontinent brief was changed before supper, a lift sling was placed under R25 when in bed, NA-F went to find someone to help with the transfer, but when could not find assistance then NA-F used the mechanical lift alone. According to the DON and DSS, NA-F stated the sling was crossed between R25's legs and when lifted, the sling rode up between R25's thighs and R25 began leaning to the side and was sideways in the air, but did not fall from the sling. NA-F then grabbed a pillow, put it on the floor and lowered R25 to the floor. The DON and DSS stated R25 did not fall to the floor, but a leg came out of the sling. The DON and DSS felt the left leg was a result of the sling sliding up between R25's legs. R25 was then sent to the hospital on [DATE], for evaluation. The DON and DSS stated NA-F was suspended, but the facility had been unable to reach NA-F since the incident for further interviews. The surveyor requested NA-F contact information, but it was not provided. The facility's policy titled Mechanical Lift and revised 3/18, indicated all mechanical lifts required a two person transfer and mechanical standing lifts required 1-2 based on the resident care plan. The type of lift used was to be determined by a registered nurse or rehab staff. R32 was observed on 1/9/19, at 8:17 a.m. and nursing assistant (NA)-B finished providing morning cares for R32. NA-B described needing to fill R32's portable oxygen device before R32 left for breakfast. R32 was observed to have two large metal tanks of oxygen in the corner of the bedroom. There was a sticker on each tank that read Oxygen Refrigerated Liquid. NA-B said staff always kept two large tanks in R32's room; one tank for oxygen, and the other tank for a backup. NA-B explained that because R32 was on hospice, which was a different pay system, staff had to fill the portable oxygen device off the oxygen tank in the room. R32 sat in a wheelchair in the room while NA-B proceeded to place the portable device on top of one of the large oxygen tanks in the corner of the room, and push down. A whooshing sound could be heard as the oxygen emptied from the large tank into the portable device. When full, NA-B hung the portable device on the back of R32's wheelchair, and placed the nasal cannula from the portable device on R32's face. NA-B explained that R32 was always supposed to be on 2 liters of oxygen, unless R32 got tired of wearing the nasal cannula, in which case the hospice provider said R32 could remove it during the day. During a follow-up interview at 9:30 a.m. NA-B was asked about why the portable oxygen was filled in R32's room, rather than in the facility's oxygen transfill room. NA-B said because R32 was on hospice, staff filled the portable device in R32's room off the large tank stored there. NA-B described filling all the other residents' portable oxygen tanks down in the oxygen transfill room, but because R32 was on hospice which was a different pay source, nobody else could use R32's tank. NA-B worried that if R32's tank was downstairs with all the other tanks in the oxygen transfill room, staff would fill other residents' portable devices off R32's tank. Upon observation of the two tanks in R32's room, one of the tanks had a red tag with R32's name on it, and the other tank had a red tag, but no label with the resident's name. NA-B explained being taught to fill portable oxygen this way for residents who were on hospice, but could not remember who provided the training because it occurred approximately one year ago. NA-B stated R32 had been on oxygen for maybe only a couple months. Review of R32's current orders revealed hospice had been elected 1/29/18. There was also an order [REDACTED]. Review of training records revealed NA-B was most recently trained about filling portable oxygen tanks before they run out on 4/11/18. On 1/9/19, at 11:05 a.m. the administrator confirmed R32's room had one tank in use, and an extra storage tank, and said that the extra storage tank would be removed from the room. In a follow-up interview at 12:16 p.m. with the administrator and interim director of nursing (IDON), the IDON confirmed the extra tank had been removed from R32's room, and NA-B had been re-educated about not filling portable oxygen devices anywhere but in the designated oxygen transfill room. The administrator and IDON confirmed being on hospice was not a reason to fill [MEDICATION NAME] anywhere other than the transfill room, and said they were re-educating all staff to ensure everyone was aware of this. On 1/11/19, at 8:16 a.m. the IDON confirmed that within 24 hours of becoming aware of the improper oxygen filling, they were able to touch base with all the nursing assistants employed by the facility to ensure they understood the correct process of taking the portable oxygen devices downstairs to the transfill room to fill. IDON said all of the nursing assistants had been aware of the proper filling procedure, except for NA-B, who had already been reeducated. Review of the Oxygen Administration Policy, dated 2010, revealed the following: NOTE: Portable oxygen tanks may NOT be filled in the resident's rooms. The facility is responsible to have a special room/area designed within safety guidelines to use with the purpose of storage of liquid oxygen and transfilling.

Based on interview and document review the facility failed to ensure 1 of 3 residents (R1) reviewed for falls were free from accidents when R1's care plan interventions were not implemented. Two different staff, on two separate occasions, assisted R1 to transfer without a standing lift. The resident fell both times, broke her ankle on the second fall, and required surgery. The facility further failed to ensure all staff were aware of the resident's care plan interventions. Findings included: R1's record was reviewed. R1's [DIAGNOSES REDACTED]. R1's brief interview of mental status (BIMS) dated indicated R1 had no cognitive impairment. R1's care plan dated (MONTH) 22, (YEAR) indicated R1 required two staff for transfers with a standing lift. R1's nursing progress note dated (MONTH) 6, (YEAR) at 1:01 p.m., written by licensed practical nurse (LPN)-B indicated R1 required assistance of one staff for transfers. R1's nursing progress note dated (MONTH) 8, (YEAR) at 8:57 a.m., written by LPN-B indicated R1 required assistance of one staff for transfers. R1's nursing progress note dated (MONTH) 10, (YEAR) at 12:59 p.m., written by LPN-B indicated R1 required assistance of one staff for transfers. R1's nursing progress note dated (MONTH) 10, (YEAR) at 3:34 p.m., written by registered nurse (RN)-C indicated RN-C transferred R1 from her wheelchair to her bed by himself with a gait belt. The progress note further indicated RN-C lowered R1 to the floor when R1 became too weak to stand during the transfer. An incident report dated (MONTH) 11, (YEAR) at 11:28 a.m. indicated R1 had an assisted fall to the floor, when RN-C attempted to transfer R1 from her wheelchair to her bed by himself with a gait belt. The report further indicated the root cause of the incident was the nurse attempted to transfer R1 by himself with a gait belt, due to not knowing or checking the care plan to see that the resident required assistance of two staff with transfers. R1's nursing progress note dated (MONTH) 16, (YEAR) at 2:36 p.m., written by RN-C indicated R1 required assistance of one staff for transfers. R1's nursing progress note dated (MONTH) 20, (YEAR) at 10:42 a.m., written by LPN-B indicated R1 required the assistance of one staff for transfers. The note further indicated R1 required a standing lift for transfers. R1's nursing progress note dated (MONTH) 26, (YEAR) at 4:15 p.m., written by RN-C indicated R1 required a standing lift for transfers. An incident report dated (MONTH) 28, (YEAR) at 3:57 p.m. indicated R1 had an assisted fall to the floor earlier that morning when nursing assistant (NA)-G transferred R1 by herself with a gait belt in R1's bathroom . The report indicated after the fall, NA-G put the resident in bed and then alerted the nurse. The report further indicated NA-G did not follow the care plan when she assisted the resident by herself and did not use a standing lift. R1's hospital record dated (MONTH) 1, (YEAR) (not timed) indicated R1 required surgery with pin placement in her right ankle due to a fracture. The record further indicated R1 remained hospitalized for [REDACTED]. During an interview on (MONTH) 14, (YEAR) at 2:10 p.m. nursing assistant (NA)-A stated the nursing assistants carry a care plan sheet that provides all the information about the residents including how many staff are needed for a transfer and if they use a lift. During an interview on (MONTH) 14, (YEAR) at 2:25 p.m., LPN-B stated R1 required a standing lift for transfers. LPN-B stated she did not know what the policy said but that she always encouraged two staff to transfer with the standing lift. LPN-B stated the nursing assistants do not carry a sheet of paper that tells them what cares the residents require, but the nursing assistants were expected to review the binders in the nurse's office before and during their shift, which has the care plan information. During an interview on (MONTH) 14, (YEAR) at 2:55 p.m., RN-C stated when R1 fell on (MONTH) 28, (YEAR) a nursing assistant called him to R1's room. When RN-C got to the room, two nursing assistants had moved R1 from the floor to the bed. RN-C assessed R1's swollen ankle and asked R1 about her pain. RN-C stated R1 required a standing lift for transfers, but there had not been a standing lift in the bathroom or R1's room when he arrived. During an interview on (MONTH) 22, (YEAR) at 10:48 a.m., NA-G stated she transferred R1 by herself with a gait belt every time she helped R1 in her bathroom. NA-G stated the standing lift did not fit into R1's bathroom, and in order to use the standing lift, NA-G would have to bring R1 down the hall to the shower room toilet, where the standing lift would fit. NA-G stated the care plan sheets used to be in a drawer so the aides could carry it with them, but the new manager put the entire resident's information into a big book in the nurse's office. NA-G stated it took too long to sign into the computer to see the information on each resident, and no one ever told her to transfer R1 differently. NA-G stated she had received no feedback from the facility on her performance of her job in the last two years, so she did not know she was doing anything wrong. During an interview on (MONTH) 22, (YEAR) at 2:13 p.m. director of nursing (DON)-H stated the facility had no consistent system of communicating care planned resident needs to the staff. DON-H stated that two floors used cheat sheets for the staff, but one floor encouraged staff to review the resident's care plans prior to the beginning of the shift and not carry reference documents. DON-H stated the nursing assistants were encouraged to check the electronic care plan for information about resident care needs, such as eating and transfers. DON-H stated the facility discouraged nursing assistants from carrying cheat sheets, which were more difficult to keep up to date, but was aware that some units used them. DON-H stated he was aware that NA-G had not received an evaluation of her job performance in the last two years. DON-H stated the facility did not have a falls protocol or policy, but they relied on the standard of care outlined by Lippincott. The transfer policy dated 2006 indicated staff were to transfer a resident as identified in the resident's care plan. The nursing assistant job description dated (MONTH) 2013 indicated staff were to transfer residents per the plan of care.