Every finding on record at Mayo Clinic Health System - Lake City

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed, revised and implemented to address unsafe smoking practices for 1 of 1 residents (R16) reviewed for smoking. R16 was found in the facility parking lot smoking a cigarette within close proximity of an active oxygen source.Findings include.See also F689R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact, uses oxygen and was dependent on staff for mobility. R16's smoking assessment dated [DATE] indicated R16 the interdisciplinary team recommended that the resident cannot smoke independently.R16's smoking assessment dated [DATE] indicated R16 failed due unsafe oxygen use. The comments section of the assessment indicated, CNA reported that resident had cigarette lit in his mouth with nasal cannula/oxygen flowing. R16's respiratory care plan entered 7/7/26 indicated R16 has a smoking history although it lacked interventions regarding oxygen safety. R16's behavior care plan created 7/24/26 and undated 8/18/26 indicated resident also going out to the parking lot and at times entering staff vehicles to try and get cigarettes or lighters. R16's care plan lacked revisions or safety interventions following the 8/8/26 oxygen-smoking incident. A notation indicating staff should keep vehicles locked was retrospectively entered on 8/18/26. R16's nursing assistant kardex indicated R16 used 2 liters per minute of oxygen via nasal prongs, although lacked resident smoking history, the 8/8/26 smoking with oxygen incident or any further smoking interventions.During interview on 8/18/26 at 2:59 p.m., nursing assistant (NA)-A stated she had worked for the facility for approximately 6 months and was somewhat familiar with R16. NA-A stated she was not certain if R16 smokes and had heard R16 may have been looking and taking cigarettes from people's vehicles.During an interview on 8/18/26 at 3:08 p.m., NA-B stated she had worked at the facility for a year and a half. NA-B stated she heard R16 was caught out in the parking lot about a week prior. During an interview on 8/18/26 at 3:14 p.m., NA-C stated she had worked at the facility for 2 years. NA-C stated R16 was observed about a week ago inside a staff members vehicle. R16 had a lit cigarette while wearing his oxygen. NA-C stated that was the only time she was aware R16 was caught smoking but had previously been seen taking things out of people's vehicles in the parking lot. During a follow up interview on 8/18/26 at 4:04 p.m., NA-C stated prior to the incident on 8/8/26, the nurses informed staff to keep their vehicles locked because R16 was found looking through vehicles, presumably looking for cigarettes. During an interview on 8/18/26 at 4:09 p.m., registered nurse (RN)-A stated he had heard R16 was caught going through vehicles in the parking lot looking for a lighter a couple weekends ago; however, he was not aware of R16 smoking. During an interview on 8/18/26 at 4:40 p.m., with the director of nursing (DON) and nurse manager (NM)-C, the DON stated nurse managers perform smoking assessments to make sure residents can safely handle smoking materials and go across the street to smoke safely. The DON stated she had never performed a smoking assessment. NM-C reviewed R16's 6/25/26 smoking assessment and confirmed it stated R16 passed the assessment however; it also indicated R16 was not safe to smoke independently. NM-C stated becoming aware on 8/10/26 of R16 going through vehicles however; was not aware of any issue prior to that. The DON reviewed the progress note from 8/8 that indicated R16 was seen in a staff member's vehicle in the parking lot looking for a lighter. R16 was removed from the area and educated not to go into staff vehicles. The DON stated the progress note does not indicate R16 was smoking. NM-C reviewed the smoking assessment on 8/8/26 and confirmed all questions were answered yes except the question referring to removal of oxygen indicated no. NM-C stated, he didn't remove the oxygen apparently. NM-C then stated R16 has been known to wear the oxygen tubing without the oxygen running because R16 feels more comfortable wearing it. When asked who updates the care plans, NM-C stated the MDS nurse usually creates the initial care plan, but all nurses know how to go in and update them. Any incidents are usually entered into the care plan by the nurse managers however the MDS nurse will also occasionally enter them. During an interview on 8/19/26 at 8:28 a.m., LPN-D and NA-G stated they received notification 'a few months ago' to ensure personal vehicles were kept locked because a resident was going through staff vehicles. They were not told why but had heard from other staff a resident was going through vehicles looking for cigarettes. They were not aware of any other incidents. During an interview on 8/19/26 at 9:36 a.m., NM-A stated R16 was previously on the short-term rehab unit prior to transferring to the long-term care unit. NM-A stated when R16 transferred to the long-term care unit, she was not aware R16 smoked or was on a nicotine patch. When she found out R16 was caught smoking in the parking lot with oxygen on, she discussed with R16 weaning off the oxygen and increasing the dose of his nicotine patch. NM-A stated she was not aware of any other time R16 was in the parking lot going through vehicles. NM-A stated a smoking assessment is done based on a resident's cognitive ability, physical limitations, and clinical judgment. Staff do not actually observe resident smoking when performing a smoking assessment. NM-A reviewed R16's care plan and could not find mention of R16 smoking in the parking lot with oxygen on. NM-A stated R16's kardex indicated staff aware to keep vehicles locked to prevent rummaging by residents however it was entered on 8/18/26 not when the incident occurred. During a follow-up interview on 8/19/26 at 10:01 a.m., with the DON and NM-C, the DON reviewed R16's care plan and confirmed a notation regarding R16 entering staff vehicles was retrospectively entered on 8/18/26 by NM-C. The care plan also indicated on 7/29/26 R16 was educated on smoking policy however neither the DON nor NM-C could recall why. Both confirmed there were no other updates to R16's care plan regarding the incident on 8/8/26. When asked how staff would know R16 was caught going through vehicles in the parking lot and smoking with oxygen on, NM-C stated it would get passed on shift-to-shift report. When asked how long she would expect the incident to be passed on in report, NM-C stated, a few days. The DON stated incidents are also on the communication page of the electronic health record for staff to review at the beginning of their shift. When asked how long the incident would remain on the communication page, the DON and NM-C were not able to identify the date of the incident on the communication page after taking several minutes to search. Both the DON and NM-C stated they were not aware of any other incident involving R16 in the parking lot. A policy titled Individualized care Plan dated 7/25 indicated A comprehensive care plan using comprehensive assessments, will individualize the plan of care to accurately reflect resident's functional capacity and medical, nursing, psychosocial, and activity, and other identified needs. Upon admission, the nursing department begins the care plan and addresses the immediate needs of the residents in the initial care plan. The interdisciplinary team (IDT) team assures all disciplines have shared their information and all problems, services and adaptive equipment are incorporated into the plan. The IDT also assures the resident's care plan is revised if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change because of an incident of abuse. All changes are entered into the appropriate area of the plan. Those interventions flow into the nursing assistant kardex for nursing assistants to provide residents' care. The interdisciplinary care plan is changed promptly in response to any change in the residents' condition. This change is initiated by any professional who recognizes the need to change the plan. The interdisciplinary team also develop individualized care plan interventions with the provider to review refusal and develop new goals and treatment interventions.

Based on observation, interview and record review, the facility failed to provide adequate supervision and an environment free from accident hazards for 1 of 1 residents (R16) reviewed for smoking. R16 was found in the facility parking lot smoking a cigarette within close proximity of an active oxygen source. Findings include: R16's quarterly Minimum Data Set, dated [DATE], indicated R16 was cognitively intact, used oxygen and was dependent on staff for wheelchair mobility. R16 had a history of stroke, respiratory failure, heart failure, and chronic obstructive pulmonary disease (COPD). The MDS also indicated R16 did not use tobacco products. R16's July Medication Administration Record (MAR) indicated R16 received a nicotine transdermal patch 7 mg daily until 8/7/26 and nursing to trial weaning of oxygen use and was wearing oxygen 75 of 93 observations. R16's August MAR indicated R16's Nicotine transdermal patch was increased to 14 mg per 24 hours on 8/8/26 and received oxygen 25 of 31 observations. On 8/7/26 R16's oxygen order indicated 2 liters via nasal cannula to achieve oxygen saturation greater than 89% for COPD. R16's smoking assessment dated [DATE] indicated R16 was on oxygen and demonstrated the ability to leave the oxygen in the facility before leaving the building and had the ability to manage smoking materials and smoke safely. Question 13 of the smoking assessment indicated R16 passed the smoking assessment. Question 13A indicated the interdisciplinary team recommended the resident cannot smoke independently but may smoke with his/her family or visitors. Smoking Policy and standards still apply. The smoking assessment also indicated R16 has a smoking care plan. R16's smoking assessment dated [DATE] indicated R16 was able to manage smoking materials and demonstrated safe smoking practices. It also indicated R16 did not demonstrate the ability to leave oxygen in facility before leaving the building. Question 13 indicated R16 failed the smoking assessment. Question 13A indicated the interdisciplinary team recommended R16 cannot smoke independently but may smoke with his/her family or visitors. Smoking policy and standards still apply. The comments section of the assessment indicated CNA reported that resident had cigarette lit in his mouth with nasal cannula/oxygen flowing. Educated resident importance of not having oxygen at the time of smoking a cigarette. R16's respiratory care plan entered 7/7/26 indicated R16 has a smoking history although it lacked interventions regarding oxygen safety. R16's behavior care plan created 7/24/26 and updated 8/18/26 indicated resident also going out to the parking lot and at times entering staff vehicles to try and get cigarettes or lighters. R16's care plan lacked revisions or safety interventions following the 8/8/26 oxygen-smoking incident. A notation indicating staff should keep vehicles locked was retrospectively entered on 8/18/26. R16's nursing assistant kardex indicated R16 used 2 liters per minute of oxygen via nasal prongs, although lacked resident smoking history, the 8/8/26 smoking with oxygen incident or any further smoking interventions. Facility progress notes indicated the following:-On 8/5/26 between 7:30 p.m. and 8:00 p.m., R16 was self-propelling himself down the hallway asking several nursing assistants for cash to purchase a cigarette. -On 8/6/26 the progress notes indicated a new physician order to increase nicotine patch to 14 mg and to attempt to wean the resident from oxygen. -On 8/8/26 at 7:41 p.m., a progress note indicated at 5:30 p.m., R16 left the building through the front door and entered a staff members vehicle in the parking lot in search of a lighter and had 6 cigarettes confiscated. -on 8/10/26 progress notes indicated staff spoke to R16 about him getting into a vehicles in the parking lot and reports of him smoking. The note indicated plans to wean off oxygen and the recent increase of his nicotine patch. The progress notes indicated R16 reported smoking at least 1 pack per day prior to admission to the facility. During an observation and interview on 8/18/26 at 12:31 p.m., R16 stated he used to smoke, however is not allowed to smoke at the facility and doesn't smoke with family because they don't visit. R16 stated he does have a smoking patch on and has not smoked in 3 months. He reported he does not keep cigarettes in his room. A liquid oxygen tank was observed in R16's room. R16 stated he only wears oxygen when he feels short of breath. During an interview on 8/18/26 at 3:08 p.m. NA-B stated she had never seen resident smoke but has heard he does. NA-B stated, people have caught him outside lighting cigarettes. NA-B stated R16 sits out in front [of the facility] a lot. NA-B stated she heard about a week prior to the interview R16 was caught out in a staff member's vehicle with a cigarette in his mouth.During an interview on 8/18/26 at 3:14 p.m., NA-C stated she was not sure if R16 had his own supply of cigarettes. NA-C stated R16 has had previous encounters of stealing out of people's vehicles. NA-C stated she and another staff member recently found R16 outside in a staff member's vehicle grabbing a lighter. R16 had a lit cigarette in his mouth and had his oxygen on. The other staff member grabbed the cigarette from R16 and put it out immediately. At that time, one of the nurses came out to get R16. NA-C stated she was not sure where R16 got the cigarettes, however R16 told her they were his. During an interview on 8/18/26 at 3:36 p.m., R16 stated he does not remember going into a staff members vehicle looking for a lighter recently. R16 stated if he chose to smoke, he would have to go across the street because he cannot smoke at the facility. R16 stated he does not smoke with oxygen on because oxygen fuels the fire and if he did, he would blow up. During a follow up interview on 8/18/26 at 4:04 p.m. NA-C stated she heard R16 had previously been observed in the same staff members vehicle, presumably looking for cigarettes and staff were told to keep vehicles locked. NA-C stated when R16 was alone when he was observed smoking and she was not aware of any other residents who smoked. During an observation and interview on 8/19/26 at 4:09 p.m., registered nurse (RN)-A stated wears oxygen intermittently and uses portable liquid oxygen tank. A portable liquid oxygen tank was observed on the windowsill near the large liquid oxygen tank. RN-A stated he was aware of R16 rummaging in vehicles a couple weekends ago looking for a lighter. To his knowledge that was the only time. During an interview on 8/18/26 at 4:40 p.m., the director of nursing stated smoking assessments are performed by the nurse managers upon a resident's admission. The DON stated the assessments are performed to make sure residents are safe to smoke. The assessment takes into consideration a resident's cognition, oxygen use, and safety crossing the street. The DON stated she has never done a smoking assessment and called in nurse manager (NM)-C. NM-C reviewed R16's smoking assessment from 6/25/26 and confirmed it stated he passed the smoking assessment, but it also indicated he is not safe and could only smoke with family/friends. NM-C stated she was aware R16 was found in the parking lot on 8/8/26, however, was not aware of any situation prior to that. The DON reviewed the progress notes from 8/8 and stated R16 was witnessed to have opened a staff vehicle in the parking lot in search of a lighter. He was removed from the area and educated not to go into other staff vehicles. One pack of cigarettes was removed. The DON stated the progress note does not mention R16 was smoking. NM-C reviewed smoking assessment from 8/8 and stated R16 didn't remove the oxygen apparently. NM-C then stated R16 has been known to wear oxygen tubing without the oxygen running as a form of comfort. The DON could not say exactly when she was informed R16 was found smoking in the parking lot and was not aware of any other incidence involving R16. During an interview on 8/19/26 at 8:08 a.m., licensed practical nurse (LPN)-B confirmed he was the nurse on duty the day R16 was in the parking lot. LPN-B stated a staff member was in another resident's room, looked out the window, and saw R16 in the parking lot by a vehicle with the door open. LPN-B left the building to retrieve R16, however 2 staff members were already bringing R16 back towards the building. R16 was found with 6-7 cigarettes and stated he was looking for a lighter. R16 sits out in front of the building all the time and knows a staff member who smokes parks out there. LPN-B stated he was instructed by the charge nurse to take the cigarettes and place them on the nurse manager's desk. LPN-B stated R16 initially told him he got the cigarettes from a staff member but later stated he found them in a bag in his room. LPN-B had never seen R16 smoking before this incident. LPN-B confirmed R16 was wearing the oxygen nasal cannula and the portable oxygen tank at the time he was found in the parking lot. LPN-B educated R16 about going through people's private property. LPN-B stated that is not the first time R16 was seen in the parking lot but was not aware of any other time R16 was going through vehicles. When asked if R16 wears oxygen continuously, LPN-B stated R16 would occasionally go without oxygen for an hour or so but would request to put it back on due to shortness of breath. LPN-B stated he is not aware of R16 wearing oxygen tubing for comfort and not having the oxygen turned on. During an interview on 8/19/26 at 8:12 a.m., RN-B confirmed she was the charge nurse on duty when R16 was found smoking in the parking lot. She was told R16 was rummaging though a staff member's vehicle and was wearing oxygen while holding lit cigarette. RN-B stated she instructed LPN-B to take R16's cigarettes away because R16 was wearing the oxygen nasal cannula and she did not want him to blow himself up. RN-B then notified the nurse manager on-call about the incident and was instructed to complete a repeat smoking assessment. RN-B stated she did not physically observe R16 smoking when she did the smoking assessment; she simply changed the question referring to leaving the oxygen in the building to no. She then indicated R16 failed the smoking assessment. On 8/10/26 RN-B spoke to the nurse manager who stated the facility was in the process of increasing R16's nicotine patches and weaning him off oxygen. During a follow up interview on 8/19/26 at 8:57 a.m., RN-B stated she doesn't feel it is the first time R16 has been caught going through vehicles. RN-B was not aware of the circumstances but recalls hearing in report R16 has been going through vehicles looking for a lighter. During an interview on 8/19/26 at 9:36 a.m., nurse manager (NM)-A stated she was notified on 8/10/26 of R16 smoking in the parking lot. NM-A stated R16 had previously been on the rehab unit before transferring to the long-term care unit. She stated she was not aware R16 was a smoker or he was on a nicotine patch prior to this incident. NM-A stated she reviewed the progress note indicating R16 was seen in the parking lot looking for cigarettes. NM-A stated she can see from her office R16 sits outside of the building a lot but has never seen him out in the parking lot. NM-A stated when smoking assessments are performed, staff do not visualize the resident smoking. They do the assessment based on a resident's cognition and physical mobility using clinical judgement. NM-A stated after learning about the incident, she met with the administrator to develop a plan based on R16's orders and diagnoses. NM-A stated she and the administrator spoke to R16 about going through other people's vehicles and the dangers of smoking with oxygen. She was not aware of how R16 got the cigarettes. NM-A stated shortly after the incident she was made aware R16 sometimes wears oxygen tubing without the oxygen on. NM-A reviewed R16's care plan and stated on 8/18/26 R16's care plan was changed to indicate he occasionally wears tubing without oxygen on. NM-A stated she cannot find anything on the care plan specifically about the incident when he was caught smoking. When asked how staff would know of the behavior, NM-A stated incidents are put on the communication page in the electronic charting system. NM-A was unable to find the incident on the communication page because it only goes back a week. NM-A reviewed the nursing assistant kardex and stated there was notation stating staff are aware that they should keep vehicles locked to prevent rummaging through by residents however the entry was not made until 8/18/26. During a joint interview on 8/19/26 at 10:01 a.m. with the DON and NM-C, they confirmed R16's care plan was not updated regarding the incident until 8/18/26. NM-C stated on R16's care plan indicated R16 was educated on smoking policy on 7/29/26 however, does not know why. NM-C confirmed no other updates were made to R16's care plan regarding the incident on 8/8/26. When asked how staff know when incidents occur, NM-C stated they are communicated through shift-to-shift report , for a few days. The DON stated changes are also placed on the communication page on the electronic charting system. The DON and NM-C could not locate or navigate back to the date on the communication page. Both the DON and NM-C stated they were not aware of any prior issues with R16 being in the parking lot. The DON stated if a resident is caught in the parking lot going through vehicles or smoking unsafely, she would expect staff to immediately intervene and make sure the resident is safe. Once the resident is safe, she expects staff to let the charge nurse and administration staff know. During an interview on 8/20/26 at 8:48 a.m., NM-B stated she was on call the day R16 was caught smoking in the parking lot. NM-B stated she was told R16 was in the parking lot between the vehicles smoking but was not aware he was wearing oxygen at the time. NM-B stated she instructed the floor nurse to document a comprehensive progress note, do a smoking assessment, and monitor R16 over the weekend to make sure he does not go back out in the parking lot. NM-B stated that is the first time she is aware of an incident of R16 in the parking lot. During an interview on 8/20/26 at 9:44 a.m., the administrator stated he was informed the following Monday that R16 had gotten into a staff member's vehicle and was found smoking. R16 was wearing his oxygen tubing at the time but he did not know if oxygen was turned on. The administrator stated R16 was known to wear oxygen tubing without the oxygen on. The administrator stated he went with NM-A to speak to R16 about the incident and told R16 he cannot go into the parking lot and go through vehicles, even if he feels he is friends with the staff member. The administrator stated R16 has been indecisive about quitting smoking but was agreeable to wean off oxygen and increase his nicotine patch.During an interview on 8/20/26 at 10:00 a.m., the customer service representative (CSR) of the facility's oxygen supply company confirmed the portable oxygen tanks the facility uses contain liquid oxygen. The CSR stated even if the oxygen flow valve is set to 0 there still could be a residual oxygen cloud and potential the valves could leak oxygen. She said there could also still be oxygen present in the tubing even with the valve off. The CSR stated while oxygen itself is not flammable, it acts as an accelerant and can cause a fire if exposed to an open flame. The CSR stated, even with the valve off, there should be no smoking anywhere near oxygen equipment. All smoking should be a minimum of 50 feet away from any oxygen source. A policy titled Tobacco Free/No smoking revised 12/25 indicated residents and visitors are not allowed to smoke or use tobacco in facility buildings or property. Residents and visitors will be informed of the tobacco policy through pre-admission and/or admission materials. If a resident or visitor insists on smoking in violation of this policy, the unit manager, house supervisor, or administrator should be notified to address the situation. Residents will be offered cessation support and any cessation treatment plans in accordance with their provider approval and required orders. An undated form titled Ebenezer Smoking Standards: indicated the facility is a smoke free campus, and the standards apply to those residents who decide to smoke safely off the campus premises. Residents must abide by the smoking policy which includes refraining from smoking in the building or anywhere on the property, and proper use and storage of flammable materials. Residents and visitors must leave the flammable materials at the nurses' station after using any of the materials. Residents requiring the use of oxygen must leave oxygen in the building prior to exiting to smoke. Residents must sign out with nurses' station before leaving building to smoke. Resident's must pass facility smoking assessment to independently smoke. The facility is not responsible for unsafe smoking by residents who are not on the premises when using flammable materials and/or smoking. A policy titled Oxygen Administration/Storage dated 12/24 indicated there is always a danger of fire when oxygen is being used. Be sure to explain the hazard of smoking in the presence of oxygen to residents and families. No open flames or smoking in a room where oxygen is being present. Turn oxygen off when not in use. The oxygen storage section states oxygen equipment should not be stored near a flame or heat source.

Based on observation, interview, and record review, the facility failed to comprehensively assess a significant weight increase and implement care-planned monitoring for edema and signs and symptoms of congestive heart failure for 1 of 3 residents (R4) reviewed for change in condition.Findings include Findings include:R4's face sheet identified diagnoses of heart failure and diabetes.R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment, no behaviors, no rejection of cares, needed partial/moderate assistance for transfers, and did not take a diuretic (water pill).R4's care plan dated 11/20/25, identified R4 had a diagnosis of congestive heart failure. Goal to have clear lung sounds, heart rate and rhythm within normal limits. Corresponding interventions as follows:-Give cardiac medications as ordered (dated 11/6/25).-Monitor/document/report as needed any signs and symptoms of congestive heart failure such as dependent edema of legs and feet, shortness of breath on exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles/wheezes in the lungs. Report to the provider as indicated (dated 11/6/25). -Weight as ordered (dated 1/8/26).R4's physician progress note dated 6/2/26, identified R4 had a diagnosis of chronic congestive heart failure and a coronary stent status post. No changes in treatment and continue to monitor. Review of R4's vital sign record from 5/2/26 through 7/24/26 identified the following weights:6/5/26: 165.6 lbs.6/12/26: 165.6 lbs.6/26/26: 164.7 lbs.7/3/26: 172.6 lbs.7/24/26: 173.6 lbs. R4's weight increased from 164.7 pounds on 6/26/26 to 172.6 pounds on 7/3/26, an increase of 7.9 pounds. Review of R4's record, including the June and July Treatment Administration Records (TARs), did not identify completed edema or congestive heart failure monitoring and no indication comprehensive assessments of the weight increase were completed.R4's progress note dated 7/6/26 at 6:22 a.m., identified R4 had concerns about her lungs filling up with fluid again and requested to see a doctor. R4 has had an almost 10-pound weight gain within the past week and is short of breath. R4's nurse practitioner note dated 7/6/26, identified R4 had been seen for evaluation of shortness of breath and a ten-pound weight gain and concern for fluid retention. New orders for chest radiograph (Xray) to evaluate pulmonary fluid retention and laboratory studies. R4's nurse practitioner note dated 7/8/26, identified results are stable and will continue to monitor.During an interview on 7/31/26 at 1:04 p.m., R4 stated she had a diagnosis of heart failure, however, does not take a water pill for it. R4 explained a few weeks prior she became short of breath and felt like she was filling up with fluid and had asked to see the doctor. R4 was worried she was having problems with her heart failure, explained staff needed to watch her closely to make sure I do not get worse and must be sent to the hospital. During an interview on 7/31/26 at 12:47 p.m., nurse manager registered nurse (RN)-B stated R4 had diagnosis of congestive heart failure, however, her record did not have any monitoring for edema or worsening CHF symptoms. RN-B explained that a resident with a diagnosis of CHF needed to be watched closely to ensure they were not having an exacerbation of CHF and without daily monitoring that could be missed. During an interview on 7/31/26 at 1:13 p.m., RN-A stated residents with a diagnosis should be watched closely to assess for changes like shortness of breath, lung sounds, weight gain and edema, however, R4 has not been monitored for any of these on a daily basis and should be. RN-A explained by monitoring a resident with CHF closely will allow small changes to be caught quickly and get treatment for it.Review of the facility's policy of Change of Condition Assessments dated 4/16/25, identified the purpose of the policy is to ensure timely detection, documentation, and intervention for any significant alteration in a patient's baseline status, thereby safeguarding patient health and wellbeing. A focus assessment (a targeted approach to assessing a patient for a specific health concern or area of care. Used to evaluate the patient's immediate needs, symptoms, or risk factors related to a particular condition, system, or issue.Requested a policy on CHF but did not receive.

Based on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 2 of 3 residents (R1, R3) who were noted to have missing information in their record. Findings include:Based on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 2 of 3 residents (R1, R3) who were noted to have missing information in their record. Findings include:R1's face sheet identified diagnoses of diabetes, interstitial pulmonary disease (need to define this), heart failure, and chronic kidney disease.R1's progress note dated 7/20/26, identified R1 complained of not being able to void with the past 12 hours. Left message for on-call provider of not void in past 12 hours. R1's progress note dated 7/22/26 at 2:00 p.m., identified R1 was seen for an acute visit related to urinary concerns over the weekend. R1's progress note dated 7/23/26, identified R1 was seen by a provider via video visit for a discharge visit. Review of R1's electronic health record (EHR) from 7/20/26, 7/22/26, and 7/23/26 did not identify any physician notes in the facility's electronic health record (EHR).R4's face sheet identified diagnoses of heart failure and diabetes.R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment, no behaviors, no rejection of cares, needed partial/moderate assistance for transfers, and did not take a diuretic (water pill). R4's progress note dated 7/6/26 at 6:22 a.m., identified R4 had concerns about her lungs filling up with fluid again and requested to see a doctor. R4 has had an almost 10-pound weight gain within the past week and is short of breath. In review of R4's record, there was no indication R4's provider had been notified however, the facility obtained and provided a physician note from an outside provider electronic record system dated 7/6/26. The note practitioner note R4 had been seen for evaluation of shortness of breath and a ten-pound weight gain and concern for fluid retention. New orders for chest radiograph (Xray) to evaluate pulmonary fluid retention and laboratory studies. Further review identified the chest X-ray was response from the testing on 7/8/26.During an interview on 7/30/26 at 4:37 p.m., nurse manager registered nurse (RN)-E stated records maintained in the outside facility's EHR were not considered part of the facility's medical record. The facility did not routinely obtain or place copies of those records in the residents' EHR because staff could access and review them through the outside facility's EHR. RN-E acknowledged that not all nurses had access to the outside facility's EHR and that, when records were not placed in the resident's EHR, there was a risk that orders or treatments could be missed.During an interview on 7/31/26 at 12:47 p.m., nurse manager registered nurse (RN)-B stated R1's notes dated 7/20/26, 7/22/26, and 7/23/26 were not in R1's EHR, and a nurse practitioner note for R4 was not in R4's EHR. RN-B explained the facility did not routinely obtain records from the outside facility's EHR because the records were available for review in that system. The facility relied on the outside facility to fax records determined to be needed for the resident's EHR.During an interview on 7/31/26 at 12:27 p.m., registered nurse (RN)-D stated she did not have access to the outside facility's EHR. If RN-D needed to review a physician note, she would look for the note in the resident's facility EHR. RN-D explained that if the note was not available in the resident's EHR, she would be unable to review the note or verify an order for accuracy, which could result in an error.During an interview on 7/31/26 at 2:25 p.m., regional nurse consultant (RNC) stated the facility did not routinely obtain records from the outside facility's EHR for inclusion in the resident's EHR and only selected records were scanned into the resident's chart. RNC acknowledged that when outside records were not reviewed and incorporated into the resident's EHR, pertinent information could be missed.Review of the facility's Documentation Standards Policy dated 10/24, identified the purpose to ensure the accuracy, timeliness, and completeness of records to support clinical decision making and regulatory compliance. The policy stated all documentation must reflect the resident's condition, behaviors, care provided and any status changes. Documentation must be completed at the time of care or as soon as possible after the care is provided.

Based on interview and document review the facility failed to ensure laboratory reports were filed in the clinical record for 1 of 1 resident (R4) reviewed for edema monitoring.Findings include:R4's face sheet identified diagnoses of heart failure and diabetes.R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment, no behaviors, no rejection of cares, and needed partial/moderate assistance for transfer. R4's progress note dated 7/6/26 at 6:22 a.m., identified R4 had concerns about her lungs filling up with fluid again and requested to see a doctor. R4's nurse practitioner note dated 7/6/26, identified R4 had been seen for evaluation of shortness of breath. New orders for chest radiograph (Xray) to evaluate for pulmonary fluid retention and laboratory studies. Review of R4's electronic health record (EHR) from 7/6/26 through 7/31/26, did not identify any laboratory or chest imaging results. During an interview on 7/31/26 at 12:47 p.m., registered nurse (RN)-B stated R4 had a chest x-ray completed on 7/7/26 and laboratory testing completed on 7/8/26; however, R4's EHR did not contain the test results or documentation of the provider's response to the results. RN-B explained the facility did not routinely place laboratory results in the resident's medical record because the results were available in the outside facility's EHR. Staff would access the outside facility's EHR when they needed to review the results. RN-B further explained it was the responsibility of the outside clinic to ensure the facility received the results and not the facility's responsibility to obtain them.During an interview on 7/31/26 at 1:13 p.m., regional registered nurse (R-RN) stated the facility should be ensuring all laboratory results are followed up on to ensure a response from the ordering provider and a copy of the laboratory results placed in the resident's EHR. Requested the facility's policy on laboratory results but did not receive.

Based on observation, interview and document review, the facility failed to protect 1 of 1 resident (R1) who had severe cognitive impairment and was unable to give consent for sexual activity from inappropriate sexual touching from R2, who had known history of sexually inappropriate behavior resulting in R2 placing his hand underneath R1's shirt and touching her breast on 4/4/26. This deficient practice resulted in immediate jeopardy (IJ) for R1, as a reasonable person would have experienced severe psychosocial harm, including dehumanization and humiliation as a result of sexual abuse. The Immediate Jeopardy (IJ) began on 4/4/26, when R1's breast was touched by R2 after the facility failed to develop and implement individualized interventions including clearly defined supervision to prevent R2's access to female residents despite a known history of sexually inappropriate behavior. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 4/16/26 at 1:35 p.m. Immediate Jeopardy was removed on 4/17/26 when the facility implemented immediate protective measures to ensure resident safety; however, noncompliance remained at a lower scope and severity level of D. Findings include: The facility reported incident (FRI), submitted to the state agency on 4/4/26 at 8:27 a.m. identified an allegation of resident-to-resident sexual inappropriate touch that occurred on 4/4/26 at 7:00 a.m. A nurse observed R2 touching R1's breast in the Country View TV lounge and immediately separated the residents. The report indicated the residents did not believe the behavior was inappropriate. R1's Face sheet printed 4/16/26, identified R1 had diagnoses of dementia and anxiety disorder. R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment, used a hearing aid and corrective lenses, and did not have behaviors and/or signs of symptoms of delirium. R1 and used a Wander guard daily. R1's care plan, dated 8/27/25, identified R1 had a focus of experiencing sexual abuse/molestation in childhood by two different individuals, an older cousin and a family friend; no triggers were identified at that time, and R1 was noted to be okay with male caregivers. Interventions, dated 8/27/25, identified to observe changes in mood, behavior, sleeping, and eating, and to allow R1 to talk as she felt appropriate. R1's progress note dated 4/4/26 at 7:20 a.m. identified confusion following the incident, including misidentification of a male resident as her father. At 12:18 p.m., R1's resident representative (RR)-B expressed concern regarding increased confusion and possible cognitive decline. At 12:50 p.m., R1 was documented to have hallucinations, confusion, and impaired reality testing, including seeing animals and bugs and misidentifying a male resident as her father. R1 was easily redirected. R1's interdisciplinary team (IDT) progress note, dated 4/8/26 at 1:51 p.m., identified R1 was inappropriately touched by a male resident while in the Country View common area. The male resident was immediately relocated and subsequently moved to the Roseview unit. Neither resident recalled the incident. R1 was seen by the in-house counselor and was monitored for changes in mood and behavior. No further incidents were identified. R1's progress note, dated 4/8/26 at 5:12 p.m. (late entry), identified Social Services (SS) met with R1 to discuss the recent incident with a male resident; R1 did not acknowledge the incident and demonstrated confusion and disorganized thinking, including unrelated statements about a thunderstorm, a house missing a wall, and her father. R1 was unable to maintain focus during questions related to decision-making and redirected conversation back to unrelated topics. R1 was referred to the in-house counselor for continued support. R1's POC (point of care) response history behavior monitoring and interventions from 3/18/26 to 4/18/26 were reviewed and identified on 4/4/26 at 7:35 p.m., R1 was observed cursing at others; interventions documented that R1's behaviors remained unchanged. R2's face sheet, printed 4/16/26, identified R2 had diagnoses of dementia and unspecified mood disorder. R2's quarterly MDS, dated [DATE], identified R2 had severe cognitive impairment and was independent with wheelchair mobility. R2's care plan behavior focus initiated 9/17/23, revised on 11/8/24, identified a behavioral instance of inappropriately sexual touching toward R3 on 9/17/23 in the Country View common area. The focus indicated this was the first reported incident of this behavior. R2 was identified as being at risk for alteration in behavior due to a diagnosis of dementia and was unable to recall the incident. The focus further identified R2 occasionally made inappropriate comments to female staff that were usually easily redirected and had been on Paxil (antidepressant) with a successful gradual dose reduction and discontinuation. R2's current care planned interventions as of 4/3/26: -9/17/23 staff were to ensure awareness of females surrounding R2 when out of room and ensure adequate space between R2 and R3, the resident involved in the prior incident. -8/12/24 R2 was able to leave the unit for all activities; any concerns for inappropriate behaviors were to be addressed immediately. R2's Kardex report (abbreviated care plan for direct care staff), dated 4/3/26, identified R2 had no longer been ambulating any distance and used wheelchair mobility due to congestive heart failure. R2 required supervision with pivot transfers and assistance for mobility to distant locations off unit, with intermittent partial assistance needed later in the day. R2 was able to propel self independently in hallways and to the Roseview lounge but required staff escort to activity functions. Interventions also included ensuring adequate space between R2 and R3, who was involved in a prior incident, and making staff aware of female residents in R2's surroundings when out of room. The Kardex further identified R2 was able to leave the unit for all activities, with concerns for inappropriate behaviors to be addressed immediately. R2's Kardex did not establish a clear, individualized supervision system sufficient to prevent contact with vulnerable residents, relying instead on general monitoring and redirection rather than defined protective supervision controls. R2's progress note, dated 4/4/26 at 9:15 a.m., identified at approximately 7:00 a.m., a hall nurse observed R2 place his hand under R1's shirt and touched her left breast in the Country View TV lounge. Staff immediately removed R2's hand, separated the residents, and returned R2 to his room. R2 was noted to have dementia and was unable to recall the incident, stating, Some people don't mind and I didn't hurt anyone. The administrator, director of nursing (DON), and nurse manager were notified, and R2 was placed on increased monitoring with separation from female residents and redirection to his room following meals. Provider was contacted to evaluate medication management due to history of similar behaviors. R2's progress note dated 4/4/26 at 11:48 a.m. identified the physician assistant was notified and recommended continued monitoring rather than immediate medication initiation, with an acute visit scheduled for further evaluation of ongoing sexual behaviors. R2's care plan, dated 4/4/26, identified a focus I had a behavioral instance of inappropriately sexual touching another resident on 9/17/23 and 4/4/26 in the Country View common area. This was the first reported incident of me displaying this behavior. I was at risk for alteration in behavior due to my diagnosis of dementia. I was unable to recall this incident. I occasionally made inappropriate comments to female staff that were usually easily redirected. I was on Paxil and had a successful GDR and discontinuation. Interventions included resident to be brought back to room following mealtimes on 4/4/26, room change to Roseview (RV) unit on 4/6/26, and provider visit on 4/10/26 with decision to resume Paxil on 4/6/26 pending prior authorization. R2's physician assistant visit dated 4/6/26 identified R2 had an episode of inappropriate sexual behavior over the past 2 days. R2 was attempting to touch another resident's breasts, and during a second episode was attempting to kiss a nurse aide's abdomen, who was currently pregnant. R2 had a history of dementia and a history of inappropriate sexual behavior. R2 was previously on Paxil 10 mg (antidepressant medication prescribed to decrease sexual libido), which was discontinued on 9/19/24 due to a gradual dose reduction. R2 had not had issues with inappropriate behavior since discontinuation until the current episode. The facility had taken precautions including separating R2 from female residents when able and initiating UTI monitoring. Provider was asked about restarting Paxil. New orders were received to restart Paxil 10 mg daily for inappropriate sexual behavior. Continue to evaluate, redirect, and monitor. R2's Kardex dated 4/14/26 identified ensure there was adequate space between R2 and R1, the resident involved in the prior incident, make sure staff were aware of females surrounding R2 when he was out of his room, R2 was able to leave the unit for all activities, and any concerns for inappropriate behaviors were to be addressed immediately. R2 was to be brought back to his room following mealtimes. R2's POC response history behavior monitoring and interventions were reviewed from 3/18/26 to 4/16/26 and identified on 4/15/26, R2 was grabbing others. R2's record was reviewed, and no corroborating information was documented about R2 grabbing others. During an observation on 4/14/26 at 2:04 p.m., R2 was seated in the Country View TV lounge at a table with his eyes closed and head down. Two unknown female nursing assistants approached R2 and asked if he would like to go to his room to lie down. R2 responded, With you? One nursing assistant clarified, No, in your bed. R2 stated he needed to use the restroom first, and R2 was then assisted to his room. During an observation and interview on 4/16/26 at 9:21 a.m., R1 was seated on the side of her bed wearing oxygen tubing. R1 stated she felt safe in the facility and that staff and residents were nice. R1 stated, If someone touched me when I didn't want them to, I don't know I wouldn't know what to expect. I would tell someone. I would probably smack them. R1 demonstrated confusion regarding her environment and residents, referring to staff and residents by nicknames and incorrect names. During an interview on 4/15/26 at 9:35 a.m., registered nurse (RN)-B stated she was working on 4/4/26 and was stationed at a medication cart positioned with view of the TV/lounge area on the Country View unit. RN-B was monitoring R1 due to confusion and recent falls. RN-B observed R1 seated in her wheelchair on the left side of R2, with R2's right arm extended across his body toward R1. RN-B observed R2's right hand inside the top of R1's shirt and immediately entered the area and instructed R2 to remove his hand, which he did. R2 questioned the intervention and complied when redirected. R1 did not demonstrate any reaction or response during the incident. RN-B stated R2 was then escorted away from the area by another nurse. RN-B was aware R2 had a history of making sexual comments but was not fully aware of prior sexual touching behaviors. RN-B stated following the incident, R2 was separated from female residents and was encouraged to remain in his room or be supervised in common areas. R2 was later moved to the Roseview unit, although she was uncertain what additional interventions were implemented. RN-B was not notified of further follow-up or updates regarding the plan of care and stated she believed both R1 and R2 lacked capacity to provide consent. During an interview on 4/15/26 at 9:58 a.m., RN-C stated she was the nurse assigned to both R2 and R1 on 4/4/26. RN-C stated R1 was already in the day room around 6:00-6:15 a.m., and was noted to be very confused and disoriented, believing she was at a zoo, and required monitoring due to fall risk. RN-C was informed by a nursing assistant during the morning med pass that R2 had engaged in inappropriate sexual behavior toward R1. RN-C immediately consulted with RN-B and RN-D and the administrator was notified. RN-C stated R2 was assessed and instructed to remain in his room while R1 was to be kept separate from him. RN-C was aware R2 had a history of intermittent inappropriate sexual comments that were typically redirectable with distraction. Current expectations included keeping R2 in his room or with male residents in the dining area and separating him from female residents. RN-C stated in her opinion neither R2 nor R1 had capacity to consent due to dementia. During a phone interview on 4/15/26 at 10:11 a.m., nursing assistant (NA)-F stated she worked the 6:00 a.m. shift on 4/4/26 and found R1 already seated in the TV lounge after night staff had gotten her up early due to inability to sleep. NA-F stated she provided morning care to R2 around 6:30 a.m. and brought him to the TV lounge in a wheelchair. R2 must have wheeled himself close to where R1 was seated because she was informed R2 had fondled R1's breast while in the TV lounge. NA-F stated she was not aware of R2's prior history of sexual misconduct at the time of the incident as it was not on their Kardex. Had NA-F been aware she would have ensured female residents were not placed near him. After the incident R1 made statements believing R2 was her father and stating, my dad just grabbed my boob. NA-F redirected R1 to her room and R1 remained confused and was talking about unrelated topics and hallucinations. R2 was subsequently removed from the area following the incident and all staff were expected to monitor him, although no specific staff member was assigned to 1:1 supervision. NA-F explained R2 had made sexually suggestive comments to her such as asking to kiss her belly but was generally redirectable when boundaries were set. NA-F reviewed general sexual abuse education but did not receive specific information regarding R2's behavioral history. NA-F stated she believed stronger supervision and direct escorting from communal areas would be necessary to prevent recurrence. During an interview on 4/15/26 at 9:10 a.m., NA-D stated he worked the day shift on 4/4/26 and was assigned to the opposite hall from R2 and did not have significant interaction with him that day. NA-D stated typically R2 was brought to the Country View TV lounge by staff around 6:30 a.m. until breakfast, where both male and female residents were present. Since NA-D was not aware on 4/4/26 of R2's sexual behavior history, he may have placed or wheeled R2 near female residents. If NA-D had known, he would not have positioned R2 next to female residents. NA-D had been recently educated that R2 was moved to Roseview unit and staff were to redirect, distract, and remove R2 from situations if inappropriate behavior occurred and to report immediately to nursing staff. NA-D believed R2 would be appropriate if maintained in an all-male environment and stated staff, including contracted staff, needed awareness of his past sexual behaviors. During an interview on 4/16/26 at 9:55 a.m., RN-D stated she was the charge nurse on 4/4/26 when she was notified that R2 placed his hand under R1's shirt and touched her breast in the Country View TV lounge, after which staff immediately removed R2's hand, redirected him, and returned him to his room. RN-D assessed R1 with no physical injuries noted but observed confusion, and she contacted the physician assistant regarding R1's condition. RN-D was aware R2 had a prior history of sexually inappropriate behavior, had previously been placed on an all-male unit, and had not had recent incidents for approximately two years. RN-D stated immediate interventions included separating R2 from female residents, returning him to his room, and verbally notifying staff for ongoing monitoring and removal from common areas after meals. RN-D was not directed to contact law enforcement or complete additional resident interviews beyond those involved and noted R2's care plan contained general guidance to be aware of female residents but lacked specific supervision parameters or structured prevention measures. R2 was able to independently propel his wheelchair and was not on continuous supervision at the time of the incident. During an interview on 4/14/26 at 1:14 p.m., NA-A stated it was her first day working on Roseview unit with R2. NA-A stated while she was getting R2 ready this morning, R2 asked if he could lick my belly while he was on the toilet, and she redirected him, stating it was not appropriate. NA-A heard that R2 had grabbed another resident's breasts and that staff were attempting to keep him on the Roseview unit due to this incident but did not require continuous supervision. R2 was sometimes left in the TV lounge unsupervised but no female residents were typically present in the lounge on that side of the unit. NA-A stated if she observed inappropriate behavior, she would separate R2, return him to his room, and report it to the nurse. NA-A had no previous knowledge of R2's previous history. During an interview on 4/14/26 at 1:24 p.m., NA-B stated she had never personally witnessed R2 being sexually inappropriate with staff or residents; however, she was aware of R2's sexual behaviors and previous incident in 2023. NA-B explained R2 was not to sit next to female residents and required supervision when out of his room. Staff at the nurses' station were responsible for monitoring R2 when he was in common areas, however no staff were specifically assigned. NA-B believed R2 should be more closely supervised due to the potential risk of him independently accessing other female residents. During an interview on 4/14/26 at 1:37 p.m., NA-C stated he had worked at the facility since 2022 and was aware R2 previously placed his hand up a female resident's shirt and fondled her breast. NA-C stated R2 was currently monitored with interventions including keeping him on the Roseview unit, preventing him from entering resident rooms, and redirecting him to the TV lounge for supervision. NA-C stated staff were expected to observe R2 when possible, but he could move throughout the unit if not directly supervised. During an interview on 4/14/26 at 1:55 p.m., RN-F stated R2 had been fine up until the incident with R1 and had not personally observed prior sexually inappropriate behaviors. Current interventions included ensuring R2 did not sit next to female residents and immediately reporting any concerns. RN-F stated since 4/4/26, R2 did not have increased supervision to her knowledge and indicated she believed prior supervision may have been reduced due to a period without incidents. During an interview on 4/14/26 at 2:06 p.m., licensed practical nurse (LPN)-A stated R2 typically requested food, sleep, and assistance with being transported to different areas of the unit. LPN-A stated an awareness of R2's prior history of sexual behaviors and was aware R2 had engaged in inappropriate sexual touching toward R1 on 4/4/26. LPN-A had not personally witnessed R2 being sexually inappropriate with staff or residents, but all behavioral concerns should be reported for documentation. LPN-A stated current interventions included keeping R2 away from female residents by limiting him to his room, the lounge, or dining room, with staff removing him from the dining room after meals. LPN-A stated R2 did not have 1:1 supervision and was able to independently wheel himself in his wheelchair. During an interview on 4/14/26 at 3:59 p.m., nurse manager (NM)-A and NM-B stated R2 had a prior history of inappropriate sexual touching involving a female resident R3 in 2023, after which R2 was moved to the Roseview unit, which was maintained as an all-male unit with increased supervision. NM-A stated R2 was previously placed on 1:1 supervision when out of his room and was started on Paxil for sexual behaviors. NM-A stated R2 was moved back to Country View on 7/25/25 due to a facility remodel, and at that time there were no identified updates to the care plan to ensure continued prevention of inappropriate sexual behaviors with female residents. NM-A stated staff were aware R2 had a history of sexual inappropriateness and were expected to monitor him when out of his room. During an interview on 4/14/26 at 4:37 p.m., the director of nursing (DON) recited R2's sexual behavior history involving a female resident resulting in move from Roseview to Country View. DON indicated when R2 moved back to Country View on 7/25/25, she was unsure whether his care plan interventions were reviewed prior to his return to that unit where female residents were present. On 4/4/26, R2 had an incident involving inappropriate sexual touching of R1, after which R2 was moved back to the Roseview unit due to fewer female residents on that unit. During an interview on 4/15/26 at 7:08 a.m., LPN-B stated she received report from the night shift that R2 had been up approximately every hour since 12:30 a.m. using the bathroom and had been real grabby with staff while being toileted. During an observation and interview on 4/15/26 at 7:50 a.m., R2 was seated at a table in the dining room. R2 stated, I didn't do it, and laughed when asked to clarify. R2 was oriented to self and location, correctly identifying his name and the dining room. R2 stated, I don't do any touching except my food. If I want something I just ask. I don't touch other people. R2 further stated he had not been told about any incidents involving another person and appeared confused when questioned. When asked about appropriate behavior if someone did not want to be touched, R2 stated, I don't touch them. During an interview on 4/15/26 at 8:38 a.m., RN-G stated he was working on 4/4/26 when RN-B informed him around 7:30 a.m. that R2 had inappropriately touched R1 earlier that morning. RN-G stated he assessed R2, who was seated in his wheelchair outside the TV lounge, and encouraged toileting; R2 did not disclose the incident during that interaction. RN-G stated he was aware of a prior incident involving another female resident from documentation in the care plan and stated he would redirect R2 if he observed him near female residents. RN-G stated current interventions included relocating R2 back to Roseview unit, where the population was primarily male, and removing him from the dining room after meals due to toileting needs. RN-G stated R1 could wheel self in wheelchair and did not currently require 1:1 supervision. During an interview on 4/15/26 at 9:23 a.m., NA-E stated she was aware R2 had a history of inappropriate sexual touching toward another resident and staff were to keep him separate from female residents. NA-E stated she did not have direct interaction with R2 on 4/4/26 but did hear he had inappropriately touched R1's breast. After the incident interventions included keeping R2 in his room, the TV lounge on Roseview or on his designated hall and immediately reporting any inappropriate behavior to nursing staff. NA-E stated R2 was able to wheel himself and required staff monitoring to ensure he remained in appropriate areas. NA-E stated staff did not provide 1:1 supervision and indicated it was possible R2 could access other areas or residents when staff were busy, although staff at the desk were expected to observe him. During a phone interview on 4/15/26 at 1:38 p.m., family member (FM)-A stated the facility contacted him approximately a week and a half prior and reported R2 was a little grabby with a female resident. R2's short-term memory was poor, but he retained long-term memories and had demonstrated dementia symptoms since admission, which impacted his judgment. FM-A had not previously been aware of any incidents involving inappropriate grabbing or sexual behavior prior to the 4/4/26 incident, and stated this behavior was new information. FM-A had not been informed of any prior supervision requirements beyond a recent discussion of possible medication management. FM-A stated he did not believe R2 was safe to be around others without close supervision. During a phone interview on 4/15/26 at 1:50 p.m., resident representative (RR)-A stated R1 was previously a happy and social individual before her cognitive decline. R1 previously would have reacted strongly if someone invaded her personal space and might have even hauled off and slugged them. R1 previously demonstrated the ability to recognize inappropriate behavior and would have reported or responded to unwanted physical contact. R1had dementia and was unsure of her current ability to consistently recognize or report inappropriate behavior. RR-A stated she believed R1 would have been upset and humiliated by the incident and R1 required close supervision and protection from such occurrences due to her cognitive impairment. During an interview on 4/15/26 at 11:39 a.m., the director of nursing (DON) stated R2 was admitted to the facility to the Country View unit in 2022 and initially had no known history of sexually inappropriate behaviors. R2's first documented inappropriate sexual touching occurred on 9/17/23 when R3 was in the Country View TV lounge, staff observed R2 groping a female resident's breast under her shirt. Following this incident, R2 was moved to the Roseview unit on an all-male hallway, started on Paxil for sexual urges and had 1:1 supervision with ongoing interdisciplinary team review and redirection strategies. Paxil was discontinued on 9/20/24 following a gradual dose reduction due to stability at that time. The DON stated during a 2025 facility remodel on the Roseview unit, R2 was relocated back to the Country View unit and DON was not aware of a comprehensive review or update of care plan interventions specific to preventing recurrence of sexual behaviors. The DON stated current interventions were primarily focused on general supervision, environmental awareness, and avoiding close proximity to female residents; however, she acknowledged R2 remained able to self-propel in a wheelchair, could move independently in common areas and was not supervised at all times. no additional structured or individualized supervision plan (such as 1:1 supervision or defined escorting protocols) was implemented after the relocation. The DON stated R2 continued to exhibit sexually inappropriate behaviors after placement changes and Paxil would be started for sexual urges pending prior authorization but confirmed that no further comprehensive intervention revisions were made following the most recent unit transfer on 4/6/26. During an interview with DON and RN-E on 4/16/26 at 11:07 a.m., DON stated current interventions for R2 included ensuring adequate space between R2 and R1 following the incident but was unable to clarify how staff were expected to consistently implement this intervention or identify clear parameters for supervision. RN-E stated interventions included ensuring staff were aware of females surrounding R2 when out of his room, allowing him to leave the unit for activities, and addressing any concerns for inappropriate behaviors immediately. RN-E stated she interpreted the intervention as keeping female residents away from R2 and removing them if they approached him, and further stated the facility used general or vague interventions to increase supervision without placing R2 on 1:1 supervision. RN-E and the DON both stated the care plan did not clearly define the level of supervision required or provide specific guidance for staff regarding R2's history of sexual behaviors. During an interview on 4/16/26 at 12:21 p.m., DON stated the level of supervision for R2 was determined using clinical judgment based on behavior monitoring, charting, and interdisciplinary team (IDT) review, and stated supervision decisions were an IDT responsibility with weekly reviews documented in resident records. The DON stated these reviews were not consistently completed after R2's transfer to Country View in 7/25/25 due to the facility remodel and further stated there was no clinical documentation reflecting updated supervision decisions following the move. 4/16/26 at 10:59 a.m., attempted call to the medical director and left voicemail for call back. DON stated she emailed the medical director asking him to call this surveyor back. No callback received. Facility policy, Individualized Care Plan, reviewed 7/2025, identified a comprehensive, individualized care plan is developed based on interdisciplinary assessments to reflect the resident's medical, nursing, psychosocial, and behavioral needs. The policy identified the interdisciplinary team (IDT) is responsible for developing and revising the care plan to address identified problems and ensure interventions are implemented through the kardex for staff to follow. The policy further identified the care plan must be revised promptly with any change in the residents' condition, including following an incident of abuse, and that interventions are to be individualized and updated to reflect the residents' needs. Facility policy, Mood and Behavioral Health, reviewed 1/22/2025, identified the facility must provide behavioral health care and services to meet residents' psychosocial and behavioral needs based on comprehensive assessment and interdisciplinary team (IDT) care planning. The policy identified behavioral symptoms may be potentially harmful to the resident or others and must be assessed, care planned, implemented, and evaluated through the Resident Assessment Instrument (RAI) process. The policy further identified the IDT is responsible to assess mood and behavioral symptoms, develop individualized interventions, and review behaviors and effectiveness of interventions on admission, quarterly, annually, and with significant change, to ensure residents' needs are met and risks are addressed. Facility policy, Vulnerable Adult-Abuse Protection Plan, reviewed 10/2024, identified the facility supports zero tolerance for abuse, including sexual abuse, and requires protection of vulnerable adults from maltreatment. The policy defined abuse to include non-consensual sexual contact, including sexual contact with a resident who lacks capacity to consent due to cognitive impairment. The policy further identified that residents must be protected from abuse and that staff are responsible for identifying, reporting, and responding to suspected maltreatment. The policy also identified the facility will assess residents for risk of abuse and implement care planning interventions to protect residents from harm and prevent abuse. The Immediate Jeopardy was removed on 4/17/26 when it was verified the facility implemented immediate corrective actions to ensure the health and safety of residents and prevent further risk of resident-to-resident sexual abuse, including: -R2 was placed on 1:1 continuous supervision to prevent unsupervised access to other residents and was observed to be under direct staff monitoring. -The facility implemented immediate separation of R2 from female residents, including structured seating arrangements and supervision in common areas. -R2's care plan and kardex were revised to include specific, individualized, and enforceable interventions, including: -Continuous supervision requirements -Direction to maintain distance from female residents (not within arm's reach) -Immediate staff intervention and redirection for any inappropriate behavior -Defined staff responsibilities for monitoring and reporting -Staff were educated on R2's supervision requirements and abuse prevention and were able to verbalize expectations for maintaining resident safety. -The facility conducted a facility-wide review of residents with potential for sexually inappropriate behaviors, and updated care plans to ensure appropriate supervision and interventions were in place. -The facility implemented a system to communicate high-risk behaviors to staff, including accessible resident-specific information at nurse stations. -The facility initiated auditing and monitoring processes to ensure compliance with supervision, care planning, and abuse prevention policies.

Based on interview and record review, the facility failed to ensure a thorough investigation of an allegation of resident-to-resident sexual abuse for 2 of 2 residents (R1) and (R2), including failure to complete staff and resident interviews and failure to fully assess the circumstances surrounding the incident, reviewed for abuse.Findings include:R1's Face sheet printed 4/16/26, identified R1 had diagnoses of dementia and anxiety disorder.R1's quarterly Minimum Data Set (MDS), dated [DATE], identified that R1 had severe cognitive impairment and used a Wanderguard daily.R1's care plan, revised 8/26/25, identified a focus of risk for vulnerability related to recent placement, impaired cognition, and limited mobility. Interventions, dated 7/30/25, identified that any suspicion of maltreatment was to be reported per facility policy, a safe environment was to be maintained, and suspected incidents of abuse were to be reported to the supervisor.R2's face sheet, printed 4/16/26, identified that R2 had diagnoses of dementia and unspecified mood disorder.R2's quarterly MDS, dated [DATE], identified that R2 had severe cognitive impairment and was independent with wheelchair mobility.R2's care plan, dated 4/1/22, identified a focus of risk for vulnerability related to recent placement. Interventions, dated 4/1/22, identified that any suspicion of maltreatment was to be reported per facility policy, a safe environment was to be maintained, and suspected incidents of abuse were to be reported to the supervisor.The facility reported incident (FRI), submitted to the state agency on 4/4/26 at 8:27 a.m., identified a nurse observed R2 touching R1's breast in the Country View (CV) TV lounge and immediately separated the residents. The report indicated the residents did not believe the behavior was inappropriate. Further identified the allegation was witnessed by staff; however, the report did not include detailed findings from a comprehensive investigation.The facility's 5-day investigative summary, submitted to the state agency on 4/10/26 at 10:36 p.m., indicated the allegation was verified as it was witnessed by staff; however, the report lacked documentation of comprehensive interviews with staff and residents who may have had knowledge of the incident or relevant history.R2's progress note, dated 4/4/26 at 9:15 a.m., identified that at approximately 7:00 a.m., a hall nurse observed R2 place his hand under R1's shirt and touch her left breast in the Country View (CV) TV lounge. Staff immediately removed R2's hand, separated the residents, and returned R2 to his room. R2 was noted to have dementia and was unable to recall the incident, stating, Some people don't mind and I didn't hurt anyone. The administrator, director of nursing (DON), and nurse manager were notified, and R2 was placed on increased monitoring with separation from female residents and redirection to his room following meals. Provider was contacted to evaluate medication management due to history of similar behaviors.During an interview on 4/15/26 at 9:35 a.m., registered nurse (RN)-B stated she witnessed the incident and reported it to the charge nurse; however, she was not contacted by administration for follow-up interview as part of the investigation.During an interview on 4/16/26 at 9:55 a.m., registered nurse (RN)-D stated she completed assessments of R1 and R2 following the incident and notified administration; however, she was not directed to interview additional residents or staff beyond those immediately involved.During an interview on 4/16/26 at 9:55 a.m., RN-D stated she was not directed to conduct interviews with other residents in the area or staff who may have had additional information regarding R2's behaviors.During an interview on 4/15/26 at 9:58 a.m., registered nurse (RN)-C stated she was the assigned nurse for both residents on the date of the incident; however, she was not interviewed by administration regarding the incident.During an interview on 4/15/26 at 10:11 a.m., nursing assistant (NA)-F stated she assisted both residents on the morning of 4/4/26 and placed them in the Country View (CV) TV lounge prior to the incident; however, NA-F stated she was not interviewed by administration as part of the investigation.During an interview on 4/15/26 at 12:43 p.m., the Director of Nursing (DON) and Administrator stated they were responsible for managing the investigation; however, no documentation was provided to demonstrate that a comprehensive investigation, including interviews with all relevant staff and residents, was completed.Facility policy, Vulnerable Adult-Abuse Protection Plan, reviewed 10/2024, identified the facility will immediately initiate an internal investigation of all alleged violations involving abuse. The policy identified the investigation will include, but is not limited to, interviews with staff, residents, and witnesses; collection of written statements; care observations; environmental review; and medical record review. The policy further identified the facility is responsible to ensure a thorough investigation is completed and results are reported.

Based on interview and record review, the facility failed to report an allegation of resident-to-resident sexual abuse involving 2 of 2 residents (R1) and (R2) to law enforcement, in accordance with established policies and procedures for abuse. Findings include:R1's Face sheet printed 4/16/26, identified R1 had diagnoses of dementia and anxiety disorder.R1's quarterly Minimum Data Set (MDS), dated [DATE], identified that R1 had severe cognitive impairment and used a Wanderguard daily.R1's care plan, revised 8/26/25, identified a focus of risk for vulnerability related to recent placement, impaired cognition, and limited mobility. Interventions, dated 7/30/25, identified that any suspicion of maltreatment was to be reported per facility policy, a safe environment was to be maintained, and suspected incidents of abuse were to be reported to the supervisor.R2's face sheet, printed 4/16/26, identified that R2 had diagnoses of dementia and unspecified mood disorder.R2's quarterly MDS, dated [DATE], identified that R2 had severe cognitive impairment and was independent with wheelchair mobility.R2's care plan, dated 4/1/22, identified a focus of risk for vulnerability related to recent placement. Interventions, dated 4/1/22, identified that any suspicion of maltreatment was to be reported per facility policy, a safe environment was to be maintained, and suspected incidents of abuse were to be reported to the supervisor.The facility reported incident (FRI), submitted to the state agency on 4/4/26 at 8:27 a.m., identified a nurse observed R2 touching R1's breast in the Country View (CV) TV lounge and immediately separated the residents. The report indicated the residents did not believe the behavior was inappropriate. The section identifying the name and position of the individual who reported the incident to law enforcement, if different from the submitter, was left blank, with no documentation indicating the allegation was reported to law enforcement.The facility's 5-day investigative summary, submitted to the state agency on 4/10/26 at 10:36 p.m., indicated the allegation was verified as it was witnessed by staff; however, the report did not identify that the incident was reported to law enforcement.R2's progress note, dated 4/4/26 at 9:15 a.m., identified that at approximately 7:00 a.m., a hall nurse observed R2 place his hand under R1's shirt and touch her left breast in the Country View (CV) TV lounge. Staff immediately removed R2's hand, separated the residents, and returned R2 to his room. R2 was noted to have dementia and was unable to recall the incident, stating, Some people don't mind and I didn't hurt anyone. The administrator, director of nursing (DON), and nurse manager were notified, and R2 was placed on increased monitoring with separation from female residents and redirection to his room following meals. Provider was contacted to evaluate medication management due to history of similar behaviors.During an interview on 4/15/26 at 12:43 p.m., the Director of Nursing (DON) and Administrator stated they were responsible for managing the investigation and confirmed the incident was not reported to law enforcement.Facility policy, Vulnerable Adult-Abuse Protection Plan, reviewed 10/2024, identified the facility supports zero tolerance for abuse and requires all alleged violations involving abuse, including sexual abuse, to be reported immediately. The policy identified mandated reporters must report suspected abuse internally and externally, including reporting reasonable suspicion of a crime to law enforcement and required state agencies within required timeframes. The policy further identified that when an allegation involves potential criminal conduct, the Administrator or designee will contact law enforcement.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for 1 of 1 resident (R2) when staff did not consistently document episodes of sexually inappropriate comments toward staff, resulting in gaps in behavioral tracking and an inability to accurately evaluate the frequency and severity of R2's behaviors, reviewed for abuse.Findings include:R2's face sheet, printed 4/16/26, identified that R2 had diagnoses of dementia and unspecified mood disorder.R2's quarterly MDS, dated [DATE], identified that R2 had severe cognitive impairment and was independent with wheelchair mobility.R2's behavior care plan focus, revised 4/7/26, identified R2 had behavioral instances of inappropriately sexual touching toward another resident on 9/17/23 and 4/4/26 in the Country View (CV) common area. R2 was identified as being at risk for alteration in behavior due to a diagnosis of dementia and was unable to recall the incidents. The care plan further identified R2 occasionally made inappropriate comments to female staff that were usually easily redirected. R2 had previously been on Paxil with a successful gradual dose reduction (GDR) and discontinuation. Interventions included not placing R2 in close proximity to female residents.R2's plan of care (POC) behavior monitoring and interventions were reviewed from 3/18/26 to 4/16/26 and identified that on 4/15/26 R2 was grabbing others; however, no corroborating documentation was identified in the medical record to support or further describe this behavior.During an interview on 4/14/26 at 1:14 p.m., nursing assistant (NA)-A stated it was her first day working on RV unit with R2. NA-A stated while she was getting R2 ready in the morning, R2 asked if he could lick my belly while he was on the toilet, and she redirected him, stating it was not appropriate.During an observation on 4/14/26 at 2:04 p.m., R2 was seated in the Country View (CV) TV lounge when he responded to staff offering to assist him to bed by stating, With you?During an interview on 4/15/26 at 7:08 a.m., licensed practical nurse (LPN)-B stated she received report from the night shift that R2 had been up approximately every hour since 12:30 a.m. using the bathroom and had been real grabby with staff while being toileted.Review of R2's medical record did not identify documentation of the above sexually inappropriate behaviors.During an interview on 4/16/26 at 11:07 a.m., the Director of Nursing (DON) stated when R2 exhibited inappropriate behaviors, staff were expected to document these in behavior notes to allow tracking and evaluation of the effectiveness of interventions.Facility policy, Mood and Behavioral Health, reviewed 1/22/2025, identified the facility must provide behavioral health care and services to meet residents' psychosocial and behavioral needs based on comprehensive assessment and interdisciplinary team (IDT) care planning. The policy identified behavioral symptoms may be potentially harmful to the resident or others and must be assessed, care planned, implemented, and evaluated through the Resident Assessment Instrument (RAI) process. The policy further identified the IDT is responsible to assess mood and behavioral symptoms, develop individualized interventions, and review behaviors and effectiveness of interventions on admission, quarterly, annually, and with significant change, to ensure residents' needs are met and risks are addressed.Facility policy, Retention and Destruction Policy, dated 10/2024, identified medical records must be retained in accordance with state and federal requirements and must be maintained in a manner that ensures they are available for audits, legal review, and quality assessment during the retention period. The policy further identified active medical records are maintained in the electronic health record (EHR) and must be accessible to authorized staff for ongoing care and documentation of resident services. The policy also identified resident medical records must be complete and maintained in a manner that supports continuity of care and accurate review of resident condition and services provided.

Based on observation, interview and document review the facility failed to comprehensively assess sling/harness sizes according to manufacturer's instructions to ensure safe transfers for 2 of 2 residents (R1 and R3) who utilized mechanical lifts sit to stand lift and full body mechanical lifts for transfers.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was intact, with diagnoses of generalized anxiety disorder, diabetes, morbid obesity and heart failure. Further indicated an impairment in range of motion (ROM) on both sides of upper and lower extremities and required extensive assist of 2 staff with transfers and used a motorized wheelchair for mobility. R1's Occupational Therapy (OT) treatment encounter note, dated 3/5/24, identified R1 was discharging from OT due to goals met and maximum potential reached. Recommendation for EZ stand use to get to/from chair and toileting (Hoyer (brand of full body lift) as needed). OT note did not identify the size of sling R1 required for lift transfers.R1's care plan dated 6/6/25, identified a focus of activities of daily living (ADL) self -care performance deficit related to back pain and decreased mobility status, morbid obesity, osteoarthritis pain in bilateral shoulders and peripheral neuropathy. Intervention revised 10/7/25, directed staff to use an extensive mechanical stand and 2 staff for going on and off the commode and in and out of bed. R1's care plan did not identify the size of sling R1 required for transfers.R1's Kardex printed 10/13/25, directed staff that R1 required extensive mechanical stand with assist of 2 staff for going on/off commode and in/out of bed. R1's Kardex did not identify the size of sling R1 required for transfers.R1's Progress note dated 10/14/25, identified R1 was readmitted to the facility at 12:30 p.m., and will need a 2 person assist with transfers with a mechanical lift using an XL sling. Will require 2-3 staff to assist with toileting. R1's record was reviewed and lacked a Mechanical Lift Sling Assessment.In review of R1's record it was not evident a comprehensive assessment for sling size was completed. The assessment should have included height, weight, measurement of the maximum distance from resident's tailbone to base of neck and girth that is required by the manufacturer for appropriate sizing and safety.During an observation and interview on 10/15/25 at 10:30 a.m., R1 was lying in her bed. R1 stated she hasn't gotten out of bed since she came back from the hospital yesterday but stated when she does, it will be with the full body lift. During an interview on 10/13/25 at 3:46 p.m., registered nurse (RN)-D stated therapy would be the ones who assess each resident for sling/harness size. RN-D reviewed R1's record and stated R1 used a mechanical lift for transfers but the care plan did not identify what size sling to use. RN-D was unable to articulate exactly what size R1 would use. During an interview on 10/13/25 at 4:04 p.m., nursing assistant (NA)-A stated R1 has her own sling in her room we use. NA-A stated our care plans do not tell us what size sling/harness to use for residents who use mechanical lifts, it's more of a guessing game.During an interview on 10/14/25 at 12:31 p.m., LPN-C stated R1 had a special sling in her room we used, was unsure what the size was. LPN-C stated she had never seen a formal sling/harness assessment used before we just go by a resident's weight.R3's admission MDS dated [DATE], indicated R3 had moderately impaired cognition, with diagnoses of Parkinson's disease (progressive brain disorder that affects movement), non-Alzheimer's dementia, and restlessness and agitation and was extensive assist of two staff with transfers. R3's care plan revised 8/5/25, identified a focus of activities of daily living (ADL) self-care performance deficit related to dementia with delirium and agitation and Parkison's. Intervention revised 9/8/25, directed staff to use a standing lift with 2 staff to move between surfaces. R3's care plan did not identify the size of harness that R3 required for transfers.R3's Kardex printed 10/21/25, directed staff that R3 required standing lift with 2 staff assist for transfers. R3's kardex did not identify the size of harness R3 required for transfers.R3's medical record reviewed and lacked a Mechanical Lift Sling Assessment.In review of R3's record it was not evident a comprehensive assessment for harness size was completed. The assessment should have included weight and circumference of patient's torso where the harness is applied that is required by the manufacturer for appropriate sizing and safety.During an interview on 10/13/25 at 4:13 p.m., physical therapist (PT)-A stated we call the EZ stand a standing lift, and we call the Hoyer lift a mechanical lift. PT-A further stated If staff feel like a resident is not doing well with a standing lift, we will talk with the resident and watch the aide do the transfer and write it up as a screen if it looks safe. If not safe and resident continues to want the standing lift, we will do an evaluation and start a therapy program. PT-A stated nursing would be responsible to assess for sling/harness size with mechanical lift use.During an interview on 10/13/25 at 4:34 p.m., nurse manager (NM)-A stated we do not have any formal sling/harness assessments. NM-A further stated the aides have access to a laminated paper chart in the tub rooms so you can look at the weight of a person to determine sling size. NM-A stated we do not put sling sizes on the resident's care plans.During an interview on 10/13/25 at 4:38 p.m., infection control nurse (ICN)-A stated she was responsible for staff education. ICN-A stated we typically go by weight to find out what size sling/harness a resident would use and the aides were educated on this. ICN-A stated we do not do any formal assessments that we would document to determine sling/harness size for residents who utilize mechanical lifts for transfers.During an interview on 10/13/25 at 4:29 p.m., director of nursing (DON) stated she was unsure who assessed sling/harness size for residents who utilized mechanical lifts, thought maybe the nurse managers did. DON stated we do not put sling sizes on the resident's care plans. During a subsequent interview at 4:49 p.m., DON stated there were roughly 22 residents who utilize mechanical lifts.During an interview on 10/14/25 at 11:03 a.m., nurse manager (NM)-B stated it would be up to nursing to assess for sling/harness assessments for residents who utilize mechanical lifts, we currently have not been doing them. The current process was the aides get the residents most current weight and look at the chart in the tub room to determine what size sling/harness to use. NM-B stated we do not put sling sizes on the resident's care plans.During an interview on 10/14/25 at 11:38 a.m., LPN-A stated we do not assess for sling/harness size for residents who utilize mechanical lifts. LPN-A stated we used to go by a resident's weight to determine the correct size. LPN-A stated if someone was 95 pounds they could be either a small or a medium, we would have to check to make sure it was a proper fit, like not too tight or too loose.During an interview on 10/14/25 at 11:44 a.m., RN-A stated we have never assessed for sling/harness size, we would just look at the weight and go by the chart to determine what size. RN-A stated the nurse should be the one doing the assessment not the aide.During an interview on 10/14/25 at 11:52 a.m., LPN-B stated we currently go by a resident's weight to determine sling/harness size. LPN-B further stated we do not put sling sizes on the resident's care plans.During an interview on 10/14/25 at 12:06 p.m., RN-B stated for residents who utilize the stand lift we should be going by resident weight and torso circumference. RN-B stated there is no formal assessment and the size of the sling/harness was not typically updated to the care plan. During an interview on 10/14/25 at 12:21 p.m., RN-C stated we do not have a specific assessment to determine sling/harness size for resident's who utilize a mechanical lift, we use the chart as a guide against the resident's weight. RN-C further stated the nurse should be monitoring the resident's weight to determine if a resident would need to go up or down in size. During an interview on 10/14/25 at 12:39 p.m., NA-B stated the sling/harness sizes are not on the resident's care plans. NA-B further stated we go by the resident's weight and look at the chart to determine what size to use.During an interview on 10/14/25 at 1:10 p.m., NA-C stated we go by a resident's weight and look at the chart to see what size sling/harness to use, the sizes are not on our care plans. NA-C stated we are the ones who have to figure out what size to use.During an interview on 10/14/25 at 1:34 p.m., NA-D stated we go by a resident's weight and look at the chart in the tub room to figure out what size sling/harness to use. NA-D stated if the sling seems too big or too small, we would grab a different size to try and make sure it fits good.During an interview on 10/14/25 at 1:34 p.m., NA-E stated there are sheets in tub room that tell us what size sling/harness to use for mechanical lift transfers, we just have to know the resident's most current weight. NA-E stated we all have pretty good judgement with the residents we work with. During an interview on 10/14/25 at 1:53 p.m., NA-G stated we did not have sling size on kardex or care plans, we had a laminated card that is on all the machines, and we have access to all resident weights of the residents. NA-G stated we would go by weights before yesterday now the sling size is on the kardex. NA-G further stated you would never transfer someone if the sling was too big or small we would not want them to fall out.Requested facility policy and procedure for mechanical lift equipment and was not received. EZ Way Classic Lift operator's instructions, revised 5/5/25, identified.patient lifts and stands should only be operated by trained personnel, and a full patient assessment should be conducted to determine the appropriate accessory size and type prior to each use.EZ Way Classic Stand operators' instructions revised 4/11/25, identified. The Classic Stand(R) was designed specifically for toileting and changing briefs of patients. The Classic Stand(R) can also be used for transferring the patient from chair, wheelchair, toilet or bed, and can be used for ambulation. As patients do vary in size, shape, weight and temperament, these conditions must be taken into consideration when deciding if the Classic Stand(R) is suitable for their needs. Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. If a patient does not meet each of these three criteria, an EZ Way total body lift must be used .patient lifts and stands should only be operated by trained personnel, and a full patient assessment should be conducted to determine the appropriate accessory size and type prior to each use.Ez Way Sling Size Chart, revised 9/13/24, identified a sling color coding system based on weight of patient and maximum distance from patient's tailbone to base of the neck:Small: gray; 70-100 pounds; 21 inchesMedium: beige; 90-220 pounds, 24 inchesLarge: burgundy; 190-320 pounds; 26 inchesExtra-large: green; 280-450 pounds; 26 inchesExtra extra large: 400 -600 pounds; black; 36 inchesExtra extra extra large: brown; 600 + pounds 37 inchesNote: The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. A proper fit will involve the judgment of the caregiver. It is important to evaluate the width of a patient in relation to the width of the sling. It is important that no portion of the patient overlap the sides of the sling. It is important that the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of neck). Note: Slings using Wipeable fabric use beige binding for all sizes and do not follow the color-coding system. Slings using antimicrobial fabric use silver binding for all sizes and do not follow the color-coding system.Ez Way Harness Size Chart, revised 9/13/24, identified a sling color coding system based on weight of patient and circumference of patient's torso where harness is applied:Small: gray; 70-100 pounds; 26 to 38 inchesMedium: beige; 90-220 pounds, 34 to 46 inchesLarge: burgundy; 190-320 pounds; 40 to 56 inchesExtra-large: green; 280-450 pounds; 50 to 64 inchesExtra extra large: 400 -600 pounds; black; 55 to 72 inchesExtra extra extra large: brown; 600 + pounds; 65 + inchesNote: The size/weight of designations are merely estimates and basic guidelines. A proper fit will involve the judgement of the caregiver. Color coding applies to the binding of the harnesses. Harnesses and accessories using Wipeable fabric use burgundy binding for all sizes and do not follow the color-coding system. Harnesses using antimicrobial fabric use silver binding for all sizes and do not follow the color-coding system.

Based on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP) were implemented with the use of personal protective equipment (PPE) during high-contact resident care activities for 1 of 1 residents (R5) who had a foley catheter, and failed to ensure shared resident equipment was disinfected between uses. Findings include: R5's annual Minimum Data Set (MDS) assessment dated [DATE], identified intact cognition, and substantial/maximal assist was required for bathing and dressing. R5 had an indwelling catheter and diagnoses of severe obesity, heart failure and renal insufficiency. R5's Incontinence/Indwelling Catheter Care Area Assessment (CAA) dated 6/12/25, was triggered due to assistance needed with toileting and an indwelling catheter was required. R5's care plan dated 2/10/25, identified EBP indefinitely due to foley catheter use. Required PPE included gloves and gown prior to the high-contact care activity; Face protection may also be needed if performing activity with risk of splash or spray. High-contact resident care activities such as but not limited to:* Dressing* Bathing/showering* Transferring* Providing hygiene* Changing linens* Changing briefs or assisting with toileting* Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator* Wound care: any skin opening requiring a dressing. Examples of activities not requiring use of Enhanced Barrier Precautions:A. During interviewsB. Hygienic medication administrationC. Meal tray deliveryD. Not physically coming in contact with patient During an observation and interview on 7/28/24 at 6:24 p.m., R5's room entrance had EBP signage directing staff to wear gown and gloves for bathing and high contact care. In the room, NA-A had a basin of soapy water and a washcloth and provided R5 with a bed bath. NA-A had gloves on, lacked a gown on while providing the bed bath. NA-A washed R5's torso, leaning over the bed with scrubs touching R5's bed. When asked about PPE, NA-A stated there was a central bin of PPE in the hallway, however, PPE was only required for care of R5's catheter. R5 then stated staff only wear gowns when they take care of his catheter. During an interview on 7/28/25 at 6:34 p.m., registered nurse (RN)-A stated EBP PPE was only required during the care of R5's device. R5's EBP signage was reviewed with RN-A, who then stated NA-A should probably have a gown on while providing the bed bath and not just for catheter care. During an interview with the infection preventionist (IP) and director of nursing (DON) together on 7/30/25 at 2:33 p.m., the infection preventionist stated shared equipment cleaning and EBP skills were reviewed at orientation and ongoing training. After leaving a resident room with shared equipment, the equipment should be cleaned and disinfected with the appropriate wipes. The purpose of EBP and disinfecting shared equipment was to prevent spread of multidrug-resistant organisms (MDROs) to residents and staff. The facility's EBP policy dated 1/22/25, identified MDRO EBP expands the use of PPE beyond situations in which exposure to blood and body fluids was anticipated, and referred to the use of gown and gloves during high-contact resident care activities which provide opportunities for transfer of MDROs to staff hands and clothing. EBP were indicated for residents with any of the following: infection or colonization with a MDRO when contact precautions do not otherwise apply; or wounds and or/indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. During observation on 7/29/2025 at 2:16 p.m., nursing assistant (NA)-A and NA-B entered room [ROOM NUMBER] with a facility lift to assist resident. Upon exiting, NA-A immediately took garbage to soiled utility room. NA-B exited room without disinfecting lift, placed lift against opposite wall and went into soiled utility room. NA-A exited soiled utility room and entered room [ROOM NUMBER] to answer the call light. NA-B exited soiled utility room and entered room [ROOM NUMBER] to assist NA-A. RN-A grabbed the lift against the wall that had not been disinfected, RN-A took that lift into room [ROOM NUMBER] without disinfecting the lift. During interview on 7/29/2025 at 2:37 p.m., NA-A and NA-B stated the process for disinfecting lifts was to disinfect the lift in the hall immediately after you were done using it. NA-A and NA-B both confirmed neither of them had disinfected the lift before placing it against the wall. NA-A and NA-B stated the lift should have been disinfected immediately after use to prevent the spread of infection from one resident to another. During interview on 7/29/2025 at 2:43 p.m., registered nurse (RN)-A stated the process was to disinfect lifts immediately after every use. RN-A stated the lifts should be disinfected after every use to prevent the spread of infection. Per facility policy titled Disinfecting of Reusable Equipment and Environmental Surfaces dated 11/8/24, reusable equipment and environmental surfaces will be properly disinfected.

Based on interviews and document reviews, the facility did not assess or analyze trends in falls to determine causal factors or root causes and implemented individualized interventions aimed at preventing or reducing the risk of falls with major injuries for one of three residents (R1) who experienced falls. This resulted in actual harm when R1 suffered two thoracic spinal fractures and hospitalization after he was left unsupervised on the commode and fell . Findings include: R1's After Visit Summary (AVS) dated 2/1/25 to 2/20/25, identified R1 had a newly diagnosed stroke with left sided hemianopsia (loss of vision in half of visual field) hemiparesis (weakness on one side of body), left sided neglect, and right gaze deviation (condition where the right eye deviates to one side and there's difficulty looking to the opposite side). Further identified R1 had safety considerations due to R1's cognition identified he had poor safety awareness, poor attention/concentration and poor judgement. R1's Fall Risk assessment dated [DATE], identified a score of 8 indicating R1 was at moderate risk of falls. R1's AVS dated 2/27/25 to 3/7/25, identified R1's admitting diagnosis was sepsis due to cholecystitis (gall bladder inflammation), presumed prostate cancer with bone metastasis (occurs when cancer cells from a primary tumor elsewhere in the body spread to and establish secondary tumors within the bones), and stercoral colitis (an inflammatory condition of the colon caused by prolonged constipation and fecal impaction). Further identified R1 had safety considerations due to R1's cognition identified he was impulsive, had poor judgement, and poor safety awareness. R1's fall care plan revised 3/13/25, R1 was at risk for falls due to impulsivity related to stroke, cognitive impairment, dependence on staff for transfers and all cares. was reviewed and identified R1 was impulsive, had cognitive impairment and required extensive assist with activities of daily living (ADL's). Interventions dated 3/6/25, included: -R1 needed prompt response to all requests for assist -Anticipate and meet needs. -Be sure call light was in reach -Encourage use for assistance as needed, needed prompt response to all requests for assist -physical therapy (PT) to evaluate and treat as ordered. Care plan was revised on 3/7/25 directed to make sure R1 was centered in bed and ensure bed is in lowest position when cares not being performed. R1's Occupational Therapy (OT) Evaluation and Plan of Treatment dated 3/7/25, identified the reason for therapy was the recommended level of skilled therapy services required due to age, complicated medical history, concomitant cognitive deficits, impairment to multiple areas of the body, impairments to multiple systems, interaction of conditions, multiple diagnoses, need for multiple therapies and patient with dementia requiring repetition of structured task to facilitate new learning. R1's progress note dated 3/8/25, identified R1 was found on the floor in front of his wheelchair at 12:45 p.m., had removed grippy socks and slid out of the wheelchair. When asked what he was doing he replied, my socks aren't very good. R1 had been needing more assist since readmission with confusion. R1 had been sitting in wheelchair but declined to eat lunch. R1 had been more restless since admission wanting staff or someone with him all the time. R1 was last toileted at 12:20 p.m. At 12:40 p.m. nurse offered R1 lunch and R1 declined. Root cause was R1 slid from his wheelchair, new intervention identified blue grippy in wheelchair, R1 not to be left unattended in room when in wheelchair and dining room for meals if family is not present. R1's Fall Incident report dated 3/8/25 at 12:45 p.m., included the aforementioned description of the fall. The incident report also included: Immediate action taken was vital signs were performed, range of motion (ROM) performed with no concerns. Neuros initiated due to an unwitnessed fall. R1 oriented to person with impaired memory. R1's corresponding Fall Scene Investigation Report (FSI) dated 3/8/25, was requested and not received. In review of R1's fall record dated 3/8/25, there was no indication the care plan had been revised with the interventions identified in the progress note. Although the report identified the intervention that directed staff not to leave R1 alone in his room in his wheelchair, the record did not include and assessment that would identify if R1 could be left alone in his room sitting on other surfaces such as commode/toilet or other type of chair. Further, the record did not identify an assessment that determined R1's overall level of supervision to prevent/negate falls related to R1's impulsivity as identified on hospital AVS dated 2/27/25. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses of stroke with left sided hemiplegia, cognitive impairment and long-term use of anticoagulants. R1 had behavioral symptoms not directed at others occurring 1-3 days, impairment in ROM to upper and lower side of body, was extensive assist of two staff with bed mobility, toileting and transfers and was frequently incontinent of bowel and bladder. In addition, R1 had one fall with no injury. R1's Care Area Assessment (CAA) dated 3/13/25, identified R1 had fall risk factors due to being newly diagnosed with a stroke, anticoagulation use, assistance needed for all cares. R1 had a fall when he slid out of his wheelchair (3/8/25) due to two cushions being in place. Cushion was removed and a slip resistant material placed in wheelchair. R1 was not to be up in wheelchair in his room alone. Internal risk factors included diagnoses of stroke with hemiplegia, incontinence, loss of arm or leg movement, cognitive impairment and agitation behavior. R1's Fall Incident report dated 3/13/25 at 6:05 a.m., indicated R1 had an unwitnessed fall and when nursing assistant (NA) entered room R1 was found on the floor; R1's legs were in bed, and he was lying on his back. R1 stated he was trying to get in wheelchair. Immediate action taken was ROM was within normal limits (WNL) for R1. Vital Signs (VS) and neuros started per policy. R1 stated his back hurt when he landed on floor but now it's his pride that hurts. No injuries noted. R1 returned to bed with assist of 2 and lift. Aides changed brief and did ADL's. Mental status identified R1 was cognitively impaired and oriented to person. Predisposing physiological factors that were identified was confused, incontinent, impaired memory and impaired safety judgement. R1's corresponding FSI included the following additional information: R1 was last seen at 4:30 a.m., when staff were taking tube feeding off and flushing his G-tube. Section 5 of the form identifying, last time toileted, was left blank. Interventions included offer fluids when restless, must be supervised and mats next to the bed. R1's progress note dated 3/13/25 at 8:03 a.m., identified R1 had a fall trying to get from his bed to his wheelchair. R1 stated he wasn't hurt and had no injury; he was just trying to get up. Activity level identified R1 had minimal activity and was restless. New intervention to place fall mats on each side of his bed. R1's Occupational Therapy (OT) notes dated 3/13/25, identified spoke with nursing who reported R1 had a fall close to 6:00 a.m., trying to get out of bed. Discussed with nursing strategies to reduce restlessness such as scheduled times to offer him ice chips due to frequently feeling thirsty, typically had not wanted to spend a lot of time outside of his bed. R1's care plan interventions dated 3/13/25, included blue floor mats to be placed on both sides of bed every time R1 was in bed, offer fluids when restless, fluids or ice chips on last rounds, oral care to be done first, scheduled assist with ice chips/free water protocol with staff only in between meals, and wear appropriate footwear; grippy socks or shoes with transfers. Review of R1's fall record dated 3/13/25, identified although the facility determined the predisposing physiological causal factors included incontinence, R1's record did not include an assessment and/or individualized interventions that would prevent or mitigate the risk for falls that would be related to incontinence. R1's Fall Risk assessment dated [DATE], identified a score of 8 indicating R1 was at moderate risk of falls. R1's progress note dated 3/16/25 at 9:30 a.m., identified aide walked past R1's room and noted him to be lying on the floor, nurse was alerted. Note indicated prior to the fall, R1 was lying in his bed slightly positioned on his left side with head of bed elevated 45 degrees. All four mats were on the floor two on each side of the bed. R1's call light was in his hand and on. R1 was transferred back to bed with the Hoyer lift and ensured R1 was positioned more in the center of the bed with the head of the bed not elevated more than 45 degrees. R1's Fall Incident Report dated 3/16/25 at 9:30 a.m., included the aforementioned fall description. Additional information included: R1 had been asking for drinks of water all morning, does not like ice chips, educated on reason why, R1 was upset about not being able to drink water. R1's FSI report dated 3/16/25 was requested and not received. R1's fall record dated 3/16/25 did not include a comprehensive analysis that identified causal factors/root cause nor identify individualized interventions that prevent and/or negate risk for re-current falls. R1's OT notes dated 3/26/25, identified R1's precautions were decreased vision to left side, left sided hemiplegia and decreased coordination, feeding tube-pureed diet with no liquids, biliary drain, safety/cognition/impulsivity, fall risk and history of 2 assist with Hoyer. R1's cognition was assessed for discharge, results identified a cognitive performance test (CPT) was completed with a score of 4.1 identifying moderate cognitive deficits, requiring 24-hour supervision, up to 1:1 cognitive assist with ADL's and assist with ADL's. All tasks were modified for left visual cut and vision deficits. During a phone interview on 4/3/25 at 2:13 p.m., Occupational Therapist (OT)-A stated R1's cognition was assessed and he required 24-hour supervision and 1:1 with ADL's which therapy educated the aides on. Therapy never saw R1 try to self-transfer, we know he had tried to get out of bed in the past, we did try to come up with a plan to reduce his restlessness. OT-A further stated R1 was impulsive when it came to toileting and drinking. Therapy educated the nurses on R1's impulsiveness quite a bit. OT-A was unable to articulate when a resident who had cognitive deficits with impulsivity and required assistance would be assessed for the level of supervision during toileting tasks. During an interview on 4/3/25 at 11:28 a.m., physical therapist (PT)-A indicated the last day she assessed R1 was on 3/27/25, where R1 had improved since his last hospitalization on [DATE]. PT-A stated R1's balance was better, required supervision and stand by assist with adl's. R1 could ambulate up to 100 feet with minimal assist and a two wheeled walker. R1 was very willing to work in therapy, however, could not tolerate sitting long because it hurt him, so he spent a lot of time in bed. R1's cognition was poor, and he was very impulsive. Therapy performed several cognitive tests with results that identified significant impairment indicating a level of dementia. PT-A stated she did not assess R1 to see if he required supervision with toileting and could not find anything in the therapy notes that indicated R1 was ever assessed for supervision with toileting. R1's Fall Incident report dated 3/29/25 at 9:25 a.m., indicated R1 had an unwitnessed fall in his room. R1 was found on the floor in between commode and foot of bed lying on his back. R1 complained of level 4 out of 10 low back pain, prn (as needed) Tylenol administered. NA had informed nurse they had placed R1 on the commode as requested. R1 explained he was on the commode and thought he could walk back to bed. R1 stated, I knew I shouldn't have, and I should have tucked and rolled. Immediate Action Taken: writer assessed R1 for physical injury, R1 transferred to bed using a Hoyer. Predisposing factors were gait imbalance, confused, weakness, impaired safety judgement, self-transfer and ambulating without assist. Staff statement identified co-worker, and myself went to toilet R1 on the commode using a gait belt. We sat him down gave him his call light and told him to turn on his call light when he was done. She was checking on other residents when his call light go on. When she went to his room, she saw him lying on the floor. R1's corresponding FSI report dated 3/29/25, was requested and not received. R1's progress notes dated 3/29/25, included the aforementioned fall description. At 4:20 p.m. R1's family wanted R1 sent to the emergency department (ED). R1 was reporting pain 10 out of 10 in his low back. On-call provider gave order to transfer R1 to ED. R1 was transferred to the ED at 4:30 p.m. R1's progress note dated 3/30/25 at 11:37 a.m., identified R1 was admitted to the hospital for fracture in T11 and T12. R1 was discharged from facility because no bed hold was signed. R1's physician visits on 3/10/25, 3/17/25, 3/24/25 and 3/26/25 did not address R1's falls. During a phone interview on 4/3/25 at 2:29 p.m., family member (FM)-A stated R1 fell on [DATE], because staff left him on the commode by himself. Nursing staff should not have done that because R1 was very impulsive and did not always remember to ask for help. FM-A stated R1 ended up in the hospital from that fall and suffered two fractures in his spine- T11 and T12. The injuries had really set [R1] back and will be transferring to another facility from the hospital today (4/3/25). During an interview on 4/3/25 at 1:21 p.m., nursing assistant (NA)-A stated on 3/29/25 around 9:00 a.m., R1 had put his call light on and had asked to go to the bathroom. NA-A was not familiar with R1's care and was not aware he had previous falls, so she checked R1's care plan before transferring him. NA-A and another staff member used a gait belt and two wheeled walker and walked R1 from his bed approximately 13 feet to his commode. NA-A placed R1's walker in front of him and tied his call light to it. NA-A instructed R1 to push his button when he was done. NA-A explained she then left the room to answer a call light a couple of rooms away. NA-A noticed call light was on then heard a thud, when she got to R1's room, she found R 1 lying on the floor partially on his right side and back. R1 had made it three steps from the commode. NA-A stayed with R1 and radioed for help. R1 had reported pain and pointed to his middle back. After the nurse assessed him, R1 was transferred back to bed using a hoyer. NA-A did not remember R1 being on the Falling Star Program and would have seen the star on R1's door. During an interview on 4/3/25 at 10:07 a.m., nurse manager (NM)-A stated with a fall, the floor nurse would assess the resident and provide any needed care. Floor nurse would then fill out a fall huddle form, make an incident report, and put in a fall progress note. After each fall nursing staff should try to determine the root cause of the fall and update the care plan with an appropriate intervention. NM-A stated R1's incident reports for the falls on 3/8/25, 3/13/25 and 3/18/25 did not identify if R1's basic needs were met. For example, the incident reports did not identify if R1 had been incontinent at the time of the fall and the last time he was toileted. Because of the lack of information it was not possible to appropriately root cause each fall. NM-A stated she did not see root cause for R1's 3/16/25 fall and did not see that R1's care plan was updated with any new interventions. The root cause of R1's fall on 3/29/25 was due to staff leaving R1 unattended on his commode where he fell and was hospitalized with two thoracic fractures. During an interview on 4/3/25 at 11:01 a.m., director of nursing (DON) verified R1 had 4 falls since 3/8/25 to 3/29/25. DON explained the facility used a fall huddle form that the floor nurse was supposed to fill out at the time of the fall to help determine a root cause of the resident's fall. During morning meeting interdisciplinary team (IDT) discuss the resident falls to ensure prevention interventions are put in place. DON reviewed R1's falls and verified the nurse did not fill out a fall huddle form for 3/8/25, 3/16/25, and 3/29/25. The fall investigations did not always identify or include in the analysis if R1's needs were met such as toileting, pain and thirst. R1's fall on 3/16/25 did not include a comprehensive analysis due to the lack of investigation. Further the care plan had not been updated to include any new fall prevention interventions. DON stated R1 was left on the commode on 3/29/25 unsupervised when he fell and was sent to the hospital that resulted in two thoracic fractures. DON was unaware of how long R1 was left on the commode and verified his cognition was impaired, was impulsive and required extensive assist with toileting. DON further stated we usually have therapy assess a resident for safety with supervision of ADL's if they are dependent on staff for care and have impaired cognition. Facility Policy entitled, Fall Risk, Post Fall Investigation, Follow Up and Care, effective dates of 7/2021, 10/21 and 12/23, identified purpose-to define Nursing's role in the management of patients at risk for falls and post fall investigation, follow up and care. 2. Universal fall precautions are used for all patients based on individual patient needs. Interventions should be selected based on individual patient needs. Document interventions in the medical record. Falls risk and interventions should be noted on the plan of care. POST FALL INVESTI AT ON, FOLLOW UP AND CARE-1. Evaluate patient's pain range of motion and level of consciousness or change in cognitive level before moving or helping patient to a safer position/chair/bed. Document Post Fall Huddle completed. Document Care Plan reviewed and revised as indicated. Document and complete UDA's that were triggered if applicable. 3. Any changes in interventions will be noted, on the resident's Care Plan and Kardex. The IDT (interdisciplinary team) will meet each weekday to review fall(s) and determine if further investigation of incident is needed; and assign who will assist with assessing further intervention(s). Risk Management Reports and statistics of the falls that have occurred to be maintained and reported to the QAPI committee for interpretation of patterns and quality improvement interventions. Nursing staff actions-information gathering .assess for basic needs-hunger, pain, toileting .bowel and bladder training programs in place and effective .review care plan to ensure fall prevention strategies are included .increase patient observation .Mandatory high-risk interventions, but not limited to: o Place a yellow wristband on wheelchair, walker, o Place Falling Star symbol on doorframe outside patient's room. and o Ensure that the falling star is removed upon discharge from falling star program.

Based on observation, interview and document review, the facility failed to ensure medications were administered to the correct resident for 1 of 3 residents (R1) reviewed for medication errors. This failure resulted in actual harm when R1 became hypotensive that required treatment in the emergency department (ED) and ongoing symptom monitoring and treatment. The facility had implemented appropriate corrective action prior to the onsite investigation so the deficiency is being cited at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of chronic kidney disease stage 3b (moderate to severe loss of kidney function) and hyponatremia (low blood sodium). R1's order summary dated 11/18/24, identified R1 was to receive the following oral medications in the morning: acetaminophen (for back pain)1000 milligrams (mg), aspirin (for stroke prophylaxis) 81 mg, citalopram (for depression)10 mg, and multivitamin. R1's medication administration record (MAR) dated 12/10/24, identified none of the above scheduled am medications were given, a 9 was documented and indicated, other, see nurses note. R4's order summary dated 12/4/24, identified R4 was to receive the following oral medications in the morning: lisinopril (for high blood pressure) 10 mg, calcium 500+D tablet (for osteoporosis) 500-10 mg-micrograms (mcg), and sennoside-docusate sodium (for constipation) 8.6-50 mg tablet. R4's medication administration record (MAR) dated 12/10/24, identified lisinopril, calcium 500+D and sennoside-docusate sodium were given at 6:47 a.m. R1's Medication/Treatment Error Report dated 12/10/24 at 8:30 a.m., identified lisinopril was given to the wrong resident, the nurse was new and on their own for the first time today. Immediate effects noted were R1 reported dizziness and a drop in blood pressure (normal blood pressure range is below 120/80 but above 90/60). Provider notified at 8:30 a.m. and ordered to check blood pressure every 30 minutes until systolic blood pressure (SBP) was greater than 90, push fluids, send to emergency department (ED) if SBP stays in the 70's and symptomatic with dizziness and hypertension. R1's Medication Error/Event Root Cause Analysis form dated 12/10/24, identified the error category E level (an error that could have caused temporary harm). R1's progress note dated 12/10/24 at 8:25 a.m., identified R1 was dizzy, weak, not feeling well and hypotensive. Blood pressure (B/P) 72/40, encouraged and assisted with pushing fluids, notified on call provider by phone, new order to check blood pressure every 30 minutes, if remained symptomatic and systolic remained in 70's send to ER. R1 inadvertently received 10mg lisinopril this am. Family members came to care center to visit and were updated on the situation. R1's progress note dated 12/10/24 at 9:20 a.m., identified R1 was sent to the ED with family accompanying for diagnosis of hypotension. Blood pressure was re-checked and was 64/43, continued to have symptoms of dizziness and would not drink fluids with encouragement and assistance. R1's Vitals summary identified the following blood pressures: 12/10/24: -8:33 a.m., was 72/40. -9:00 a.m., was 64/43. -9:20 a.m., was 88/52. R1's Emergency Department (ED) summary dated 12/10/24, at 9:28 a.m., identified R1's blood pressure was 89/49 and the reason for visit was hypotension (care center called and stated R1 was given lisinopril in error and pressures were 60's/40's with dizziness). Assessment and plan identified evaluation for hypotension due to receiving lisinopril in error at 6:47 a.m., antihypertensive effect of lisinopril started within 2 hours and will peak at 6 hours, gave IV fluids in attempt at improvement of hypotension. At 10:51 a.m., R1 has no urge to urinate, gave another liter of fluids, blood pressure still low at 74/45, nausea was better. At 12:02 p.m., blood pressure 82/47 progressive improvement, lowest blood pressure earlier was 68/44. At 12:23 p.m., R1 has no urge to urinate, felt better after receiving 2 liters of fluids, gave another liter of fluids and monitor blood pressure closely. At 12:53 p.m., blood pressure 97/51, at 2:35 p.m., blood pressure 102/61 improved with sitting, and at 2:45 p.m. blood pressure 121/63 increased with movement. At 2:48 p.m. Zofran given for nausea. At 3:09 p.m., R1 hypotensive again at rest, R1 would like to go back to the care center as soon as possible, will hold off on anymore fluids, no lightheadedness with standing. At 3:32 p.m., R1 had a liter of watery output from ileostomy while at ER, will give does of albumin to attempt at improvement of hypotension at rest. At 5:12 p.m., mean arterial pressures (MAP's) - (represents the average pressure in your arteries throughout the cardiac cycle, indicating how well your organs are being perfused with blood, most people need a MAP of at least 60 to ensure blood flow to vital organs) consistently remaining in the 60's. R1 would like to be discharged home will have nursing home staff monitor blood pressure this evening and tomorrow morning. Return to ER with concerning signs and symptoms, R1 discharged back to nursing home at 5:35 p.m. R1's progress note dated 12/10/24 at 5:50 p.m., identified R1 returned to the facility via wheelchair at 5:30 p.m. with family present. R1 received 3L of IV fluids and 500 ml of albumin. Output of 1300 ml out of ostomy. Resident asymptomatic at this time, just weak and tired. R1's progress note dated 12/11/24 at 10:16 a.m., identified blood pressures were 72/45 and 69/35. After pushing fluids and eating blood pressure was 90/53. R1 was seated at the edge of her bed for all blood pressures. Denied dizziness, nausea, vertigo, or any other symptoms. R1 reported feeling tired. R1's progress note dated 12/11/24 at 10:47 a.m., identified R1 was asymptomatic and felt better. Blood pressure was 88/58 while lying in bed. reported no urine output since yesterday, new order to check blood pressure every 4 hours and as needed, if symptomatic and SBP <80 notify provider. R1's Video Nurse Practitioner visit dated 12/11/24, identified an evaluation regarding concern about acute urinary retention with hypotension noted over the past 24 hours. R1's blood pressure was 76/43. R1 continued to have poor urinary output was continent of urine and stated she had gone twice this afternoon. R1 had post void bladder scan which noted retention of 322 ml. New Orders to check basic metabolic panel (BMP) (blood test to monitor blood pressure and kidney disease) and post void bladder scan for 3 days to assess decreased urinary output. With each post void scan, if >300 milliliters (ml) then in and out Cath to completely empty bladder. R1's Vitals summary identified the following blood pressures: 12/10/24 at 9:36 p.m., was 88/52. 12/11/24: -12:31 p.m., was 76/43. -6:23 p.m., was 97/46. -9:23 p.m., was 87/48. 12/12/24: -2:32 a.m., was 94/51. -4:53 a.m., was 119/59. -10:00 a.m., was 111/64. During an observation and interview on 12/17/24 at 2:35 p.m. R1 was lying in bed with a blanket covering her. R1 stated one of the staff gave her the wrong medication, it was a blood pressure medication. R1 indicated on the morning of 12/10/24, she got up at 6:15 a.m., was given her pills, and then a short while later she started to feel dizzy and weak. When she went to the bathroom to get ready for the day, she looked in the mirror and could not see herself, everything was fuzzy, that's when she told, the girls, she was nauseated and would not be able to eat breakfast. R1 indicated at some point they were checking her blood pressure over and over and it was pretty low, so they sent her to the ER. R1 stated she was scared because she did not feel right from getting the wrong medication and had to spend most of the day in the ER and was given several IV fluids. R1 stated ever since she was given the wrong medication, she has been weak, had not had an appetite and both legs between her knees and her hips hurt even when she wasn't doing anything but lying in bed. R1 indicated she never had the leg pain until the day they gave her the wrong medication. R1 stated she had the pain if she stood too long and stated the left leg had gotten better but not the right leg, R1 stated the pain was a steady pain and was experiencing it in her right leg at this time. During a phone interview on 12/17/24 at 1:58 p.m., registered nurse (RN)-B indicated on 12/10/24, it was his first day to independently pass medications. RN-A stated he had mistakenly given R1 lisinopril that was meant for R1's roommate. RN-A stated he didn't realize it until R1 was exhibiting hypotension, dizziness, nausea, blurred vision, lightheadedness, and weakness. RN-A verified R1 was sent to the ED for treatment of hypotension. RN-A stated he was educated on the medication administration policy, the 5 rights of medication, and had additional training. During an interview on 12/18/24 at 9:18 a.m., registered nurse (RN)-A stated RN-B told her on 12/10/24 around 8:30 a.m., that he had given R1 lisinopril in error that was meant for R4. She was given the medications at 6:47 a.m. RN-A stated R1 was assessed and noted to be weak, dizzy, and nauseated with systolic blood pressures in the 70's. RN-A indicated she called the provider to notify of R1's medication error was given new orders to monitor blood pressures and to send to the ER if blood pressures did not come up. RN-A stated R1 was being monitored closely by nursing staff and the providers and was sent to the ER at around 9:30 a.m. RN-A stated RN-B was immediately supervised for the remainder of the shift, was re-educated, and had additional training. During an interview on 12/18/24 at 12:24 p.m., director of nursing (DON) indicated on 12/10/24 R1 had received her roommates lisinopril that caused R1 to be transferred to the ER to be treated for hypotension. DON indicated this was a significant medication error because of the adverse side effect of hypotension. DON indicated RN-B was responsible for the medication error, root cause was incorrect -RN-B was immediately re-educated, had another nurse assist him that day. DON indicated immediately all staff were re-educated on the 5 rights of medication and the medication administration policy had been performing medication administration audits to ensure compliance. During a phone interview on 12/18/24 at 1:04 p.m., consultant pharmacist (CP)-A indicated if a resident without the diagnosis of high blood pressure was given lisinopril in error the resident would need to be monitored closely for low blood pressure and would be considered a significant medication error. CP-A indicated the effects of 10 mg of lisinopril would take effect within 2 hours of ingestion, peak at 6 hours and can last for up to 24 hours. CP-A stated lisinopril can lead to dehydration and side effects would be nausea, dizziness, fatigue, and headache. During an interview on 12/17/24 at 1:40 p.m., medical director (MD)-A stated R1 was given 10 mg of lisinopril on 12/10/24 that resulted in a significant medication error. MD-A indicated R1 had kidney disease and had to be sent to the ER to have her blood pressures monitored along with her kidney function and was treated with IV fluids and IV albumin; albumin can help raise blood pressure by drawing fluid back into circulation. MD-A stated after the ER visit R1 was having trouble with not making any urine which was a sign of the kidneys not working properly. MD-A further stated there will be further assessments, labs, and monitoring for R1 to return to baseline. Facility policy, Medication Administration Guidelines revised 3/10/23, identified Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 7. Residents are identified before medication is administered using two methods of identification. Methods of identification include a) By checking the resident's name band, b) By asking a reliable resident for his or her first and last name, c) By referring to the photo attached to the EMAR record and d) If necessary, verifying resident identification with other facility personnel . 10. Check for the five rights: the right resident, the right medication, the right dosage, the right route, and the right time . 17. Medications supplied for one resident are never administered to another resident. During the onsite visit on 12/17/24 and 12/18/24, the facility's corrective actions were verified as implemented on 12/10/24, prior to the survey visit, therefor this deficient practice is being cited as Past Non-compliance. Corrective actions included: -On 12/10/24, the facility completed an investigation and causal analysis -On 12/10/24, RN-B was immediately re-educated and supervised. -On 12/10/24, provided educated to licenses and unlicensed staff regarding giving medications as ordered and medication administration policy.

Based on interview and document review, the facility failed to provide the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to 3 of 3 residents (R2, R162, R258) reviewed whose Medicare A coverage ended and then remained in the facility and/or discharged home. Findings include: R2 R2's Centers for Medicare and Medicaid Services (CMS)-10123 (NOMNC) identified a last covered day (LCD) of 3/13/24. NOMNC indicated community support manager (CSM) called family member (FM)-A, who was also R2's power of attorney (POA), on 3/11/24 to notify that skilled services would be ending on 3/13/24 with financial liability being on 3/14/24. NOMNC lacked signature of FM-A acknowledging notification of services ending. R2's undated Census Records listing identified on 4/14/24, R2's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R2's SNFABN lacked signature acknowledging that FM-A had received and understood the notice. SNFABN indicated beginning on 3/14/24, estimated cost of room and board was up to $743.59 with additional fees for physical, occupational and/or speech therapy. SNFABN indicated under additional information to: See NOMNC - FM-A given options verbally on 3/11/24. During interview on 6/11/24 at 3:54 p.m. FM-A stated he vaguely remembered a phone call regarding this and had not received and/or signed either written notice. R162 R162's NOMNC identified a last covered day of 4/22/24. NOMNC indicated CSM called FM-B, who was also R162's POA, on 4/19/24 to notify that skilled services would be ending on 4/22/24 with financial liability beginning on 4/23/24. NOMNC lacked signature of the power of attorney acknowledging notification of services ending. R162's undated Census Records listing identified on 4/23/24, R162's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R162's SNFABN lacked signature acknowledging FM-B had received and understood notice. SNFABN indicated beginning on 4/23/24, estimated cost of room and board was up to $743.59 with additional fees for physical, occupational and/or speech therapy. SNFABN indicated under additional information to: See NOMNC - POA did not want to appeal. During interview on 6/11/24 at 4:00 p.m. FM-B stated he never received and/or signed either written notice. FM-B stated, on a different occasion, he received a piece of paper with a table on it which included different care levels and prices but did not know what care level R162 was. R258 R258's NOMNC identified a last covered day of 4/24/24. NOMNC indicated CSM called FM-C on 4/22/24 to notify that skilled services would be ending on 4/24/24 with financial liability being on 4/25/24. NOMNC lacked signature of the FM-C acknowledging notification of services ending. R258's undated Census Records listing identified on 4/25/23, R258 discharged from facility. During an interview on 6/11/24, at 4:12 p.m., CSM verified she was responsible to provide the Medicare NOMNC and the SNFABN notices within the nursing home. CSM stated she got the last covered day from therapy or resident's insurance. CSM then gave the resident/representative a two-day notice. CSM stated she gave the resident/representative a NOMNC with appeal information and asked if they would like to appeal. CSM stated if resident is planning to remain in the facility, she also gave the resident/representative the SNFABN. CSM stated these conversations occur over the phone and sometimes she asked if they would want a copy mailed to them. CSM stated she did not remember offering and/or giving written copies and/or obtain written signatures for R2, R162 and/or R258. CSM stated it was be important to provide written documentation to residents/representative as conversations can be forgotten and or misconstrued. CSM also stated it was important to have a signature to ensure the resident/representative understood the process and the financial liability they would be responsible for. The facility Medicare A Denial policy, dated 6/2019, indicted the facility must deliver a completed copy of the NOMNC to beneficiaries/enrollees of Medicare and Medicare Advantage plans receiving covered skilled services. The facility must ensure that the resident or resident representative signs and dated the NOMNC and when applicable the SNFABN to demonstrated that they received the notice and understand that the termination decision can be disputed.

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 1 resident's reviewed for wandering. Findings include: R26's admission MDS dated [DATE], indicated severe cognitive impairment, physical and verbal behaviors with rejection of care. Wandering with no significant risk. Wanderguard in place. R26's quarterly MDS dated [DATE] indicated severe cognitive impairment, physical and verbal behaviors directed toward others. No documented wandering. Wanderguard in place. R26's provider orders included mirtazapine (medication for depression and sleep), buspirone (medication for anxiety). R26's diagnoses list included delusional disorders and dementia with anxiety. R26's elopement careplan indicated history of elopement at previous facility in addition to multiple attempts to exit current faciliy with increased wandering during episodes of delusional thoughts. Facility progress notes reviewed from 3/20/24 through 3/27/24 indicated on 3/22/24 R26 attempted to leave the facility multiple times, refused medications, and required redirection and 1:1 care. During interview on 06/13/24 10:12 a.m., MDS coordinator (RN)-C stated she used a reference sheet to confirm what assessments were due and the dates they were be completed. The reference period used for assessments was 6 days prior to and including the assessment reference date (ARD). RN-C stated she referenced task documentation and progress notes made during reference period when completing MDS assessments. RN-C reviewed progress notes for reference period 3/20/24 through 3/27/24 and confirmed progress noted dated 3/22/24 indicated multiple attempts to exit the facility. RN-C stated she must have overlooked it. RN-C stated accurate MDS documentation would be important for careplanning and accuracy of medicare payment. During interview on 6/13/24, director of nursing confirmed the importance of accurate MDS assessments for appropriate resident care. She confirmed inaccurate MDS assessment could also lead to inaccurate Medicare reimbursement. A facility policy titled MDS/Careplan Process dated 2/1/2024 indicated the purpose of a comprehensive assessment as identify the resident's care needs, develop a comprehensive plan of care for the resident, identify the resident's strengths, assist the resident to attain the highest practical level of mental and physical function and well-being.

Based on interview and document review, the facility failed to ensure medications were administered per physician's order for 1 of 1 resident (R40) reviewed for assessment prior to medication administration. Findings include: R40's admission Minimum Data Set (MDS) dated [DATE], identified R40 had intact cognition and required assistance with all activities of daily living (ADLs). R40's diagnoses included chronic combined systolic and diastolic heart failure (heart failure that occurs when the heart has trouble relaxing between beats), atrial fibrillation (abnormal electrical impulses suddenly start firing in the atria), heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), hypertension (pressure in your blood vessels that is too high), obstructive sleep apnea (intermittent airflow blockage during sleep) and chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). During review of R40's electronic health record (EHR), signed physician's order indicated an order for Metoprolol Tartrate 150 mg (milligram) to be given by mouth one time a day for hypertension and to hold for heart rate less than 50 and systolic blood pressure less than 100. Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of obtaining and monitoring blood pressure and pulse prior to administration of medication from 5/17/24 to present. During interview on 6/12/24 at 10:22 a.m., trained medication aide (TMA)-A stated R40 did not have special monitoring for medication administration. TMA-A checked signed physician's orders and confirmed that R40 should have blood pressure and pulse checked prior to administration of Metoprolol. It was important to check blood pressure and pulse as medication may not be able to be administration if blood pressure and/or pulse are below parameters. During interview on 6/12/24 at 4:10 p.m., registered nurse clinical manager (RN)-D stated staff had been checking resident's blood pressure occasionally but was not with every dose and not being checked per physician's orders. RN-D stated checking the blood pressure and pulse prior to administration of medication was important because it is a physician's order, and it should not be administered if blood pressure or pulse was low as R40 could get dizzy or blood pressure could decrease more. RN-D reviewed signed physician's orders and confirmed the blood pressure and/or pulse were not being obtained with every dose administered. During interview on 6/13/24 at 8:22 a.m., consultant pharmacist (CP) stated staff should have been obtaining R40's blood pressure and pulse prior to administration of Metoprolol to ensure that medication was able to be administered per physician's orders. CP stated he would expect them to be obtained and documented on the medication administration record (MAR). CP stated monitoring of blood pressure and pulse is important as R40 would be at risk of having too low of a blood pressure or too low of a pulse. CP reviewed R40's EHR and confirmed that there was no documentation of blood pressure and pulse prior to medication administration. During interview on 6/13/24 at 8:33 a.m., director of nursing (DON) stated she expected provider's orders to be followed, including parameters of medication administration. DON confirmed R40's blood pressure and pulse should have been obtained prior to administration of the Metoprolol. DON stated following these parameters was important, so the blood pressure doesn't bottom out leading to the resident being transferred out of facility to the emergency room (ER) as it could be life threatening. A Medication Administration/Monitoring policy and procedure was requested but was not received.

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning to promote healing of pressure ulcer for 1 of 1 resident (R4) in accordance with the individualized care plan. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had moderately impaired cognition and required assistance with all activities of daily living (ADLs). R4's diagnoses included non-traumatic brain dysfunction (brain damage caused by internal factors), atrial fibrillation (abnormal heart rhythm), heart failure (syndrome cause by an impairment in the heart's ability to fill with and pump blood), renal insufficiency/failure (kidneys are functioning poorly), diabetes mellitus (disease that affect how the body uses blood sugar (glucose)), non-Alzheimer's dementia (loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual activities), seizure disorder or epilepsy (disorder of the nervous system that causes abnormal electrical activity in the brain), depression, pressure ulcer - stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer), muscle weakness, restlessness and agitation and major depressive disorder severe with psych symptoms. R4's pressure ulcer Care Area Assessment (CAA) dated 5/21/24, indicated R4 was at risk for the development of pressure ulcers. R4's care plan dated 5/20/24, identified R4 had a stage three pressure ulcer and was at risk for the development of pressure ulcers and directed to reposition R4 every two hours while in bed and/or wheelchair. During continuous observations on 6/11/24 from 9:42 a.m. to 12:57 p.m., R4 was observed to be seated in a Broda (reclining wheelchair with bilateral supportive cushions) chair. At 9:42 a.m., R4 was in the common area watching television with other residents. At 10:25 a.m., R4 remained in common area watching television. At 11:45 a.m., staff assisted R4 to the dining room for lunch. At 6/11/24 at 12:23 p.m., R4 was sitting in dining room eating independently. At 12:43 p.m., staff assisted R4 from the dining room to the common area where R4 remained in broda chair? and watched television. At 12:57 p.m., staff assisted R4 to her room to assist R4 with toileting (checking and changing) incontinence products and was assisted back seated in her wheelchair. During interview on 6/12/24 at 8:34 a.m., nursing assistant (NA)-A stated R4 is unable to reposition herself in her wheelchair and needs staff to assist with repositioning. NA-A stated R4 was to receive assistance with repositioning every two to three hours per R4's care plan. During interview on 6/12/24, at 9:11 a.m., NA-F stated R4 should be laid down once in the morning after breakfast but R4 frequently refused to lay down. NA-F stated R4 was to receive assistance with repositioning every two hours when in wheelchair. NA-F stated R4 was not able to reposition herself in her wheelchair. During interview on 6/12/24, at 10:22 a.m. trained medication aide (TMA)-A stated R4 was to receive assistance with laying down after meals but R4 frequently refused as she liked to be out with other residents watching television and attended activities regularly. TMA-A stated R4 was to receive assistance with repositioning every two hours in accordance with the care plan. During interview on 6/12/24, at 4:27 p.m., registered nurse clinical manger (RN)-D stated R4 liked to attend activities and watched television with other residents. RN-D stated R4 has a stage three pressure ulcer that has stalled (wound initially began to heal, but patient- or wound-related factors have prevented the wound from continuing to heal in an orderly and timely manner), provider was aware. RN-D stated R4 had the order to try and encourage R4 to lay down due to the pressure ulcer but R4 refused frequently. RN-D stated R4 was to receive assistance with repositioning every two to three hours if R4 refuses to lay down. RN-D stated repositioning R4 is important so her wound did not worsen as are result of not being repositioned. During interview on 6/13/24, at 8:49 a.m., the director of nursing (DON) stated the staff were to provide assistance with repositioning in accordance with the care plan. DON stated repositioning a resident with pressure ulcers was important, so the wound did not worsen. The Individualized Care Plan Policy dated 10/26/22, indicated the facility would develop a comprehensive care plan using the comprehensive assessments, will individualize the plan of care to accurately reflect resident's functional capacity and medical, nursing, psychosocial, activity and other identified needs. The Positioning the Resident Policy dated 11/2021, indicated the staff reposition identified residents to relieve pressure, prevent skin breakdown, pain, and promote proper body alignment.

Based on observation, interview and document review, the facility failed to investigate, review and analyze underlying causes of resident's anxiety and agitation for 1 of 1 resident (R24) who was reviewed for behaviors. Findings include: R24's significant change Minimum Data Set (MDS) dated [DATE], identified R24 had moderate cognitive impairment and diagnoses included dementia, repeated falls, malignant neoplasm of the prostate, weakness, hematuria and recent urinary tract infection. R24 required setup or clean up with personal hygiene and toileting and supervision or touch assist with ambulation. R24 had exhibited behaviors of physical, verbal and other behaviors one to three days during the observation period and wandered daily. R24's behaviors were identified as potentially harmful to himself or others. R24's care plan with review date 6/5/24, identified R24 was at risk for wandering and elopement as he had tried to exit the facility. R24 had impaired cognitive function due to diagnosis of dementia. Interventions included ask yes/no question, cue and reorient and supervise as needed, give verbal reminders, engage in purposeful activity, identify if there is a certain time of day wandering and elopement attempts occur, provide clear, simple directions, identify wandering/elopement de-escalation behaviors and wanderguard on left extremity. Progress notes identified the following: -On 5/15/24, interdisplinary team (IDT) review note identified R24 had increased wandering, exit seeking, and aggression toward staff. R24 was moved to a different, quieter wing. Staff would continue to monitor his behavior. -On 5/19/24, R24 was wandering into other resident rooms, unsteady on his feet and hard to redirect. -On 5/22/24, R24 walked off the unit with another resident. Staff were able to redirect back to unit. -On 5/23/24, R24 was wandering halls and seeking exits. Interventions were somewhat effective. -On 5/24/24, R24 had attempted to disrobe in public areas. Interventions were ineffective. -On 5/25/24, R24 was wandering halls, verbally and physically aggressive with staff. R24 exited building and staff was able to redirect him back in to the building. -On 5/26/24, R24 was wandering halls and exit seeking. Nearly did get out of building before staff intervened. -On 5/27/24, R24 was wandering the halls, attempting to go in to other resident rooms, and attempting to find exits to elope. Became combative with staff when attempted to assist him to the bathroom. -On 5/29/24, R24 was wandering halls and into others rooms. Attempting to exit out doors. Was difficult to redirect. -On 5/31/24, R24 was wandering and agitated with redirection. -On 6/1/24, R24 was wandering and urinated on the floor in another resident's room. R24 became agitated when staff tried to assist him to change his wet pants. Staff walked away to allow R24 to calm down. R24 exited out of the building. Staff responded to door alarm, had significant difficulty getting R24 to return to the building. A nurse from a different wing came to assist and was able to get R24 to return to the building. -On 6/3/24, R24 was seen by provider related to psychotropic medication review. -On 6/4/24, order received to increase mirtazapine (an antidepressant). -On 6/5/24, R24 was wandering halls and attempting to exit building. Unable to distract and re-direct. Requested assistance from other nursing staff. -On 6/6/24, R24 was wandering halls and into others rooms, searching for an exit. Interventions ineffective. -On 6/8/24, R24 wandering halls and going into others rooms. Interventions ineffective. -On 6/9/24, R24 had water and urine all over floor in bathroom. Refusing to allow staff to change his soiled clothes. Interventions ineffective. During observation on 6/10/24, at 4:30 p.m. R24 was seen wandering the halls. Staff attempted prompts for him to sit down and rest. R24 walked away from them and refused to sit down. During continuous observation on 6/11/24, at 10:15 a.m. to 12:00 p.m. R24 was observed wandering the halls and attempted to enter other resident rooms. R24 stated he had to go to the bathroom, however, when assisted to the toilet at 10:30 a.m., was unable to void. R24 continued to pace the halls and refused staff attempts to redirect. At 10:35 a.m. R24 was wandering and stated he had to go to the bathroom. When brought to the bathroom, immediately turned around and stated he did not have to go. At 11:35 a.m. R24 exited the unit doors into another hallway. Nursing assistant (NA)-A noted he had exited the unit and went out to redirect him back into the unit. R24 was resistive to redirection. NA-B approached to assist and they were able to get R24 to return to the unit. During observations on 6/11/24, at 1:45 p.m. through 4:00 p.m. R24 continued to pace the halls with unsteady gait and agitated manner. Staff attempted to intervene with diversional activity and one to one, however, were unsuccessful. During a joint interview with registered nurse (RN)-D and RN-E on 6/11/24, at 4:00 p.m. RN-E stated the staff were doing one to one with R24 and trying more redirection. They were trying to find activities and music he would enjoy or offered food or drink. They had put a wanderguard on R24 to address his wandering and exit seeking behaviors. The staff document a lot of behavior notes, but as far as assessments, the provider had seen R24 twice to address his medications. The providers could do assessments and address a resident behaviors. They discussed resident behaviors during their weekly IDT meetings but she was not sure if it was documented in the resident chart as social services would be the one to document that. An analysis of behaviors would be important to see if there was a cause such as infection, and to treat it and maybe improve the behaviors. When they put in for an acute provider visit they communicated the resident behaviors with the provider and then it would be up to the provider to address the behaviors and order tests if they wanted them. RN-E had not been made aware R24 would ask for the bathroom and then refuse to go and the behavior could possibly be related to R24's diagnosis of untreated prostate cancer. RN-D stated she was only able to find the one IDT note on 5/15/24 and the two provider notes related to medications. R24's medical record reviewed 5/15/24 through 6/11/24, lacked review and analysis of R24's behaviors to try to determine underlying causes or triggers. During joint interview on 6/12/24, at 4:40 p.m. with the director of nursing (DON) and clinical operations manager (CO)-D, CO-D stated she was not sure if the facility had behavior meetings but resident behaviors were addressed in IDT weekly meetings and daily stand up meetings. It would be the IDT team to look at the bigger picture of resident behaviors. It would be important to really have a look at what the resident was doing and what was preceding the behavior. She had not found an overall review of resident behaviors. The facility policy Mood and Behavior/Behavioral Health dated 10/5/22, identified the facility would assess and develop individualized behavioral care plan interventions for individuals with dementia. Mood and behavior would be reviewed by the IDT team on a quarterly basis or more often as needed to determine trends and effectiveness of care plan interventions.

Based on interview and record review the facility failed to follow up on provider orders for 1 of 1 (R26) residents reviewed for dementia care. Findings include: A quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had a BIMs (test to assess cognitive impairment) score of 04 indicating severe cognitive impairment. No functional limitation in range of motion, history of falls, received antidepressants, antianxiety, and antipsychotic medication. R26's physician orders included mirtazapine (medication for depression that helps with sleep) and buspirone (medication used to treat anxiety). R26's diagnoses list included delusional disorders and dementia with anxiety. R26's elopement careplan, revised [DATE], indicated R26 was at risk for elopement due to dementia. R26 had a history of attempting to leave previous facility and wandering might increase with delusional thoughts, had wanderguard in place and, has history of going into other residents' rooms. It further indicated R26 has attempted to exit the facility. A mood/behavior careplan, revised [DATE], indicated R26 had a history of refusing care and scratching/hitting out at staff and had a history of delusional statements. R26's progress notes dated [DATE] through [DATE] indicated several incidents of behaviors that include verbal agressivness and threats, and elopement attempts. On [DATE] the provider wrote an order for psychological and psychiatric consult. Progress notes dated [DATE] through [DATE] continued to show behavioral episodes that include verbal agression and elopement attempts, however did not indicate an increase in behavior. The progress notes lacked documentation a psychiatric consult appointment was made. During interview on [DATE] at 4:37 p.m., registered nurse (RN)-B confirmed R29's diagnoses of delusions, anxiety, and dementia. She stated R29 was forgetful and spoke of her deceased husband often. R29 had a wanderguard on due to attempts to leave the facility. R29 requested staff call 911. RN-B stated they had the hospital security staff member speak to R29 which was effective in reassuring R29. R29 has successfully exited the facility however was redirected back inside without issue. During interview on [DATE] at 10:53 a.m., nursing assistant (NA)-M stated R29 was independent with ambulation and has been more confused lately. R29 has been fixated on family and wandered back and forth from room to tv common area. NA-M stated R29 has successfully eloped from the facility however staff was able to redirect her. During interview on [DATE] 03:42 p.m., nurse managers (RN)-D and RN-E stated R29 looked for her deceased husband and children a lot. R29 had increased behaviors after family visits. R29 required a lot of redirection. R29's elopement attempts were either related to looking for her family or fear something horrible is happening. Staff have been instructed to be mindful of what is on the television (TV) in R29's room because R29 had trouble thinking TV was reality. R29's providers have made changes to medications including Seroquel (antipsychotic) and mirtazapine (antidepressant that aids in sleep). R29 was also taking buspirone (medication for anxiety) three times a day. They have also requested testing and labs to rule out medical issues. A psychiatric consult was ordered on [DATE] by the provider. When asked when R29's psychiatric appointment was, RN-D stated, Does she see psych? I don't know. Both RN-D and RN-E were unable to confirm date of psychiatric appointment. RN-D printed provider order for psychiatric appointment stating she would confirm with the unit secretary. During interview on [DATE] 08:59 a.m., the unit secretary (HUC) stated she was responsible for transcribing provider orders in the electronic record. When she completed transcribing, she pulled a specific tab on the resident's physical chart for the nurse to verify and, if necessary, clarify orders. The HUC recalled calling the provider in April to make the psychiatric appointment, however did not document making the call. She stated she was told by the clinic she could not make the appointment because the order was in review or something. She did not recall the specific reason she could not make the appointment. She confirmed no follow up phone call was made until RN-D asked her about the appointment on [DATE]. The HUC stated she called on [DATE] and was told the in-house psychiatrist would no longer be available and a referral to an outside psychiatric provider would have to be made. The HUC stated she should have sent an email to the ordering provider in April informing them an appointment could not be made and confirmed she should have followed up with the provider. During interview on [DATE] the director of nursing stated she would expect staff to follow-up on provider orders. This is important for the proper healthcare of the resident. A policy for provider orders was requested and not received.

Based on observation, interview and document review, the facility failed to ensure proper hand hygiene was completed when assisting with therapy for 1 of 2 residents (R38) whose therapy care was observed. In addition, the facility failed to ensure soiled and potentially contaminated laundry was sorted in a manner to reduce the risk of cross contamination and subsequent infection spread. These findings had the potential to affect all 58 residents who utilized laundry services. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE], identified R38 had intact cognition and diagnoses included fracture of left humerus and femur and enterocolitis due to clostridium difficile (C-Diff). R38 required moderate assist with grooming and hygiene, was dependent with transfers and frequently incontinent of bowel. R38's progress note dated 6/12/24, 1:25 p.m. identified R38 continued to have loose, watery stools due to C-Diff infection. On 6/11/24, at 11:00 a.m. R38 was observed sitting in his wheelchair in the physical therapy room. Physical therapist (PT)-A donned disposable gloves and wheeled R38 onto the parallel bars ramp and locked his wheelchair brakes. On assisting R38 to a standing position, R38's clean, dry, incontinence brief slid down his legs onto the parallel bars ramp. PT-A reached down and pulled R38's brief back on and tightened the tape to secure more snuggly. PT-A continued to wear the same gloves and assisted R38 to ambulate a few steps, then to sit in wheelchair for a brief rest. Still wearing the same gloves, PT-A assisted R38 to stand and ambulate a few steps two more times, once snugging R38's brief again to prevent it from falling off. After completion of the exercise, PT-A, still wearing the same contaminated gloves wheeled R38 off the ramp toward the exit door. Still wearing the same contaminated gloves, PT-A opened the bleach wipe container and pulled out a wipe. PT-A used the wipe to wipe down the parallel bars and discarded the wipe in the garbage. PT-A then discarded her gloves in the garbage. PT-A opened the therapy window blinds and then washed her hands with soap and water. PT-A wheeled R38 back to his room, entering the resident's room without putting on personal protective equipment (PPE) of gown or gloves. PT-A situated R38's wheelchair in front of his television and pushed his bedside table in front of him, handed R38 his remote control, after turning on his television. PT-A used alcohol based hand rub on exiting the room, however, did not wash her hands with soap and water. R38's door was clearly labeled for staff to utilize contact precautions of gown and gloves prior to entering his room and a cart with appropriate PPE was placed next to the entrance to R38's room. A sign to remind staff to wash hands with soap and water was visible on R38's bathroom door. During interview on 6/11/24, at 11:45 a.m. PT-A stated she had been told C. Diff was very contagious. If she were to work with R38 in his room, such as transferring him, she would need to put on an isolation gown and gloves and to wash hands with soap and water afterward. When working with R38 in the therapy room, she had been instructed to just wear gloves and to wipe any equipment used with bleach wipes and wash hands after therapy. PT-A stated she had pulled R38's brief up with her gloved hands when the brief slid off him and did not wash her hands and re-glove afterwards. PT-A stated she could see how her gloves could have been potentially contaminated, but she had washed her hands after working with R38. During interview on 6/11/24, at 4:15 p.m. infection preventionist, registered nurse (RN)-A stated R38 was on contact precautions for C-Diff and staff were to gown and glove when entering R38's room, even if not providing direct care. As long as R38 washed his hands beforehand, he was not restricted to his room. The facility did not require therapy to wear an isolation gown when working with R38 in the therapy room as long as they gloved and wiped equipment used with bleach wipes. If PT-A had needed to pull up R38's brief during his therapy session, she should have removed her gloves and washed her hands and then re-gloved before continuing therapy. PT-A should have also gowned and gloved when she entered R38's room and washed her hands as soon as possible when she left the room. Both incidents were a breach in infection control and potential for spread of infection. During interview with the director of nursing (DON) and clinical operations manager (CO)-D on 6/12/24, at 5:00 p.m., the DON stated staff not changing their gloves after touching potentially contaminated items would be an infection control issue. It was important to follow all infection control practices and guidance to prevent the spread of infection. The facility's policy Clostridiodes Difficile Infection Prevention and Control and treatment of Residents dated 11/1/23, indicated all residents with suspected C-Diff infection would be placed on contact precautions. Gloves and gown would be worn prior to entering resident's room and removed prior to exiting room. Hand hygiene would be performed before putting on gloves, after removing gloves and any time hands were visibly soiled. Therapists, technicians, and all other personnel would follow contact precautions, wear appropriate personal protective equipment (PPE) and perform hand hygiene accordingly. Laundry On 6/13/24. at 8:45 a.m. a laundry tour was completed with housekeeper (HSK)-A. HSK-A stated laundry staff picked up filled, dirty laundry carts from the nursing floor, covered them with a drape and brought the carts to the laundry room. Laundry staff weighed each dirty laundry cart, put gloves on and opened each bag into the cart and put the loose, soiled resident laundry into the washer until the washer was full. With facility laundry, the soiled laundry bags were put in to the large open yellow bins to be picked up by the laundry company that was used to wash the facility laundry, such as personal protective gowns, sheets, towels, and other linens. Loose facility laundry, towels and isolation gowns were visible in the open yellow storage carts with several isolation gowns hanging out over the carts opening. HSK-A stated the laundry was suppose to be bagged but they also frequently found it loose in the bins. After handling the soiled laundry, she removed her gloves and washed her hands. The laundry staff did not wear a gown for sorting laundry, despite having to lift the dirty laundry bags and the loose soiled laundry, including isolation gowns from the floor cart to either the yellow storage cart or into the washers. HSK-A always put disposable gloves on but had never been instructed to wear a disposable gown to complete the sorting process. HSK-A had never observed anyone to gown while sorting soiled laundry and did not think gowns were kept in the area for that purpose. There were no gowns observed in the area for staff to use to sort the laundry. The facility did have a resident with active C-Diff and that resident's laundry was not handled any differently. Laundry got alot of isolation gowns because of all the residents on enhanced barrier precautions as well as the resident with C-Diff and there was no way to tell what resident room the gowns had been used in. During interview on 6/13/24, at 10:00 a.m. the infection preventionist, registered nurse (RN)-A stated housekeeping staff should be wearing an isolation gown to sort all laundry due to the potential to contaminate their uniforms or other clean laundry. She planned to discuss the issue with the laundry supervisor when he returned to work. The facility policy Linen Handling to Prevent and Control Infection Transmission, dated 4/25/24, directed laundry staff to wear gloves and gowns when handling contaminated laundry.

Based on interview and document review the facility failed to accurately transcribe order for baclofen (medication used to treat muscles spasms) upon admission, identify withdrawal symptoms, and tapered baclofen according to manufacturer's recommendations for 1 of 3 residents (R1) who received baclofen. R1 had significant withdrawal symptoms resulting in hospitalization . The facility failure resulted in an immediate jeopardy (IJ) for R1. The IJ began on 12/14/22, when nurse practitioner (NP)-A abruptly discontinued R1's baclofen resulting in R1 having significant withdrawal symptoms was sent to the emergency department (ED) on 12/18/22 and admitted to the ICU where R1 remained hospitalized . The administrator and the director of nursing (DON) were notified of the IJ on 12/30/22, at 4:30 p.m. The IJ was removed on 1/1/23, but non-compliance remained at the lower scope and severity of level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The manufacturer's package insert for baclofen included: Warnings and Precautions * Abrupt discontinuation of baclofen has resulted in serious adverse reactions including death; therefore, reduce the dosage slowly when baclofen is discontinued. 5.1 Adverse Reactions from Abrupt Withdrawal Abrupt discontinuation of baclofen, regardless of the cause, has resulted in adverse reactions that include hallucinations, seizures, high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity, that in rare cases has advanced to Rhabdomyolysis, multiple organ-system failure, and death. Therefore, reduce the dosage slowly when OZOBAX (baclofen) is discontinued, unless the clinical situation justifies a rapid withdrawal. R1's admission record copied on 12/29/22 identified R1 was admitted to the facility on [DATE], with diagnoses that included: pain due to internal orthopedic quadriplegia (paralysis of all 4 limbs), chronic pain syndrome, and autonomic dysreflexia (a potential life-threatening medical emergency where an abnormal overreaction of the involuntary nervous system to stimulation resulting in excessive sweating, a change in heart rate and high blood pressure, fever anxiety, and goosebumps with flushed skin above the level of the spinal cord injury). R1's hospital After Visit Summary (AVS) indicated R1 received baclofen 40 milligrams (mg) on 12/12/22, at 12:10 p.m. R1's hospital Discharge Summary Brief Overview dated, 12/12/22, under section Medication List at Discharge as of 1:22 p.m included the order: Baclofen 20 mg tablet patient taking differently: (he) takes 20 mg by mouth in the morning, 40 mg at 11:00 a.m., 20 mg at 5:00 p.m., and 40 mg at bed time. The start date of this dosage was 11/8/22, over a month ago. Hospital records did not identify how long R1 had been taking baclofen medication. R1's facility physician order dated 12/12/22 for baclofen upon admission to the NH was inconsistent with the discharging physician order. The order transcribed into R1's record was baclofen 20 mg four times a day, which was 40 mg less than the hospital discharge summary identified. R1's care plan dated 12/12/22, identified R1 had chronic pain and right shoulder surgical pain. R1 required scheduled Baclofen for muscle spasms in his back. Interventions included to administer medications for pain as ordered and monitor response. Further directed staff to evaluate the effectiveness of the pain interventions, review for compliance, alleviating of symptoms, dosing schedules and satisfaction with results, impact on functional ability and on cognition. R1's medication administration record (MAR) for December 2022, indicated R1's baclofen was administered on 12/12/22, 20 mg at 4:00 p.m. and again at 8:00 p.m. Baclofen was given 20 mg four times a day from 12/12/22 and discontinued on 12/14/22 with the last dose given at 4:00 p.m. R1's progress note dated 12/13/22, at 4:39 a.m. indicated R1 was so uncomfortable in bed; wanted to lay flat but complains of shortness of breath (SOB), hydrocodone (narcotic pain med) given for comfort. R1 had been repositioned over 5 times this shift. -At 7:00 a.m. R1 was asking for his medications and refused to put the head of the bed (HOB) up because R1 stated that he gets back spasms. Blood pressure (B/P) 210/111 (normal is 120/80). -At 2:59 p.m. indicated R1 was in pain and had spasms most of the day. B/P was 178/96, heart rate (HR) 78 (normal heart rate 60-100), respirations at 24 (normal 12-16). -At 5:35 p.m. R1 was given ibuprofen (medication to treat pain, fever, and inflammation) and the follow up pain scale was a 6/10, still having back pain and muscle spasms. R1 stated, could not wait until 7:00 p.m. to get scheduled meds. -At 7:20 p.m. R1's HOB lowered per request due to being uncomfortable and muscle spasms while raised. R1's monitoring sheet, dated 12/14/22 indicated R1's had frequent spasms to the extent of causing him to start falling out of bed and required repositioning to prevent falls. R1's progress note dated 12/14/22, at 1:38 p.m. indicated R1 had requested a different bed because of spasms caused his legs to come out of the bed. Vital sign records at 2:33 p.m. BP was 166/86, HR-88, and respirations were 18. At 2:59 p.m. progress note indicated R1 had been calling out for assistance every 1.5 hours if not more frequently for positioning because of the spasms. R1's physician visit dated 12/14/22, indicated R1 was seen by nurse practitioner (NP)-A for muscle spasms in R1's legs. The note identified NP-A gave order to immediately stop R1's Baclofen (without a taper) and to start Flexeril (muscle relaxer) for better muscle spasm control. New order for Flexeril 10 mg to take 4 times a day. Continue to monitor, notify senior service team provider if symptoms fail to improve or worsen. Physician visit documentation did not identify or mention effectiveness of R1's current dose of baclofen that was inconsistent with hospital discharge orders. R1's progress note, dated 12/15/22, at 3:58 a.m. R1 required repositioning every 30 to 45 minutes. At 4:52 a.m. at 10:25 a.m. hydrocodone administered for pain and discomfort. Vital sign record at 3:01 p.m. B/P was 144/75, HR was 101, and Respirations were 20. At 3:03 p.m. hydrocodone was administered for pain, R1 ' s comfort level was fluctuating throughout the shift. At 6:43 p.m. R1 was having spasms and pain. At 8:20 p.m. R1 administered hydrocodone for pain and muscle spasms. At 10:33 p.m. R1 had been repositioned 5 during the evening shift due to having trouble trying get his legs adjusted so he could lay on his side. R1's progress note dated 12/16/22, at 1:05 a.m. indicated R1 had an unwitnessed fall, found beside his bed on the floor, lying on his right side. Prior to the fall R1 was in bed trying to lower his 70-degree head of bed when his legs began spasming. At 4:20 a.m. R1 continued to have uncontrolled back and arm pain after the fall, with a heart rate of 140. R1 was transferred to the emergency room and returned to the facility at 6:00 a.m. with diagnoses of back contusion. Upon return B/P-203/122 and HR-137. At 7:34 a.m. physician communication was completed to see provider due to increased blood pressure, hallucinations during the night, uncontrolled back spasms. R1 complained of feeling hot, extreme episodes of anxiety at times, abdominal breathing during times of distress and has a history of autonomic dysreflexia. R1's Consultant Pharmacist's Medication Review, dated 12/16/22 at 11:18 a.m. identified an irregularity of a high dose of baclofen was stopped on 12/14/22, withdrawal has been reported with abrupt discontinuation. Suggested course of action: Discussed with medical director (MD)-A today, recommend taper of baclofen dose to prevent withdrawal (i.e., 20 mg three times a day (TID), then 5 mg TID, then 5 mg twice a day (BID), then 5 mg every day. Implementation timeframe: physician to address as soon as possible (ASAP). R1's Provider visit, dated 12/16/22, indicated R1 was seen for admission visit following a hospital stay from 12/8/22 to 12/12/22 for planned right total reverse shoulder arthroplasty (a surgical procedure to restore the function of a joint). Past medical history includes significant quadriparesis following a motor vehicle accident (MVA), spasticity on baclofen. R1 is reporting ongoing difficulty with muscle spasms and was transitioned from baclofen to Flexeril. Staff have been concerned about increasing anxiety and reported intermittent hallucinations. R1 also reported some visual hallucinations. Consultant pharmacist (CP)-A expressed concern for risk of baclofen withdrawal given recent transition from baclofen to Flexeril. On reviewing vitals, noted that R1 has been running tachycardic and hypertensive. R1 has been quite variable in his blood pressures, but have run typically higher rather than low recently and running particularly high this morning with systolic in the 180's. Because of hypertension, staff were able to obtain supply from a local pharmacy of nifedipine (medication to manage blood pressure) of 10 mg one time. R1 has also had some fluctuations in temperature control, being hot most of the time but cold at other times. R1's blood pressure was noted to be 188/105, pulse 101 and respiratory rate was 24. Physical exam identified R1 was seated in motorized wheelchair, tremor noted that varies in intensity. R1 does express fluctuations in temperature/comfort feelings. Does have some odd comments at times but is able to provide accurate recent history. Mildly anxious but otherwise cooperative during visit. Assessment/Plan Number 1: Autonomic Dysreflexia: Suspect findings here today are consistent with baclofen and potentially autonomic dysreflexia. Note indicated new orders for terazosin (blood pressure medication), baclofen 20 mg three times a day, reduce Flexeril to 5 mg three times a day alternating with baclofen. R1's progress note, dated 12/16/22, at 2:30 p.m. indicated R1 had visual hallucination in morning and afternoon. R1 reported feeling comfortable during the shift, however during bouts of spasms rated pain 10 out 10. At 10:11 p.m. progress note identified R1 required frequent repositioning. R1's progress note dated 12/17/22, at 6:26 a.m. indicated R1 continues to be hallucinating and has been noted to be very restless this shift. R1 stated he thinks his medications are making him crazy. At 1:19 p.m. R1 was repositioned every 30-45 minutes. At 4:20 p.m. family member reported R1 was not his usual self, was hallucinating, and confused. R1 was sent to emergency room at 11:00 p.m. and returned to the facility at 11:30 p.m. with order for antibiotics for possible urinary tract infection and instruction to follow-up with primary care provider. R1's progress notes dated 12/18/22, at 10:20 a.m. identified R1 complained of back pain and was agitated. HR-141. R1 was transferred back to the ER for further evaluation. Review on R1's hospitalization records, dated 12/18/22 identified upon arrival to ER, R1 was tachycardia (rapid heartrate), Tachypnea (rapid breathing) and altered mental status. R1 was admitted to medical intensive care unit (MICU) for change in mental status and apnea. Hospital records dated 12/20/22, identified diagnoses of encephalopathy (brain disease that alters brain function) in the setting of baclofen withdrawal. Recommendation to resume R1's prior dose of baclofen, if he continues to have worsening spasticity that is causing pain or difficulty with positioning the baclofen could be increased to maximum daily dosing if it was not already at this level at home. Baclofen is the primary medication I would recommend treating his spasticity. Botox injections could also be considered. I would not recommend using Flexeril or other muscle spasm medications as the primary treatment for his spasticity. If baclofen is to be stopped again in the future, it should be slowly tapered to avoid dangerous withdrawal. During a phone interview on 12/30/22, at 11:43 a.m. consultant pharmacist (CP)-A stated that R1's baclofen was abruptly discontinued by NP-A on 12/14/22 and should not have been discontinued without a taper. The symptoms of baclofen withdrawal would be similar of opiate withdrawal and would include symptoms R1 was exhibiting such as increased blood pressure and pulse, hot flashes, hallucinations anxiety, spasticity, and restlessness. During an interview on 12/30/22, at 12:15 p.m. clinical manager (CM)-A stated R1 was admitted on [DATE] and was here to rehab from his right shoulder arthroplasty. Also had a diagnosis of a spastic quadriplegic. R1 was having some pretty severe muscle spasms and NP-A saw R1 on 12/14/22 and discontinued his baclofen and started him on Flexeril. CM-A stated that R1 was not tapered off the baclofen and should have been. CM-A stated that R1 was having symptoms to include heat intolerance, severe anxiety, restlessness, hallucinations when the baclofen was discontinued and continued to exhibit them until he was discharged to the ED on 12/18/22. CM-A stated these symptoms would be from the baclofen withdrawal. During a follow-up interview at 2:34 p.m. CM-A stated she did the admission for R1. She did not notice the discrepancy between the discharge summary orders and the signed orders were different. Had she noticed she would have called the provider for clarification. During an interview on 12/30/22, at 2:11 p.m. DON stated, R1's baclofen upon admission on 12/12/22 was not transcribed correctly. R1 was supposed to get a total of 120 mg of baclofen a day in 4 divided doses upon admission and was only receiving 80 mg in 4 divided doses until it was discontinued abruptly by NP-A on 12/14/22. DON stated a taper should have been done and that their consulting pharmacist gave a recommendation on 12/16/22 noting to not stop baclofen without a taper. During a phone interview on 12/30/22, at 5:24 p.m. medical director (MD)-A stated he was aware of R1's transcription error regarding baclofen and verified R1 was initially receiving 40 mg less baclofen per day initially than when he was in the hospital until it was abruptly discontinued on 12/14/22. MD-A stated, the baclofen should not have been discontinued without a taper and that the CP-A made him aware of this on 12/16/22. MD-A stated, the symptoms R1 was exhibiting were most likely from baclofen withdrawal leading to autonomic dysreflexia. The immediate jeopardy that began on 12/14/22, was removed on 1/1/23, when it was verified, the facility implemented the following: -reviewed policies and procedures for transcribing medications upon admission and educated staff on these policies -educate staff and providers on medications that require tapers and withdrawal symptoms -review and revise policy for change in condition and acceptable parameters for vital signs and educated staff on these policies Facility policy titled, Medication Error Management Policy, revised 5/17, Procedure: 1. All medication errors must be reported immediately upon identification of error occurring, complete the medication error report fully and give to nursing supervisor or director of nursing (DON). 2. Resident's MD/NP needs to be notified: the immediacy of the notification is dependent on the category of error, harm/lack of harm to the resident and time of day; notification of timing will be determined by the nursing supervisor or DON. 3. Initiate any orders received by the MD. 6. Root cause analysis is to be completed for all medication errors. 8. DON reviews all medication reports, is responsible for determining notification of error to the Medical Director and intervention, if any, regarding the individual employee or medication systems/procedures re-education and/or disciplinary measures are to be implemented as outlined below based on the type of error and prescribed educational and/or counseling intervention. Significant error: an error that resulted in the need for treatment or intervention and caused temporary resident discomfort; an error occurred that resulted in hospitalization . Significant Medication Error with change in condition and hospitalization : if a nurse/TMA has one error in this category, a root cause an analysis of error will be completed in 3 days. An investigation suspension until completion of an internal review and the root cause analysis may be imposed.