Every finding on record at Parmly on the Lake LLC

Based on observation, interview and document review, the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares were completed timely or as ordered. This affected activities of daily living (ADLs) for 4 of 5 residents (R52, R66, R50, R2), positioning for meals for 1 of 1 resident (R9), toileting program schedules and check and changes for 3 of 5 residents (R66, R8, R9), timely pain medication delivery timely for 1 of 3 resident (R62), dialysis care for 1 of 1 resident (R11). This also affected timely meal service for 9 of 9 residents (R56, R30, R44, R26, R2, R8, R72, R10, R73). This deficient practice had the potential to affect all 89 residents who resided in the facility.Findings include:Resident and family interviews:During an interview on 8/23/26 at 4:18 p.m., R52 stated there had been times when his call light was on for over an hour, especially at night. R52 also stated his call light could not been seen from the nurse's station.During an interview on 8/23/26 at 4:41 p.m., R8 stated it could be 30 minutes or longer for a call light to be answered if agency staff were working. R8 stated he would have bowel and bladder accidents related to his call light not being answered timely. R8 said this occurred in the past week.During an interview on 8/24/26 at 8:29 a.m., R66 stated she was told the night before when she needed a boost in bed that the other person was on break and she would have to wait until the staff returned. R66 stated she would be left wet and would not be changed when she asked. She stated she had also asked staff to wipe her back because her brief leaked upward, staff did not comply with her request, so she rang again and two hours later a nursing assistant came in and complied with her request. R66 also stated she would sometimes have to wait up to two hours for pain medication after requesting the medication. She also stated staff had told her to just go in her brief. R66 stated staff would come in shut off the call light but not return to complete the requested care.During an interview on 8/24/26 at 10:09 a.m., R62 stated the facility did not have enough help.During an interview on 8/24/26 at 12:10 p.m., R12 stated he had a fall and hurt his head and bruised his shoulder when he was trying to get to the bathroom and no one came to help him so he went on his own and fell.During an interview on 8/26/26 at 1:22 p.m., residents in the resident council meeting stated they did not think the call lights were answered timely and stated sometimes the call light would be on for up to two hours or sometimes staff would shut off the call light but not come back and help the resident.During interview on 8/26/26 at 12:04 p.m., family member (FM)-A stated on she visited on Sunday 8/23/26 and R99 was in bed at 1pm and lying flat on his back, not dressed, and his food tray was at the nursing station, and no food had been eaten. This tends to be on Sunday's when I visit when he isn't dressed and still in bed in the afternoon. The facility seems to be shorter staffed on the weekends. A review of the grievance logs identified the following:Call light response time concerns were 6 for April, 2 for May, 2 for June, and 1 for July.Customer service/interaction concerns were 10 for April, 13 for May, 35 for June, and 18 for July. A review of the needs of the 28 residents on the North unit revealed the following:-Five residents who required a two person assist with activities of daily living (ADLs).-Sixteen residents who required one person assist with ADLs.-Nine residents who required two person assist for Hoyer (full body mechanical lift) for transfers in/out of bed.-Fourteen residents who required; one person assist with transfers, six who needed an assist of one person for a PAL (patient assist lift strap for transfers), and eight who needed a pivot assist of one staff for transfers.-Three residents who required assistance with eating at meals.-Fourteen residents who required assistance with checking and changing.-Seven residents who were independent with their cares.The facility assessment dated [DATE], reviewed on 8/26/26, identified licensed nursing would be 10-20 staff and nursing assistants would be 20-40.Activities of Daily Living:See also F677R52R52's admission Minimum Data Set (MDS) dated [DATE], identified he had diagnoses which included encephalopathy (a serious decline in brain function caused by severe liver disease), Parkinson's disease (a long-term brain disorder that affects movement, balance, and coordination), anxiety, depressive disorder, and insomnia. R52's MDS identified he was cognitively intact and had no rejections of care. In addition, R52's MDS identified he required set up for oral hygiene and personal hygiene, partial to moderate assistance with toileting, upper and lower dressing, and putting on footwear.R52's care plan dated 6/17/26, identified R52 had a self-care deficit. Interventions included an assist of one staff for personal hygiene and dressing. In addition, R52's care plan identified he required an assist of one staff with toileting. Other interventions included assistance of one staff with peri-cares morning, bedtime and as needed.During an observation on 8/24/26 at 3:30 p.m., R52 was seated in his wheelchair near the nurse's station. He was wearing a blue ball cap, light blue/green long sleeve shirt, long black pants, blue non-skid slippers and black shoes.During an observation on 8/25/26 at 8:28 a.m., R52 was seated in the main dining room, he was wearing a blue ball cap, light blue/green long sleeve shirt, long black pants, blue non-skid slippers and black shoes.During an observation on 8/25/26 at 12:05 p.m., R52 was seated in his wheelchair by the nurse's station, he was wearing a blue ball cap, light blue/green long sleeve shirt, long black pants, blue non-skid slippers and black shoes. R52 stated he was waiting for the nurse to put in some eye drops and then he planned to go to the dining room for lunch.During an observation and interview on 8/25/26 at 1:11 p.m., R52 stated he slept in his clothes from yesterday, he also said no staff had helped him with morning cares today.During an observation on 8/26/26 at 7:26 a.m., R52's door to his room was open he was observed lying in bed, he was wearing the light blue/green long sleeve shirt, one foot was out from under the covers, and blue non-skid slipper was visible.During an observation on 8/27/26 at 9:26 a.m., R52 was observed lying in bed, his covers were on covering his lower body, he was wearing the light blue/green long sleeve shirt.During an interview on 8/23/26 at 4:17 p.m., R52 stated staff were no longer helping him with personal cares in the morning and at bedtime. R52 thought this might be because he was able to transfer himself from chair to bed and bed to chair.During an interview on 8/25/26 at 1:26 p.m., nursing assistant (NA)-C stated staff were supposed to help R52 get dressed in the morning and set him up for brushing his teeth. NA-C stated she arrived later in the morning and received report from another NA, the report did not include who had received morning cares, it was just about how residents were doing. She was not sure if R52 had received any morning cares.During an interview on 8/27/26 at 10:52 a.m., registered nurse (RN)-C reviewed R52's electronic medical record and verified he was an assist of one staff for activities of daily living, which included dressing and personal hygiene. RN-C verified R52 should not be sleeping in his clothes every night and staff should have been offering assistance every morning and at bedtime.During an interview on 8/27/26 at 11:52 a.m., the director of nursing (DON) stated she would expect staff to offer to help residents with morning and bedtime cares, she stated she would not expect residents to sleep in their clothes unless it was what they wanted to do. The DON stated if that was the case she would expect that information to be part of their care plan. R66R66's quarterly Minimum Data Set (MDS) dated [DATE], identified R66 had diagnoses which included chronic heart failure (a chronic condition where the heart muscle cannot pump blood and oxygen efficiently enough to meet the body's needs), chronic respiratory failure, hypothyroidism, hemiplegia (paralysis on one side of the body) on the left nondominant side, pain, chronic atrial fibrillation (an irregular and often very rapid heart rhythm), diabetes mellitus, obstructive sleep apnea, hypertension, and hyperlipidemia. In addition, R66's MDS identified that she was cognitively intact, was dependent on staff for assistance with activities of daily living and had no rejections of care.R66's care plan dated 8/29/25, identified R66 had an alteration in elimination related to overactive bladder. Interventions included to provide assistance with peri-cares morning, bedtime and as needed. In addition, R66's care plan identified that she had an alteration in mobility related to chronic heart failure, respiratory failure and weakness. Interventions included transfers with an assist of two and the use of a Hoyer (full body mechanical lift), and to provide routine morning and bedtime cares. R66 had an identified self-care deficit. Interventions included assistance with oral cares morning and bedtime and as needed. If resistive to care staff were instructed to leave and return in 10 minutes. Assist with one to two for personal hygiene, staff were instructed to do peri-care after each elimination/incontinent episode and as needed.During an interview on 8/25/26 at 9:21 a.m., R66 was seated in her chair at her bedside and her hair was uncombed, and she was wearing a hospital gown. She stated they had not offered her an opportunity to wash her face and hands, brush her teeth or comb her hair. R66 stated she was supposed to have had a bath on Saturday, she stated she did not receive this bath and then stated it had been three weeks since she had a bath.A review of R66's past three months of weekly skin inspections identified the following:8/22/26, Saturday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.8/15/26, Saturday bed bath8/8/26, Saturday bed bath. She had gone 19 days without a documented bath.8/1/26, Saturday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.7/25/26, Saturday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.7/19/26, Sunday bed bath7/5/26, Sunday bed bath7/4/26, Saturday bed bath. She had gone 23 days without a documented bath.6/25/26, Thursday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.6/14/26, Sunday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.6/10/26, Wednesday bed bath. There were no other baths documented for June.R66's comprehensive MDS dated [DATE], section F (preferences for customary routine and activities) identified it was very important for her to choose between a tub bath, shower, bed bath, or sponge bath.A request for last documented shower was requested but not provided.During an interview on 8/26/26 at 12:19 p.m., nursing assistant (NA)-D stated there were often not enough slings available for use and a lot of time was spent looking for slings, regular slings and shower slings.During an interview on 8/26/26 at 12:33 p.m., R66 stated there was not a sling available for her to take a shower on Saturday.During an interview on 8/26/26 at 1:22 p.m., the participating residents at the resident council meeting stated they did not think call lights were answered timely. It was said residents have waited up to two hours and/or staff will come in and shut the call light off, say they will be back, but then no one returns because the call light was turned off.During interview on 8/26/26 at 1:57 p.m., licensed practical nurse (LPN)-B stated she has 28 residents she is responsible for all treatments and medications, and ends up staying late to get finished. She has brought it up to management, but they say they are doing what they can. There are 2 NAs she is working with, float gets pulled to other areas of the building. Sometimes baths won't get done and it gets passed on to the next shift. When they have a float, they always get done. Some days are terrible and they just can't get to all of them. During an interview on 8/26/26 at 2:51 p.m., RN-E stated they would frequently run out of slings. RN-E said they were in the dirty laundry.During an interview on 8/27/26 at 10:00 a.m., RN-B stated she was not sure why R66 was getting bed baths instead of showers but thought maybe it was her preference. RN-B stated she would expect staff to re-approach several times when a resident refuses a shower and document the refusal. RN-B stated she would expect staff to check and change R66 every two hours.R50R50's comprehensive MDS dated [DATE], identified R50 had diagnoses which included atrial fibrillation, anemia, chronic embolism and thrombosis of deep veins of proximal lower extremity, edema, and pain. In addition, R50 was moderately cognitively intact and had no rejections of care. R50's MDS identified she required partial to moderate assistance with upper body dressing and substantial to moderate assistance with lower body dressing.R50's care plan dated 6/17/26, identified a self-care deficit. Interventions included an assist of one staff for dressing and with personal hygiene.During an observation on 8/26/26 at 9:34 a.m., R50's call light was on along with three other call lights. Heard through the closed door, help me.at 9:38 a.m., R50's call light remained on and could be heard through the closed door someone help me.At 9:40 a.m., knocked on the door to ensure they had not fallen on the floor. R50 was seated in a chair with nothing on the top half of her body struggling to get her bra on. Immediately went looking for help from facility staff. The RN on duty was found, and she went to assist R50.During an interview on 8/27/26 at 10:56 a.m., RN-C stated it was the expectation that call lights would be answered within 15 minutes. RN-C verified it was not a dignified experience for anyone to put on their call light, wait, and struggle to get dressed. RN-C stated the wait might possibly be related to not having enough staff.During an interview on 8/27/26 at 11:54 a.m., the DON stated it was not dignified for a resident to put on their call light, wait, struggle to dress and have to call out for help before anyone arrived to help. The DON stated she was not sure if this was a staffing related concern.R2R2's significant change MDS dated [DATE], identified she had diagnoses which included orthopedic aftercare for closed fracture of left femur, anxiety, Alzheimer's disease, cognitive communication deficit, depression, and pain. In addition, R2 was severely cognitive impaired, was rarely understood/understands, required set up for meals and was dependent on staff for activities of daily living.R2's care plan dated 8/4/26, identified R2 was deemed unsafe with hot liquids without proper interventions. Interventions included Needs staff assistance with eating or drinking.During an observation on 8/23/26 at 6:01 p.m., R2 was observed in a common area near the nurse's station, she had a partially eaten slice of pizza in her chair, a chocolate ice cream in her chair with the cover on and two containers of food on her tray with covers on them. There were no staff in the area.During an observation on 8/25/26 at 8:18 a.m., R2 was observed in a common area near the nurse's station. Her meal tray was on the counter with covers on the food.-at 9:04 a.m., R2 was served her tray, a staff member was seated at the table assisting both R2 and another resident. Her tray sat for approximately 45 minutes before she was served and assisted with eating.-at 9:32 a.m., R2 remained in the common area, her food tray remained within her reach, no staff were present. Her breakfast was oatmeal, juice, bread, bacon, yogurt. Not much of her food had been eaten.During an observation on 8/26/26 at 7:49 a.m., dietary staff delivered about 14 trays on an open cart. R2's tray was placed on the counter.-at 8:49 a.m., staff brought R2 to the common area near the nurse's station. A hospice NA brought the tray to R2 reheated the meal and helped her eat. The tray sat for approximately one hour before it was served.During an observation on 8/27/26 at 8:43 a.m., R2 was observed sitting in the common area near the nurse's station. She had her tray in front of her; there were no staff present. The lid was still on the beverage.During an interview on 8/27/26 at 11:24 a.m., the DON verified R2 was supposed to have an assist of one staff for eating. Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23, identified the intent of the policy was to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. In addition, the policy identified A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.See also F686:R66R66's quarterly Minimum Data Set (MDS) dated [DATE], identified R66 had diagnoses which included chronic heart failure (a chronic condition where the heart muscle cannot pump blood and oxygen efficiently enough to meet the body's needs), chronic respiratory failure, hypothyroidism, hemiplegia (paralysis on one side of the body) on the left nondominant side, pain, chronic atrial fibrillation (an irregular and often very rapid heart rhythm), diabetes mellitus, obstructive sleep apnea, hypertension, and hyperlipidemia. In addition, R66's MDS identified that she was cognitively intact, was dependent on staff for assistance with activities of daily living (ADLs) and had no rejections of care.R66's care plan dated 8/29/25, identified R66 had an alteration in mobility. Interventions included offering turn and repositioning/offloading every two to three hours and as needed and to assist with movement in/out of bed with an assist of two staff and a Hoyer lift (a full body mechanical lift).During an interview on 8/24/26 at 8:29 a.m., R66 stated that last evening she wanted to be boosted up in bed but was told she would have to wait until the other nursing assistant (NA) came back from break. R9 stated she would frequently be left wet and not changed when she asked for help, she stated she had been told to just go in her brief. She stated she had also been told they couldn't get her up because they couldn't find a sling to use. R66 said she has had to wait for up to two hours for pain medication.R8R8's significant change MDS dated [DATE], identified he had diagnoses which included acute and chronic respiratory failure, heart failure, diabetes mellitus, depression, paroxysmal/chronic atrial fibrillation (an irregular and often very rapid heart rhythm), urgency, insomnia, and lymphedema. In addition, R8's MDS identified he was cognitively intact and was dependent on staff for ADLs and was frequently incontinent of bowel and bladder.During an interview on 8/23/26 at 4:41 p.m., R8 stated there were not enough staff, he stated he might have to wait 30 minutes or longer to have his call light answered. R8 said he had had bowel and bladder accidents during the past week because staff didn't answer his call light in time.During an interview on 8/26/26 at 12:07 p.m., R8 stated his call light had been on for a long time that morning. He stated he was no longer able to recall what he had wanted. R8 stated if staff didn't come when he called then they would have to change him (he would be incontinent).R9R9's annual MDS dated [DATE], identified he had diagnoses which included hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness of one entire side of the body), dysphagia (difficulty swallowing), aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury), pain, diabetes, insomnia, restlessness and agitation. In addition, R9 was cognitively intact, was dependent on staff for assistance with ADLs, and was frequently incontinent of bowel and bladder. In addition, R9 had an alteration in mobility. Interventions included offering to turn and reposition/offload every two to three hours and as needed, and to assist with transfers with an assist of two staff with the Hoyer lift.R9's care plan dated 5/12/25, identified R9 had an alteration in elimination. Interventions included an assist of two staff for toileting, toilet resident every two to three hours and as needed and check and change.During an interview on 8/23/26 at 5:04 p.m., trained medication aide (TMA)-A stated they were caring for 28 staff with two NAs on each unit. The TMA-A stated it would sometimes work depending on the staff who were on the shift, they said agency staff didn't always help because some of them look at the 28 residents as those are yours and these are mine. TMA-A stated agency staff would not always answer call lights if they were not assigned to the residents.During an interview on 8/24/26 at 3:09 p.m., family member (FM)-A stated R9 had not been out of bed since Thursday, 8/20/26. FM-A stated it was because they couldn't find a sling to get him out of bed.During an interview on 8/26/26 at 10:02 a.m., NA-F stated they were taking care of 28 residents, two staff and a float NA (the float NA) who worked between the units. NA-F said most of the residents on the unit were dependent on staff for cares. NA-F stated lots of things didn't get done depending on who the team was. NA-F stated they had to get residents up for breakfast (assist some with eating) many needed two staff because they needed to use the Hoyer. NA-F reviewed the check and change book and stated there were three residents who were late for checking and changing R66, R8, R9. NA-F stated when hospice staff were in the building it helped but they were not there daily. NA-F stated when they start their rounds residents would often be soaking wet.During an interview on 8/26/26 at 12:19 p.m., NA-D stated it was hard to keep up with answering call lights, hard to keep up with resident requests, they just do the best they can and try to keep track of the order the call lights went on. NA-D stated it was harder to keep up on weekends, because there were not any activity staff or hospice NAs working.During an interview on 8/26/26 at 1:12 p.m., registered nurse (RN)-D stated the NAs were taking care of 26 to 28 residents with most of them dependent on staff for assistance and prone to fall. RN-D stated they often worked as an NA because they can't do it with two NAs. RN-D stated they can't always keep up with the call lights.During an interview on 8/27/26 at 10:00 a.m., RN-B stated it was important for residents to be checked and changed every two hours. RN-B stated she thought there were enough staff on the unit to get the checks and changes done timely.During an interview on 8/27/26 at 10:40 a.m., RN-C stated for most of the residents they needed to be checked and changed every two hours to prevent skin issues. RN-C stated she thought they had enough staff to get their work completed timely although she was unable to say how many of the 28 residents required checking and changing every two hours.During an interview on 8/27/26 at 11:24 a.m., the director of nursing (DON) stated residents who were care planned for checking and changing should be checked and changed and repositioned every two to three hours. The DON stated she expected staff to answer call lights within 10-15 minutes. Skin Assessment & Wound Management dated 2/2025, identified the purpose of the policy was to provide guidelines for assessing and managing wounds. Interventions included to review and update care plans including interventions. Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23, identified the intent of the policy was to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. In addition, the policy identified A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Pain medication delivery and call lights:During an observation on the North unit on 8/26/26, at 7:07 a.m., there were seven call lights on.-at 7:15 a.m., there were five call lights on.-at 7:25 a.m., there were six call lights on.-at 7:29 a.m., there were five call lights on, the nurse was preparing medication at the medication cart.-at 7:37 a.m., there was one call light on. -at 7:48 a.m., there were two call lights on.-at 7:51 a.m., there were four call lights on.-at 7:55 a.m., there were three call lights on.-at 7:59 a.m., there were two call lights on.-at 8:01 a.m., the same two call lights remained on.-at 8:04 a.m., there was one call light on.-at 8:07 a.m., two staff were at a computer there were two call lights on, the nurse was delivering medications. -at 8:12 a.m., two staff came out of the room, one of the two call lights remained on, the two staff went into a different room after putting on personal protective equipment (PPE). Two more call lights came on. -at 8:20 a.m., one of the call lights was flashing red and a different call light went on. -at 8:23 a.m., a staff member entered a room with food, there were five call lights on. The other two staff were still in the room they entered at 8:12 a.m -at 8:24 a.m., the nurse went into the room with the two staff after putting on PPE.-at 8:27 a.m., three staff remained in the room where they had to put on PPE, one call light flashing red and three more call lights went on.-at 8:31 a.m., there were four call lights on.-at 8:34 a.m., a staff member brought a resident to the dining room for breakfast there were still four call lights on.-at 8:37 a.m., a hospice went into R62's room, she left the room walked down the hallway and asked where the nurse was. The message was delivered to the registered nurse (RN).-at 8:46 a.m., RN-G delivered pain medication to R62 after a 26-minute wait.-at 8:55 a.m., R62 stated he needed the medication for his breathing, not for pain control. R62 would not comment on the length of time he waited stating he didn't want to get anyone in trouble. R62 did state the length of time he would have to wait depended on how busy the staff were.-at 8:53 a.m., there were four call lights on, one of which was flashing red.-at 8:58 a.m., there were four call lights on two of which were new ones.-at 9:04 a.m., hospice staff (H)-E stated R62 would talk to her about how long he would have to wait to have his call light answered. H-E stated she saw R62 twice a week and he would bring up the long call light waits a few times a month.-at 9:07 a.m., there were two call lights on. Two had been on since 8:53 a.m.-at 9:10 a.m., there was one call light on for R66, staff looked in but did not go in, two other call lights were on, one of which had been on since 8:53 a.m -at 9:18 a.m., R9 stated no one had helped him, but his call light was off (it had been noted to be on at 8:53 a.m.).-at 9:20 a.m., there were two call lights on and one was flashing red.-at 9:27 a.m., there were two call lights on.-at 9:34 a.m., there were three call lights on. One was for R50, could hear her calling through the closed door, help me.-at 9:38 a.m., could hear her calling, someone help me through her closed door.-at 9:43 a.m., there were four call lights on, one was flashing red.-at 9:50 a.m., there was one call light on. During a continuous observation from 7:07 a.m. to 9:50 a.m., two hours and 57 minutes there was always one or more call light on. See also F698:R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included end stage renal disease (a disease where there is permanent kidney failure that requires a regular course on dialysis or a kidney transplant), dependent on dialysis, anemia, chronic pain, hypertension, and fibromyalgia (a long-term medical condition that causes widespread body pain, extreme tiredness, and sleep problems. In addition, R11's MDS identified that she was cognitively intact and received dialysis.R11's care plan dated 4/21/26, identified R11 was at risk for complications related to dialysis. Interventions included for uncontrolled bleeding at dialysis site, call 911. Order a meal for patient upon dialysis return. Send communication folder to dialysis with each run. R11's care plan dated 5/26/26, identified a potential alteration in nutrition. Interventions included communication with dialysis team as needed. Provide diet order per medical doctor order. Diet education. Fluid restriction 1500 milliliters (ml).R11's Order Summary Report identified the following orders:-complete dialysis communication form and send with resident to dialysis every day shift every Monday, Wednesday, Friday dated 10/7/25-dialysis is on Monday, Wednesday and Friday. Remember to send a snack or lunch with the resident dated 4/7/26-dialysis-Review Post Dialysis Treatment Report for updates. If none found, call dialysis. Dated 11/8/25-dialysis-Vital Signs after dialysis. Monday, Wednesday, Friday. Dated 11/8/25.-dialysis: Monitor Dialysis site for bleeding. If excessive bleeding is noted call 911. Dated 8/25/26-dialysis: Post dialysis offer rest and snack. Dated 8/25/26-send midodrine (medication used to treat low blood pressure) with dialysis on Monday, Wednesday, Friday. Dated 7/21/26-midodrine give 10 milligrams (mg) by mouth one time a day for hypotension. Send with dialysis days repeat times one for low blood pressure. Hold if systolic blood pressure is greater than 180. Dated 7/21/26A review of August vital signs (VS) and the dialysis center communication records revealed the following:-8/3/26, 2:56 p.m., 98.2 - 78 - 16 - 134/77 - per the dialysis center communication record these were the pre-VS no post VS documented. Nothing on the communication sheet filled out by the dialysis center.-8/5/26, 2:26 p.m., 97.8 - 68 - 16 - 162/99 - per the dialysis center communication record these are the pre-VS, no post VS documented. Nothing on the communication sheet filled out by the dialysis center.-8/7/26 5:06 p.m., 98 - 65 - 18 - 158/89 - Nothing on the communication sheet filled out by the dialysis center.-8/10/26, 3:07 p.m., 97.9 - 68 - 18 - 143/78 - Nothing on the communication sheet filled out by the dialysis center.-8/12/26, 4:49 p.m., 98.2 - 66 - 18 - 131/77 - Nothing on the communication sheet filled out by the dialysis center.-8/14/25, 5:04 p.m., 98 - 64 - 18 - 140/77 - Nothing on the communication sheet filled out by the dialysis center.-8/17/26, 3:05 p.m., 97.8 - 72 - 16 - 155/91 - per the dialysis center communication record these are the pre-VS, no post VS documented. Nothing on the communication sheet filled out by the dialysis center.-8/19/26, 2:00 p.m., 97.8 - 62 - 16 - 143/83 - per the dialysis center communication record these are the pre-VS, no post VS documented. Nothing on the communication sheet filled out by the dialysis center.-8/21/26, 11:13 p.m., 97.9 - 70 - 18 -122/72 - Nothing on the communication sheet filled out by the dialysis center.-8/24/26, 10:54 p.m., 97.5 - 78 - 16 - 135/78 - Nothing on the communication sheet filled out by the dialysis center.-8/26/26, 5:36 p.m., 97.4 - 70 - 16 - 162/83 - per the dialysis center communication record these are the pre-VS, no post VS documented. Nothing on the communication sheet filled out by the dialysis center.A review of R11's August 2026 nurses notes did not document any refusals of vital signs following her return from dialysis.During an observation and interview on 8/24/26 at 3:58 p.m., R11

Based on observation, interview, and record review the facility failed to ensure refrigerated medications categized as controlled substance were properly stored with a two-lock system in 3 of 4 medication rooms reviewed for safe medication storage. In addition, the facility failed to ensure stock supply lab specimen collection supplies were not outdated. Findings include: On [DATE] at 1:35 p.m., a review of the Lakeside TCU medication room was completed with registered nurse RN-A. RN-A used a key to gain access to the medication room. The medication room fridge was not locked. There was an unlocked black box on the shelf inside the fridge. There was a bottle of Ativan inside the box. RN-A was not able to find a key that would lock the box. RN-A stated the Ativan belonged to a resident that was no longer at the facility and the bottle should have been disposed of.On [DATE] at 9:42 a.m., a review of the North unit medication fridge was completed with LPN-C. LPN-C used a key to access the North unit medication room. The fridge was not locked. The fridge contained a bottle of liquid Ativan in the door of the fridge. LPN-C stated they did not keep the North unit medication fridge locked, only the medication room door was kept locked.During a follow-up interview on [DATE] at 9:52 a.m., RN-A checked the medication fridge and confirmed it was not locked. RN-A stated the medication fridge needed to be locked at all times and when narcotics were stored the fridge, the narcotics should be double locked. RN-A instructed the medication nurse on the unit to lock the medication fridge.On [DATE] at 2:07 p.m., a review of Parkside mediation room was completed with licensed practical nurse LPN-B. LPN-B used a key to enter the medication room. The medication fridge was not locked. LPN-B stated they did not have a way to lock the fridge. The fridge contained a bottle of liquid lorazepam and a bottle of dronabinol (medication containing THC) located on a shelf in the fridge. Stored lab supplies were also reviewed. A large bag of e-swabs (generally used for collection from nasal, throat, genital, and wound sites) were also found with an expiration date of [DATE]. LPN-B confirmed the e-swabs were all expired. LPN-B confirmed facility staff did collect lab samples outside of their lab service hours.During an interview on [DATE] at 11:09 a.m., RN-C went into the Parkside medication room and confirmed the medication fridge was not locked and at present there was not a way to lock the fridge. RN-C explained that narcotics should be double locked in the medication room. RN-C stated they had been given expired lab swabs. It was not acceptable to have expired swabs in their supply areas as it created the risk for altered results or the potential for a lab to have to be redone. At this time, they did not know of a formal process for supply out date checks, however they expected nurses to check for out dates before they used supplies.During an interview on [DATE] at 12:00 p.m., the director of nursing stated all medication fridges should be locked at all times. Narcotics should be double locked at all times. My expectation would be for the policy to be followed. Diversion of medication is a concern.Medications need to be locked so access is limited only to the nurse who has keys and is responsible for the narcotics/medications on that shift. Best practice and the policy should be used to ensure medications no longer in use are disposed of as soon as possible. Facility nurses did collect lab specimens outside of Monday, Wednesday, and Friday when they had lab services on site. Expired swabs should be removed from supply rooms so that they were not accidentally used for lab collection. The DON stated they were not aware of a formal process to check for outdated supplies, however they did expect nurses to check dates before they utilized supplies.The policy Medication Storage in the Facility ID2 Controlled Substance Storage dated 1/2018, section C directed controlled substances that required refrigeration must be stored within a locked box that attached to the inside of the fridge.

Based on interview and document review, the facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals. This had the potential to affect all residents who resided in the facility.Findings include:During an observation on 8/25/26 at 11:47 a.m., a sign posted on the main dining room indicated mealtimes for dinner were 5:30 p.m., and breakfast at 8 a.m. (which is 14.5 hours between meals).During an interview on 8/26/26 at 1:22 p.m., R36 stated they did not come around with snacks in the evening, but we can ask and they will bring them to us.During an interview on 8/26/26 at 1:39 p.m., R18 stated they didn't come around with snacks in the evening, he got really hungry around midnight.During interview on 8/26/26 at 2:24 p.m., culinary director (CD)-F stated they don't have a snack pass but have snacks always available at the nursing stations at all units. They are stocked at minimum three times a week; some daily.During an interview on 8/27/26 at 11:32 a.m., CD-F stated she was new to the facility and learning the processes and did know there were snacks available for residents to ask for and staff would get them.A policy, Meal Times dated 09/2012, identified it was the policy of Monarch Healthcare Management to serve meals to meet the standards of the surveying agencies specifying no more than 14 hours between the evening meal of one day and the breakfast meal of the next day.

Based on observation, interview and document review the facility failed to ensure food was delivered promptly after it was delivered. This had the potential to affect all residents who ate meals served in their rooms and or ate meals in designated dining rooms. Findings include: During an observation on 8/25/26 at 8:44 a.m., dietary staff delivered two meal trays and set them on a counter. They did not alert any nursing staff that the trays had been delivered. The meals trays were for R56 and R30. -at 9:10 a.m., trays for R44 and R26 were delivered and placed on the counter. -at 11:49 a.m., two trays were delivered and placed on the counter they were for R2 and R8. -at 11:51 a.m., there were 10-11 trays on an open tray rack, there were no staff delivering the trays. On 8/26/26 at 7:49 a.m., dietary staff brought an open tray rack, about 14 meal trays. The dietary staff delivered some of the trays to resident rooms. -at 7:52 a.m., R2's meal tray and R72's meal tray were delivered and both were placed on the counter. -at 7:55 a.m., the trays for R2 and R72 remained on the counter. -at 8:01 a.m., dietary staff placed a tray for R10 on the counter were R2's and R72's trays were sitting. -at 8:27 a.m., the three trays remained on the counter for R2, R72, and R10. -at 8:43 a.m., the three trays remained on the counter for R2, R72, and R10. -at 8:44 a.m., staff were starting to pick up breakfast trays. -at 8:48 a.m., the three trays remained on the counter for R2, R72, and R10. The three trays had been sitting for 59 minutes since delivery. -at 8:49 a.m., R2 was served her breakfast by hospice staff. The hospice staff re-heated the meal in the microwave that had been sitting for one hour on the counter. -at 9:00 a.m., dietary staff returned bringing breakfast trays for R73, R56, and R30 and placed the trays on the counter. R72 and R10's trays remained on the counter; they had been sitting for one hour and 51 minutes. Dietary staff picked up R10's tray and brought it to her room. The meal tray was not reheated, the room was dark, R10 was not in the room. -9:07 a.m. three trays remained on the counter they were for R72, R56, and R30. R73's tray remained on the counter. -at 9:16 a.m., R56 had been served his breakfast, pancakes and sausage, the meal had not been reheated. -at 9:22 a.m., R72 was served his breakfast. His meal had been sitting on the counter for one hour and seven minutes. -at 9:24 a.m., R72 was asked if his breakfast was hot, he responded with hmmmm. -at 9:28 a.m., R10's breakfast remained in her room. R73's tray remained on the counter. -at 9:51 a.m., R73's tray remained on the counter, R10's was removed from her room. -at 10:20 a.m., R73 was brought to the dining room. His meal was served to him at 10:22 a.m., and had been sitting on the counter for one hour and 22 minutes. It was microwaved for 30 seconds to reheat. During an interview on 8/26/26 at 9:45 a.m., R72 stopped in the hallway and said, are you the one who asked me if my meal was hot?. He then stated the staff re-heated his breakfast but stated it wasn't really any better and stated he only ate a few bites and maybe half of the chocolate drink. During an interview on 8/26/26 at 10:02 a.m., nursing assistant (NA)-F stated it was a typical morning. She stated she was taking care of 28 residents and was working with another NA and an NA who floated between the units. NA-F stated, lots of things don't get done, depends on who you're working with. NA-F stated the unit was very dependent on staff for cares. During an interview on 8/26/26 at 12:19 a.m., NA-D stated it was difficult to keep up with resident requests, and she did the best she could. During an interview on 8/27/26 at 11:33 a.m., the director of nursing (DON) stated she was not sure how long it was safe for a meal tray to sit before being served. The DON stated the danger of a tray sitting for greater than an hour and then being re-heated was there could be potential for bacteria growth. The DON stated the liquids needed to be replaced when a tray sat without being served for any length of time. The DON stated it was her expectation that meal trays would be served when the meals arrived. The DON was not sure why meals were not being served on arrival at the unit but was not sure if it was related to the number of staff working. R37: R37's admission Minimum Data Set (MDS) indicated R37 was severely cognitively impaired. R37's face sheet included diagnoses of traumatic subdural hemorrhage with loss of consciousness, dementia with agitation, and unspecified sequelae of cerebral infarction. R37's care plan indicated R37 was at risk for altered cognition and communication and identified interventions for staff to follow to support the goal for 37 to be able to communicate basic needs as able. R37's care plan also identified R37 was considered malnourished per MNA and included intervention to prevent significant weight loss and to meet R37's nutritional needs. During a continuous observation on 8/25/26 at 8:26 a.m., physical therapist PT-A was in the dining room with R67. Dietary aide (DA-B) was passing out meal trays to residents seated at the dining room table. DA-B approached R67 and asked where R67 wanted to eat their breakfast. PT-A instructed DA-B to hold R67's breakfast tray stating they were taking R67 to the therapy room. -At 8:34 a.m., PT-A and R67 left the area. R67's tray was placed on a side table next to another tray. -At 9:13 a.m., PT-A returned with R67 and positioned R67 at the main dining table where other residents were seated with their breakfast trays in front of them -At 9:27 a.m., the medication nurse gave R67 the held breakfast tray containing eggs, oatmeal, bread, and beverages. -At 9:39 a.m., another resident told staff not to take R67's breakfast tray because R67 had just received it. -At 9:44 a.m., Registered nurse RN-B sat down beside R67 and asked if they wanted their oatmeal. R67 replied no, do you want it? -At 9:48 a.m., RN-B instructed an NA not to serve a resident the breakfast that has been sitting on a table since the trays arrived at 8:26 a.m. RN-B told the NA to get a new breakfast tray. During an interview on 8/27/26 at 10:57 a.m., nursing assistant (NA-I) stated residents should get their food right away when it comes so it was served at the right temperature. They would hold a tray for maybe twenty minutes, and they would reheat a meal if a resident requested, but if food sat for more than 20 minutes, they would get a new tray delivered from the kitchen. They hadn't had formal training on how long food could sit, but they would be concerned for safety and about how reheated food would taste to a resident. NA-J was with NA-I and both stated they would not want to eat reheated eggs or toast so they wouldn't want to have a resident do it. During an interview on 8/27/26 at 11:28 a.m., RN-B stated residents should eat their meals before going to therapy. In general trays should not be saved and left sitting out for more than 15 to 20 minutes. If that happens a new tray of food should be requested from the kitchen for food safety and palatability. During an interview on 8/27/26 at 12:09 p.m., the director of nursing (DON) stated nutrition and hydration were a priority for all residents, but it became an increased area of focus for residents with cognition impairments. Meals should not be delayed for therapy. They expected residents to receive their food trays when they were delivered to the units. For safety, food and beverages should not be served to residents after sitting out nor should they be reheated and served to residents. An hour was too long for any tray to sit out. Food and beverage should also be at the right temperature, so residents would want to consume them. The facility policy Meal Tray Service dated 9/2012, indicated meals were to be served in an attractive manner observing temperatures. Trays were to be taken out of the food cart, delivered to resident, and set up for each resident's special needs. The policy did not address reheating meal trays or proper handling of trays when not served immediately. A policy on safe holding temperatures for food trays and re-heating meals was requested but not provided.

Based on observation, interview, and document review the facility failed to complete a Self-Administration of Medication (SAM) assessment and acquire a physician order for self-administration for 1 of 2 resident (R102) who was observed to have medications left at bedside Findings include:R102's Brief Interview for Mental Health performed on admission indicated severe cognitive impairment. (MDS?)R102's electronic medical record (EMR) indicated diagnoses of altered mental status and cognitive communication deficit. The EMR Lacked a SAM assessment or orders to keep medications at bedside.R102's care plan, undated, lacked a care plan related to ability to self-administer medicationsOn 8/23/26 at 5:08 p.m., nystatin powder was observed on the counter next to the bathroom in R102's room.On 8/26/26 at 10:33 a.m., nystatin powder was again observed on the same counter in R102's room.During an interview on 8/26/26 at 10:44 a.m., nurse assistant (NA)-A looked in R102's room and confirmed there was a bottle of medication with the label nystatin powder on the counter next to the bathroom in R102's room.During an interview on 8/26/26 at 2:33 p.m., licensed practical nurse (LPN)-A stated prior to leaving medications at bedside a SAM assessment needed to be completed and orders received. The nurse manager would complete the SAM assessments when a resident wanted to have medications left at bedside or self-administer medications.During an interview on 8/27/26 at 10:23 a.m., registered nurse (RN)-A stated the RN's would do the SAM assessments when residents requested to self-administer medications or so medications could be left at bedside. Rn-A reviewed R102's medical record and acknowledged a SAM was not completed but should have been completed if medications wanted to be left at bedside.During an interview on 8/27/26 at 12:14 p.m., the director of nursing (DON) stated the expectation was the SAM assessment would be completed prior to medications being left at bedside.Facility policy Self-Administration of Medication last revised 2/24, indicated a SAM assessment would be performed at admission and orders obtained, if approved, prior to medications left in the room. The care plan would also be updated, adding the SAM assessment to the care plan.

Based on interview and document review, the facility failed to review and revise the resident care plans as needed for 2 of 2 residents (R1, R18) reviewed for care planning. Findings include: R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment. Diagnoses included cancer, anemia, and chronic obstructive pulmonary disease. R1's care plan undated, lacked a diagnosis related to a risk of aspiration related to recent hospitalization for a new diagnosis of aspiration pneumonia. R1's IM Transfer Forms dated 5/2/26, indicated R1 was admitted to the hospital due to diagnoses that included hypoxia and aspiration pneumonia of both lungs. During an interview on 8/27/26 at 10:31 a.m., registered nurse (RN)-B stated all department heads would work on their own areas of the care plan to make sure they were filled out correctly. If a resident was sent to the hospital, upon return the nurse manager would review all information and make sure any new diagnoses and treatment plans were added to the care plan, so staff were aware of treatments and risks related to that specific resident. A new diagnosis of aspiration pneumonia would warrant a risk for aspiration care plan. RN-B reviewed R1's medical record and confirmed R1 had been hospitalized for aspiration pneumonia but the risk of aspiration care plan was never added to her resident specific care plan. During an interview on 8/27/26 at 12:14 p.m., the director of nursing (DON) stated staff needed to make sure all resident specific diagnosis and treatments were added to the resident care plan at either admission, at time of review, or when returning from the hospital. R18: R18's admission MDS dated [DATE], identified intact cognition and a diagnosis of right humerus fracture with limited range of motion on one upper extremity. R18 needed assist with personal hygiene and was dependent on staff for bathing and toilet hygiene. R18's care plan dated 7/22/26, didn't identify sling management for the right shoulder, and didn't reflect R18's refusal to accept assistance with activities of daily living (ADL)s or wear the sling. Provider orders for R18 identified an order on 7/20/26 for shoulder immobilizer to be worn at all times, may remove only for exercises, hygiene, and skin checks twice daily. During an observation on 8/24/26 at 3:04 p.m., R18 was observed sleeping on his bed without a sling on his right arm. R18 had a beard and his hair appeared wet. During an observation and interview on 8/25/26 at 8:28 a.m., R18 was observed not wearing a sling on his right arm. R18 stated he wasn't wearing it because it was gone. R18 stated he hadn't had a shower since he got here, he did have someone wash his hair with some kind of cap thing. R18 stated he didn't normally have a beard; he just hadn't been shaved here. During an interview on 8/26/26 at 2:48 p.m., RN-C stated when residents refuse something, they should offer a couple different times and at different times of day or with different people. If they continued to refuse, they needed to document they refused. RN-C stated she would think refusals would be something to put on a care plan. During an observation on 8/26/26 at 1:30 p.m., R18 was lying on his bed; he was not wearing a sling to his right arm. During an interview on 8/27/26 at 10:50 a.m., the DON stated care plan updates were a collaborative effort, they would update them on the spot if something was discussed during interdisciplinary team meetings (IDT). The DON stated refusals of care should be on the care plan. During an interview on 8/27/26 at 11:14 a.m., NA-G stated R18 would sometimes refuse his bath or shower, he didn't want to need the help and would refuse and then try to do it on his own. NA-G stated R18 had a sling for his right arm, she had just seen it in his room, but he had been refusing to wear it. Facility policy Care Planning last revised 11/24, indicated a residents would have a person-centered care plan to meet the residents' individual medical, physical, psychosocial, and functional needs. The care plan would identify problem areas and their causes.

Based on observation, interview and document review the facility failed to ensure 3 of 5 residents (R52, R66, R50) received assistance with morning and evening cares. In addition, the facility failed to ensure 1 of 5 residents (R66) received a shower at least weekly. The facility further failed to ensure 1 of 5 residents (R2) received assistance with meals. The residents were reviewed for assistance with cares for dependent residents. Findings include:R52's admission Minimum Data Set (MDS) dated [DATE], identified he had diagnoses which included encephalopathy (a serious decline in brain function caused by severe liver disease), Parkinson's disease (a long-term brain disorder that affects movement, balance, and coordination), anxiety, depressive disorder, and insomnia. R52's MDS identified he was cognitively intact and had no rejections of care. In addition, R52's MDS identified he required set up for oral hygiene and personal hygiene, partial to moderate assistance with toileting, upper and lower dressing, and putting on footwear.R52's care plan dated 6/17/26, identified R52 had a self-care deficit. Interventions included an assist of one staff for personal hygiene and dressing. In addition, R52's care plan identified he required an assist of one staff with toileting. Other interventions included assistance of one staff with peri-cares morning, bedtime and as needed.During an observation on 8/24/26 at 3:30 p.m., R52 was seated in his wheelchair near the nurse's station. He was wearing a blue ball cap, light blue/green long sleeve shirt, long black pants, blue non-skid slippers and black shoes.During an observation on 8/25/26 at 8:28 a.m., R52 was seated in the main dining room, he was wearing a blue ball cap, light blue/green long sleeve shirt, long black pants, blue non-skid slippers and black shoes.During an observation on 8/25/26 at 12:05 p.m., R52 was seated in his wheelchair by the nurse's station, he was wearing a blue ball cap, light blue/green long sleeve shirt, long black pants, blue non-skid slippers and black shoes. R52 stated he was waiting for the nurse to put in some eye drops and then he planned to go to the dining room for lunch.During an observation and interview on 8/25/26 at 1:11 p.m., R52 stated he slept in his clothes from yesterday, he also said no staff had helped him with morning cares today.During an observation on 8/26/26 at 7:26 a.m., R52's door to his room was open he was observed lying in bed, he was wearing the light blue/green long sleeve shirt, one foot was out from under the covers, and blue non-skid slipper was visible.During an observation on 8/27/26 at 9:26 a.m., R52 was observed lying in bed, his covers were on covering his lower body, he was wearing the light blue/green long sleeve shirt.During an interview on 8/23/26 at 4:17 p.m., R52 stated staff were no longer helping him with personal cares in the morning and at bedtime. R52 thought this might be because he was able to transfer himself from chair to bed and bed to chair.During an interview on 8/25/26 at 1:26 p.m., nursing assistant (NA)-C stated staff were supposed to help R52 get dressed in the morning and set him up for brushing his teeth. NA-C stated she arrived later in the morning and received report from another NA, the report did not include who had received morning cares, it was just about how residents were doing. She was not sure if R52 had received any morning cares.During an interview on 8/27/26 at 10:52 a.m., registered nurse (RN)-C reviewed R52's electronic medical record and verified he was an assist of one staff for activities of daily living, which included dressing and personal hygiene. RN-C verified R52 should not be sleeping in his clothes every night and staff should have been offering assistance every morning and at bedtime.During an interview on 8/27/26 at 11:52 a.m., the director of nursing (DON) stated she would expect staff to offer to help residents with morning and bedtime cares, she stated she would not expect residents to sleep in their clothes unless it was what they wanted to do. The DON stated if that was the case she would expect that information to be part of their care plan. R66R66's quarterly Minimum Data Set (MDS) dated [DATE], identified R66 had diagnoses which included chronic heart failure (a chronic condition where the heart muscle cannot pump blood and oxygen efficiently enough to meet the body's needs), chronic respiratory failure, hypothyroidism, hemiplegia (paralysis on one side of the body) on the left nondominant side, pain, chronic atrial fibrillation (an irregular and often very rapid heart rhythm), diabetes mellitus, obstructive sleep apnea, hypertension, and hyperlipidemia. In addition, R66's MDS identified that she was cognitively intact, was dependent on staff for assistance with activities of daily living, and had no rejections of care.R66's care plan dated 8/29/25, identified R66 had an alteration in elimination related to overactive bladder. Interventions included to provide assistance with peri-cares morning, bedtime and as needed. In addition, R66's care plan identified that she had an alteration in mobility related to chronic heart failure, respiratory failure and weakness. Interventions included transfers with an assist of two and the use of a Hoyer (full body mechanical lift), and to provide routine morning and bedtime cares. R66 had an identified self-care deficit. Interventions included assistance with oral cares morning and bedtime and as needed. If resistive to care staff were instructed to leave and return in 10 minutes. Assist with one to two for personal hygiene, staff were instructed to do peri-care after each elimination/incontinent episode and as needed.During an interview on 8/25/26 at 9:21 a.m., R66 was seated in her chair at her bedside her hair was uncombed, and she was wearing a hospital gown. She stated they had not offered her an opportunity to wash her face and hands, brush her teeth or comb her hair. R66 stated she was supposed to have had a bath on Saturday, she stated she did not receive this bath and then stated it had been three weeks since she had a bath.A review of R66's past three months of weekly skin inspections identified the following:8/22/26, Saturday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.8/15/26, Saturday bed bath8/8/26, Saturday bed bath. She had gone 19 days without a documented bath.8/1/26, Saturday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.7/25/26, Saturday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.7/19/26, Sunday bed bath7/5/26, Sunday bed bath7/4/26, Saturday bed bath. She had gone 23 days without a documented bath.6/25/26, Thursday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.6/14/26, Sunday it was documented she refused, there was not a corresponding progress note to identify if she was re-approached.6/10/26, Wednesday bed bath. There were no other baths documented for June.R66's comprehensive MDS dated [DATE], section F (preferences for customary routine and activities) identified it was very important for her to choose between a tub bath, shower, bed bath, or sponge bath.A request for last documented shower was requested but not provided.During an interview on 8/26/26 at 12:19 p.m., nursing assistant (NA)-D stated there were often not enough slings available for use and a lot of time was spent looking for slings, regular slings and shower slings.During an interview on 8/26/26 at 12:33 p.m., R66 stated there was not a sling available for her to take a shower on Saturday.During an interview on 8/26/26 at 1:22 p.m., the participating residents at the resident council meeting stated they did not think call lights were answered timely. It was said residents have waited up to two hours and/or staff will come in and shut the call light off, say they will be back, but then no one returns because the call light was turned off.During an interview on 8/26/26 at 1:57 p.m., licensed practical nurse (LPN)-B stated there were two NAs to take care of 28 residents, the float NA would be pulled to other areas of the building and they would not always get the baths done and would have to pass the work on to the next shift.During an interview on 8/26/26 at 2:51 p.m., RN-E stated they would frequently run out of slings. RN-E said they were in the dirty laundry.During an interview on 8/27/26 at 10:00 a.m., RN-B stated she was not sure why R66 was getting bed baths instead of showers but thought maybe it was her preference. RN-B stated she would expect staff to re-approach several times when a resident refuses a shower and document the refusal. RN-B stated she would expect staff to check and change R66 every two hours.R50R50's comprehensive MDS dated [DATE], identified R50 had diagnoses which included atrial fibrillation, anemia, chronic embolism and thrombosis of deep veins of proximal lower extremity, edema, and pain. In addition, R50 was moderately cognitively intact and had no rejections of care. R50's MDS identified she required partial to moderate assistance with upper body dressing and substantial to moderate assistance with lower body dressing.R50's care plan dated 6/17/26, identified a self-care deficit. Interventions included an assist of one staff for dressing and with personal hygiene.During an observation on 8/26/26 at 9:34 a.m., R50's call light was on along with three other call lights. Heard through the closed door, help me.at 9:38 a.m., R50's call light remained on and could be heard through the closed door someone help me.At 9:40 a.m., knocked on the door to ensure they had not fallen on the floor. R50 was seated in a chair with nothing on the top half of her body struggling to get her bra on. Immediately went looking for help from facility staff. The RN on duty was found and she went to assist R50.During an interview on 8/27/26 at 10:56 a.m., RN-C stated it was the expectation that call lights would be answered within 15 minutes. RN-C verified it was not a dignified experience for anyone to put on their call light, wait, and struggle to get dressed. RN-C stated the wait might possibly be related to not having enough staff.During an interview on 8/27/26 at 11:54 a.m., the DON stated it was not dignified for a resident to put on their call light, wait, struggle to dress and have to call out for help before anyone arrived to help. The DON stated she was not sure if this was a staffing related concern.R2R2's significant change MDS dated [DATE], identified she had diagnoses which included orthopedic aftercare for closed fracture of left femur, anxiety, Alzheimer's disease, cognitive communication deficit, depression, and pain. In addition, R2 was severely cognitive impaired, was rarely understood or understands, required set up for meals and was dependent on staff for activities of daily living.R2's care plan dated 8/4/26, identified R2 was deemed unsafe with hot liquids without proper interventions. Interventions included Needs staff assistance with eating or drinking.During an observation on 8/23/26 at 6:01 p.m., R2 was observed in a common area near the nurse's station, she had a partially eaten slice of pizza in her chair, a chocolate ice cream in her chair with the cover on and two containers of food on her tray with covers on them. There were no staff in the area.During an observation on 8/25/26 at 8:18 a.m., R2 was observed in a common area near the nurse's station. Her meal tray was on the counter with covers on the food.-at 9:04 a.m., R2 was served her tray, a staff member was seated at the table assisting both R2 and another resident. Her tray sat for approximately 45 minutes before she was served and assisted with eating.-at 9:32 a.m., R2 remained in the common area, her food tray remained within her reach, no staff were present. Her breakfast was oatmeal, juice, bread, bacon, yogurt. Not much of her food had been eaten.During an observation on 8/26/26 at 7:49 a.m., dietary staff delivered about 14 trays on an open cart. R2's tray was placed on the counter.-at 8:49 a.m., staff brought R2 to the common area near the nurse's station. A hospice NA brought the tray to R2 reheated the meal and helped her eat. The tray sat for approximately one hour before it was served.During an observation on 8/27/26 at 8:43 a.m., R2 was observed sitting in the common area near the nurse's station. She had her tray in front of her; there were no staff present. The lid was still on the beverage.During an interview on 8/27/26 at 11:24 a.m., the DON verified R2 was supposed to have an assist of one staff for eating. Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23, identified the intent of the policy was to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. In addition, the policy identified A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and document review the facility failed to ensure daily weights were completed as ordered for 1 of 1 resident (R13) reviewed for quality of care. In addition, the facility failed to provide assessment and provider notification for changes in urinary output, pain management and blood sugar values for 1 of 1 resident (R3) reviewed for hospitalization.Findings include: R13: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had diagnoses which included metabolic encephalopathy (a change in how the brain works due to an underlying condition, it can cause confusion and memory loss), anxiety, heart failure (a serious condition where the heart muscle cannot pump blood and oxygen efficiently enough to meet the body's needs), and depression. In addition, R13's MDS identified he was moderately cognitively intact, had no rejections of care and was dependent on staff for activities of daily living. R13's Order Summary Report identified he had an order for weekly weights everyday shift on Wednesday, the order was dated as 6/23/26, with a start date of 6/24/26. R13's care plan dated 1/29/26, identified he had a potential alteration in nutrition related to diagnoses which included heart failure. Interventions included to obtain and record weights at least monthly as able. A review of R13's June 2026 weights had one entry on 6/4/26, 200 pounds. A review of R13's July 2026 weights had one entry on 7/3/26, 195 pounds. A review of R13's August 2026 weights had five entries as follows: -8/26/26 5:52 p.m., 201.5 pounds -8/19/26, 1:55 p.m., 203.6 pounds -8/19/26, 9:10 a.m., 204 pounds -8/12/26, 12:37 p.m., 201.8 pounds -8/5/26, 2:30 p.m., 201.8 pounds During an interview on 8/27/26 at 10:10 a.m., registered nurse (RN)-B reviewed R13's electronic medical record and verified he had an order for weekly weights starting on 6/24/26. RN-B verified the order was not being followed. RN-B verified orders should be followed as written. During an interview on 8/27/26 at 11:51 a.m., the director of nursing (DON) verified R13's weights should have been completed weekly as ordered. The DON stated this was important to monitor for weight loss so interventions could be implemented if needed. A policy on provider orders was requested but not provided. R3: indings include:The Assessment Technologies Institute (ATI, a leading provider of nursing education), defined the minimum acceptable urine output for an adult as 30 milliliters (mL) per hour. Persistent output below this threshold over two consecutive hours is considered a significant clinical concern. R3's significant change in status assessment (SCSA) dated 8/13/26, identified intact cognition and diagnoses of hydronephrosis with ureteral stricture, chronic pain, and retention of urine. R3's care plan didn't address care of the nephrostomy tube (a thin catheter inserted through the skin into a kidney to drain urine directly to an external bag). On 9/1/25 a focus statement for pain related to right femur fracture, fibromyalgia and diabetes mellitus with neuropathy included a goal for R3 to have adequate pain relief as evidenced by verbalization and freedom from signs or symptoms of non-verbal indicators of pain. On 3/19/26, a focus statement for potential for alteration in blood sugar with a goal for R3 to be free from hypo or hyperglycemic episodes and interventions to monitor blood sugar, signs and symptoms of hypo or hyperglycemic episodes, and to administer medication per order. R3's provider orders contained the following orders: 8/8/26, for oxycodone 5 milligrams (mg) every six hours for pain rated four to six on a scale to 10. And oxycodone 10 mg every six hours for pain rated seven to 10 on a scale to 10. 8/9/26, to clean around nephrostomy tube exit site with soap and water, pat dry, apply split gauze around the tube and apply tape every two days, and to empty nephrostomy bag when half-full. R3's treatment administration record (TAR) identified nephrostomy tube care was not provided on 8/13/26. R3's TAR for August 2026 identified nephrostomy tube output in mL per 8-hour shift: 8/10: AM 575 mL, PM no value recorded, overnight (NOC) 575 mL 8/11, AM 150 mL, PM 250 mL, NOC 650 mL 8/12, AM 150 mL, PM 300 mL, NOC 650 mL 8/13, AM 250 mL, PM 250 mL, NOC 500 mL 8/14, AM 200 mL, PM 125 mL, NOC 0 mL R3's progress notes didn't include an assessment, or provider notification, for R3 and their nephrostomy status after a decrease in output on 8/14/26. R3's progress notes identified the following blood sugar values: 8/13/26 at 8:18 a.m., blood sugar value 55, insulin held. 8/14/26 at 8:26 a.m., blood sugar value 69, insulin held. 8/15/26 at 8:07 a.m., blood sugar value 69, insulin held. R3's progress notes didn't include provider notification for low blood sugar values. R3's medication administration record (MAR) identified the following: 8/14 at 12 p.m., oxycodone 10 mg given for pain rating of 8, and marked as effective. 8/14 at 6:35 p.m., oxycodone 10 mg given for pain rating of 9, and marked as ineffective. 8/15 at 9:27 a.m., oxycodone 5 mg given for pain rating of 8, and marked as effective. 8/15 at 5:43 p.m., oxycodone 10 mg given for pain rating of 7, and marked as effective. R3's progress notes didn't include a pain assessment following a pain intervention indicated to be ineffective, or provider notification for pain management. On 8/15/26 at 10:39 p.m., R3 requested to go to the emergency room for vaginal and lower back pain. During an interview on 8/24/26 at 11:38 a.m., family member (FM)-C stated he had concerns with nursing staff not calling him when R3 asked staff to call him, and with staff not emptying the bag often enough reportedly seeing it plumb full and backing up into her kidney's. FM-C also stated concerns for R3's pain on Friday and Saturday 8/14 and 8/15/26, when R3 had to wait 15 hours for her pain medication and the same night had to go to the ER because of pain. During an interview on 8/27/26 at 9:40 a.m., RN-C stated pain was assessed every time they were giving pain medication. RN-C would expect follow-up within an hour to two hours, and Point Click Care (PCC) triggered that also. RN-C reviewed R3's PCC record and stated she would have expected a provider update or letting herself know, and making a progress note about what they found. A policy, Notification of Changes Policy dated 3/2024, identified it the policy of this facility that changes in a resident's condition or treatment be shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident.

Based on interview and document review the facility failed to ensure dependent residents were checked and changed timely for 3 of 5 residents (R66, R8, R9) reviewed for checking and changing.Findings include:R66R66's quarterly Minimum Data Set (MDS) dated [DATE], identified R66 had diagnoses which included chronic heart failure (a chronic condition where the heart muscle cannot pump blood and oxygen efficiently enough to meet the body's needs), chronic respiratory failure, hypothyroidism, hemiplegia (paralysis on one side of the body) on the left nondominant side, pain, chronic atrial fibrillation (an irregular and often very rapid heart rhythm), diabetes mellitus, obstructive sleep apnea, hypertension, and hyperlipidemia. In addition, R66's MDS identified that she was cognitively intact, was dependent on staff for assistance with activities of daily living (ADLs) and had no rejections of care.R66's care plan dated 8/29/25, identified R66 had an alteration in mobility. Interventions included to offer turn and repositioning/offloading every two to three hours and as needed and to assist with movement in/out of bed with an assist of two staff and a Hoyer lift (a full body mechanical lift).During an interview on 8/24/26 at 8:29 a.m., R66 stated that last evening she wanted to be boosted up in bed but was told she would have to wait until the other nursing assistant (NA) came back from break. R9 stated she would frequently be left wet and not changed when she asked for help, she stated she had been told to just go in her brief. She stated she had also been told they couldn't get her up because they couldn't find a sling to use. R66 said she has had to wait for up to two hours for pain medication.R8R8's significant change MDS dated [DATE], identified he had diagnoses which included acute and chronic respiratory failure, heart failure, diabetes mellitus, depression, paroxysmal/chronic atrial fibrillation (an irregular and often very rapid heart rhythm), urgency, insomnia, and lymphedema. In addition, R8's MDS identified he was cognitively intact and was dependent on staff for ADLs and was frequently incontinent of bowel and bladder.During an interview on 8/23/26 at 4:41 p.m., R8 stated there were not enough staff, he stated he might have to wait 30 minutes or longer to have his call light answered. R8 said he had had bowel and bladder accidents during the past week because staff didn't answer his call light in time.During an interview on 8/26/26 at 12:07 p.m., R8 stated his call light had been on for a long time that morning. He stated he was no longer able to recall what he had wanted. R8 stated if staff didn't come when he called then they would have to change him (he would be incontinent).R9R9's annual MDS dated [DATE], identified he had diagnoses which included hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness of one entire side of the body), dysphagia (difficulty swallowing), aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury), pain, diabetes, insomnia, restlessness and agitation. In addition, R9 was cognitively intact, was dependent on staff for assistance with ADLs, and was frequently incontinent of bowel and bladder. In addition, R9 had an alteration in mobility. Interventions included to offer to turn and reposition/offload every two to three hours and as needed, and to assist with transfers with an assist of two staff with the Hoyer lift.R9's care plan dated 5/12/25, identified R9 had an alteration in elimination. Interventions included an assist of two staff for toileting, toilet resident every two to three hours and as needed and check and change.During an interview on 8/23/26 at 5:04 p.m., trained medication aide (TMA)-A stated they were caring for 28 staff with two NAs on each unit. The TMA-A stated it would sometimes work depending on the staff who were on the shift, they said agency staff didn't always help because some of them look at the 28 residents as those are yours and these are mine. TMA-A stated agency staff would not always answer call lights if they were not assigned to the residents.During an interview on 8/24/26 at 3:09 p.m., family member (FM)-A stated R9 had not been out of bed since Thursday, 8/20/26. FM-A stated it was because they couldn't find a sling to get him out of bed.During an interview on 8/26/26 at 10:02 a.m., NA-F stated they were taking care of 28 residents, two staff and a float NA (the float NA) who worked between the units. NA-F said most of the residents on the unit were dependent on staff for cares. NA-F stated lots of things didn't get done depending on who the team was. NA-F stated they had to get residents up for breakfast (assist some with eating) many needed two staff because they needed to use the Hoyer. NA-F reviewed the check and change book and stated there were three residents who were late for checking and changing R66, R8, R9. NA-F stated when hospice staff were in the building it helped but they were not there daily. NA-F stated when they start their rounds residents would often be soaking wet.During an interview on 8/26/26 at 12:19 p.m., NA-D stated it was hard to keep up with answering call lights, hard to keep up with resident requests, they just do the best they can, and try to keep track of the order the call lights went on. NA-D stated it was harder to keep up on weekends, because there were not any activity staff or hospice NAs working.During an interview on 8/26/26 at 1:12 p.m., registered nurse (RN)-D stated the NAs were taking care of 26 to 28 residents with most of them dependent on staff for assistance and prone to fall. RN-D stated they often worked as an NA because they can't do it with two NAs. RN-D stated they can't always keep up with the call lights.During an interview on 8/27/26 at 10:00 a.m., RN-B stated it was important for residents to be checked and changed every two hours. RN-B stated she thought there were enough staff on the unit to get the checks and changes done timely.During an interview on 8/27/26 at 10:40 a.m., RN-C stated for most of the residents they needed to be checked and changed every two hours to prevent skin issues. RN-C stated she thought they had enough staff to get their work completed timely although she was unable to say how many of the 28 residents required checking and changing every two hours.During an interview on 8/27/26 at 11:24 a.m., the director of nursing (DON) stated residents who were care planned for checking and changing should be checked and changed and repositioned every two to three hours. The DON stated she expected staff to answer call lights within 10-15 minutes. Skin Assessment & Wound Management dated 2/2025, identified the purpose of the policy was to provide guidelines for assessing and managing wounds. Interventions included to review and update care plans including interventions. Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23, identified the intent of the policy was to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. In addition, the policy identified A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and document review the facility failed to ensure 1 of 6 residents (R9) was positioned safely to prevent aspiration while eating/drinking. Findings include:R9's annual MDS dated [DATE], identified he had diagnoses which included hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness of one entire side of the body), dysphagia (difficulty swallowing), aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury), pain, diabetes, insomnia, restlessness and agitation. In addition, R9 was cognitively intact, was dependent on staff for assistance with ADLs and required eating set up or clean up assistance. R9's care plan identified R9 was at risk for aspiration related to the presence of a feeding tube. Intervention dated 5/14/25, identified R9's head of bed was supposed to be elevated at least 45 degrees during and for one hour after feeding. Monitor for signs/symptoms of aspiration. Report suspected aspiration to medical doctor or physician's assistant. On 9/25/25 pureed textured snacks twice a day and nectar thick liquids and small portions at meals. In addition, R9's care plan dated 8/6/26, identified he had a potential alteration in nutrition. Interventions included snacks two times per day with staff supervision and small portions at meals, with a history of refusing meals except for supper.R9's Order [NAME] Report identified the following order:-Regular diet IDDSI (international dysphagia diet standardization initiative) level 4: pureed texture, level 2: mildly thick liquids consistency, small portions with 1 glass liquid. Room tray. Needs staff assistance. Order dated 3/10/26During an interview on 8/24/26 at 3:09 p.m., family member (FM)-A stated they had arrived at about 11:00 a.m., and he was not upright in bed, food was on the table next to him, they stated he fed himself all of the tray with the exception of the pudding which he never eats because it might have artificial sweeteners in it.During an observation on 8/25/26 at 11:45 a.m., dietary staff delivered R9's lunch tray to his room.During an observation on 8/25/26 11:46 a.m., R9 was observed drinking one of the two beverages while at less than 30 degrees while lying in bed. He had already finished the other beverage.During an interview on 8/25/26 at 11:57 a.m., nursing assistant (NA)-H verified R9's bed was less than 30 degrees, NA-H said, that's not high enough to eat or drink. NA-H stated there was a risk for R9 to choke or aspirate if he was not high enough up to eat and drink.During an observation and interview on 8/26/26 at 12:00 p.m., R9 had received his lunch meal, he was reclined in bed eating at less than 30 degrees. NA-F and NA-I verified he was too reclined to be drinking and eating safely. NA-I stated they thought he was supposed to be at 45 degrees at least.During an interview on 8/27/26 at 11:24 a.m., the director of nursing (DON) said R9 should be at 45 degrees or higher whenever eating and drinking to prevent aspiration.Meal Tray Service dated 9/2012, identified it was the policy of the facility to offer meals delivered to the residents' rooms that ensure special needs. In addition, The nursing assistant will see that any special needs of the resident are met before leaving the room.

Based on interview and document review the facility failed to assess a resident with significant weight loss for 1 of 6 residents (R107) reviewed for nutrition. Findings include: R107's admission minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of compression fractures to lumbar and thoracic vertebrae, anxiety disorder, low back pain and constipation. R107 was independent with eating and had no known weight loss. R107's care plan identified a focus statement dated 6/21/26, for potential for alteration in nutrition related to diagnoses and a mini-nutrition risk assessment identifying R107 was at risk for malnutrition. The care plan included interventions to provide diet per provider order, review food and fluid intake, offer substitutes for dislikes when not eating, encourage adequate fluid intake, protein supplement per order, and offer fluids and snacks between meals. R107's order summary report identified an order on 6/15/26 to obtain weight weekly on Monday evenings, and an order on 8/11/26 to provide Ensure (protein supplement) 240 milliliters (mL) two times per day. A Clinical Nutrition assessment dated [DATE], identified R107 was at risk for malnutrition, had Ensure two times per day, and would continue to monitor weights and intakes for changes. R107's electronic medical record (EMR) identified the following weight values: 6/17/26 128.4 pounds 7/27/26 128.4 pounds 8/11/26 120.5 pounds, 7.9 pounds or 6-percent loss in 13 days 8/24/26 118.8 pounds, 9.6 pounds or 7.5-percent loss in 28 days R107's dietary ticket dated 8/26/26, identified a two-gram sodium diet, and eight ounces of Ensure with each meal. R107's EMR didn't contain dietician assessments after 6/17/26. Progress notes for R107 included: 8/7/26, a progress note identified R107's vital signs, not including the weight, and that R107 didn't have an appetite at all but did drink Ensure. 8/20/26, a late entry progress note by the registered dietician (RD) identified R107 had slight weight loss, not triggering significant weight loss. Nursing notified and re-weigh requested and completed. R107 had been on Ensure two times per day to support oral intake for weight stability related to low BMI on admission as a proactive approach to weight loss. 8/21/26, a provider visit note identified R107's weight at 120 pounds and eight ounces but didn't address weight loss. During an observation and interview on 8/24/26 at 11:18 a.m., R107 was lying in his bed with a bedside table to his right, there were three bottles of Ensure on the table. R107 stated he had no appetite but wasn't sure if he had lost weight as they hadn't weighed him for long time, he stated he was 128 pounds. During an interview on 8/26/26 at 10:34 a.m., the regional registered dietician (RD)-D stated they did a weekly wound and weight meeting to review high risk residents. RD-D stated she reviewed each week any weight changes and looked into those patients weekly. RD-D looked at R107's EMR and noted his weight loss was more recent and recalled she had asked for a re-weigh for him on 8/20/26 to confirm the weight. RD-D stated now that she saw he had lost weight she would be talking about him in meetings for sure, she had been out of town after requesting the re-weigh on 8/20, so she didn't see the most recent weight. RD-D stated she guessed it was a little late, but he was on a supplement, between 8/11 and 8/24 they could have gotten a weight sooner. RD-D clarified his diet type was a two-gram sodium, low fat diet as noted in the order details and stated her first step would be to liberalize his diet. During an interview on 8/26/26 at 2:48 p.m., registered nurse (RN)-C stated they reviewed residents with weight loss weekly, and she would look into whether or not R107 was part of those weekly meetings, they were driven by the dietician or dietary tech. RN-C stated R107 did like the Ensure and was taking that. RN-C noted R107 had lost 10 pounds in the past two and a half months. During an interview on 8/27/26 at 10:50 a.m., the director of nursing (DON) stated they could have seen the weight loss sooner if he was getting weekly weights. The DON also stated they did miss some weekly weight meetings due to RD-D being out, but R107 was started on supplements on 6/18/26 and increased again on 8/11/26 and they had talked about his weight loss on 7/14/26. A policy, Weight Policy dated 5/1/24, identified to obtain accurate weights and provide monitoring to ensure each resident's nutrition parameters were maintained within acceptable parameters to prevent avoidable decline in nutritional status unless their clinical condition demonstrated that was not possible. The registered dietitian (RD) and/or registered dietetic technician (DTR) shall review residents who trigger for significant weight gain or loss. Significant is defined as a person with 5% weight change over 30days, 7.5% weight change over 90days, or 10% weight change over 180days.

Based on observation, interview and document review the facility failed to ensure respiratory equipment was cared for properly and oxygen therapy was administered as per the order for 1 of 1 resident (R66) reviewed for respiratory care. Findings include:R66's quarterly Minimum Data Set (MDS) dated [DATE], identified R66 had diagnoses which included chronic heart failure (a chronic condition where the heart muscle cannot pump blood and oxygen efficiently enough to meet the body's needs), chronic respiratory failure, diabetes mellitus, obstructive sleep apnea, and hypertension. In addition, R66's MDS identified that she was cognitively intact, was dependent on staff for assistance with activities of daily living (ADLs) and had no rejections of care.R66's Order Summary Report identified R66 had an order dated 8/7/26, for ipratropium-albuterol inhalation solution 0.5-2.5 milligrams per 3 milliliters 1 vial inhale orally every four hours for shortness of breath. R66's orders also identified an order for oxygen at 3 liters via nasal cannula dated 7/24/26.R66's care plan dated 8/29/25, identified R66 had an alteration in oxygen/gas exchange. Interventions included to elevate the head of bed to prevent shortness of breath, monitor oxygen saturations, administer oxygen as ordered, and keep medical doctor informed of changes. The care plan did not address the use of as needed nebulizer treatments.R66's electronic medical record for August 2026, identified she received the nebulizer treatment every day starting on 8/8/26, with the exception of 8/26/26, when the treatment was documented as refused.During an observation on 8/24/26 at 2:15 p.m., R66's nebulizer set up was noted to be set up and in a box with unused oxygen supplies. R66's oxygen was running at 3.5 liters per minute.During an observation on 8/25/26 at 12:14 p.m., R66 was observed in bed, her oxygen was running at 3.5 liters.During an interview on 8/25/26 at 12:17 p.m., registered nurse (RN)-G reviewed R66's orders and verified the oxygen was supposed to be running at 3 liter per nasal cannula. RN-G checked R66's oxygen verified it was at 3.5 liters and adjusted it down to 3 liters.During an interview on 8/27/26 at 11:46 a.m., the director of nursing (DON) stated it was her expectation that each time a resident received a nebulizer treatment they would rinse it and leave it open to air dry. The DON stated staff needed an order from a provider to increase an oxygen rate.A policy on oxygen therapy was requested but not provided.

Based on observation, interview and document review the facility failed to ensure orders for post dialysis care were carried out. In addition, the facility failed to ensure there was coordination of care and communication between the facility and the dialysis center for 1 of 1 resident (R11) reviewed for receiving hemodialysis.Findings include:R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included end stage renal disease (a disease where there is permanent kidney failure that requires a regular course on dialysis or a kidney transplant), dependent on dialysis, anemia, chronic pain, hypertension, and fibromyalgia (a long-term medical condition that causes widespread body pain, extreme tiredness, and sleep problems. In addition, R11's MDS identified that she was cognitively intact and received dialysis.R11's care plan dated 4/21/26, identified R11 was at risk for complications related to dialysis. Interventions included for uncontrolled bleeding at dialysis site, call 911. Order a meal for patient upon dialysis return. Send communication folder to dialysis with each run. R11's care plan dated 5/26/26, identified a potential alteration in nutrition. Interventions included communication with dialysis team as needed. Provide diet order per medical doctor order. Diet education. Fluid restriction 1500 milliliters (ml).R11's Order Summary Report identified the following orders:-complete dialysis communication form and send with resident to dialysis every day shift every Monday, Wednesday, Friday dated 10/7/25-dialysis is on Monday, Wednesday and Friday. Remember to send a snack or lunch with the resident dated 4/7/26-dialysis-Review Post Dialysis Treatment Report for updates. If none found, call dialysis. Dated 11/8/25-dialysis-Vital Signs after dialysis. Monday, Wednesday, Friday. Dated 11/8/25.-dialysis: Monitor Dialysis site for bleeding. If excessive bleeding is noted call 911. Dated 8/25/26-dialysis: Post dialysis offer rest and snack. Dated 8/25/26-send midodrine (medication used to treat low blood pressure) with dialysis on Monday, Wednesday, Friday. Dated 7/21/26-midodrine give 10 milligrams (mg) by mouth one time a day for hypotension. Send with dialysis days repeat times one for low blood pressure. Hold if systolic blood pressure is greater than 180. Dated 7/21/26A review of August vital signs (VS) and the dialysis center communication records revealed the following:-8/3/26, 2:56 p.m., 98.2 - 78 - 16 - 134/77 - per the dialysis center communication record these were the pre-VS no post VS documented. Nothing on the communication sheet filled out by the dialysis center.-8/5/26, 2:26 p.m., 97.8 - 68 - 16 - 162/99 - per the dialysis center communication record these are the pre-VS, no post VS documented. Nothing on the communication sheet filled out by the dialysis center.-8/7/26 5:06 p.m., 98 - 65 - 18 - 158/89 - Nothing on the communication sheet filled out by the dialysis center.-8/10/26, 3:07 p.m., 97.9 - 68 - 18 - 143/78 - Nothing on the communication sheet filled out by the dialysis center.-8/12/26, 4:49 p.m., 98.2 - 66 - 18 - 131/77 - Nothing on the communication sheet filled out by the dialysis center.-8/14/25, 5:04 p.m., 98 - 64 - 18 - 140/77 - Nothing on the communication sheet filled out by the dialysis center.-8/17/26, 3:05 p.m., 97.8 - 72 - 16 - 155/91 - per the dialysis center communication record these are the pre-VS, no post VS documented. Nothing on the communication sheet filled out by the dialysis center.-8/19/26, 2:00 p.m., 97.8 - 62 - 16 - 143/83 - per the dialysis center communication record these are the pre-VS, no post VS documented. Nothing on the communication sheet filled out by the dialysis center.-8/21/26, 11:13 p.m., 97.9 - 70 - 18 -122/72 - Nothing on the communication sheet filled out by the dialysis center.-8/24/26, 10:54 p.m., 97.5 - 78 - 16 - 135/78 - Nothing on the communication sheet filled out by the dialysis center.-8/26/26, 5:36 p.m., 97.4 - 70 - 16 - 162/83 - per the dialysis center communication record these are the pre-VS, no post VS documented. Nothing on the communication sheet filled out by the dialysis center.A review of R11's August 2026 nurses notes did not document any refusals of vital signs following her return from dialysis.During an observation and interview on 8/24/26 at 3:58 p.m., R11 was observed seated in the main dining room eating yogurt. R11 stated activities brought her food and a warm blanket, nursing staff had not seen her yet. R11 stated she would not go back to her room until after dinner.During an interview on 8/24/26 at 4:08 p.m., registered nurse (RN)-H stated he filled out a form and sent her midodrine with her to dialysis. He stated she was not back yet, said he had checked her room. RN-H stated when she returned, he would check her blood pressure.During an observation on 8/26/26 at 8:10 a.m., R11 was in the dining room waiting for her breakfast. R11 confirmed it was a dialysis day and stated she would get picked up around 10:00 a.m During an interview on 8/27/26 at 8:31 a.m., licensed practical nurse (LPN)-C looked for R11's dialysis binder and was not able to find the book at the nurse's station. LPN-C then went to R11's room and found the dialysis binder in R11's backpack, LPN-C stated the binder should have been at the desk. LPN-C opened the binder and found a pill marked midodrine in a clear plastic bag in the binder. The binder had the communication forms, the form from 8/26/26, was in the binder the top part of the form was filled out by the facility staff, the bottom part was not filled out (it should have been filled out by the dialysis center staff). LPN-C stated dialysis never filled out their part of the form. LPN-C stated they did not call either.During an interview on 8/27/26 at 9:39 a.m., RN-A reviewed the dialysis communication binder and found the medication in the binder. RN-A verified she would expect to find the dialysis communication binder at the nurse's station and not in the resident's room. RN-A stated if dialysis staff did not give the medication, then she would expect the facility staff to destroy the medication. RN-A then reviewed the communication forms and verified the dialysis staff were not filling out their part of the form. RN-A stated she had not reached out to the dialysis center to discuss the omission. RN-A verified it was important for staff to know what happened during the dialysis run. RN-A stated when R11 returned from dialysis she would expect the facility staff to check the site for bleeding and do a set of vital signs.During an interview on 8/27/26 at 11:38 a.m., the director of nursing (DON) stated the dialysis orders directed staff on how to care for residents on dialysis. The DON stated the dialysis binder would go with the resident along with the midodrine, upon return she would expect staff to destroy the midodrine if it wasn't used, do a set of vital signs, and check the communication form for any orders. The DON stated she was aware dialysis was not filling out the form and had last talked to them on 4/24/26. The DON stated the communication form was important for continuity of care, to be alerted to any concerns there might have been during the dialysis run. The DON stated R11 might have been refusing to have her vital signs checked, but then stated if that was why there was missing documentation, she would expect a nurse's note about the refusal. A policy on dialysis care was requested but not provided.

Based on observation and interview, the facility failed to ensure shared equipment was appropriately sanitized between uses. This had the ability to affect any resident who came in contact with shared equipment. Findings include: During an observation on 8/26/26 at 7:56 a.m., registered nurse (RN-I) set up R75's medication, sanitized hands, applied PPE according to the contact precautions sign on the door, proceeded into R75's room, obtained a set of vitals, administered meds, exited R75's room with vitals machine, removed PPE, and sanitized hands. RN-I then parked the vitals machine along the wall and plugged it in without sanitizing it.During a continuous observation on 8/26/26 at 8:12 a.m., (the vitals machine used on R75 still had not been sanitized) RN-I set up R41's medications, grabbed the vitals machine referenced, did not sanitize it, entered R41's room, obtained R41's vitals with the non-sanitized machine, and then administered medications to R41.During an interview on 8/26/26 at 8:18 a.m., RN-I confirmed they had not sanitized the vitals machine after they had used it on R75 (who was on contact precautions) or before use on R41. RN-I stated equipment should definitely be cleaned between residents and normally they did. It was even more important to do so when removing equipment from a precautions room for infection prevention. RN-I stated they should have cleaned the vitals machine right away after use in R75's room.During an interview on 8/27/26 at 10:57 a.m., NA-D and NA-J stated all equipment shared between multiple residents should be cleaned as soon as it was taken out of a room. Both shared they had received education on equipment sanitization.During an interview on 8/27/26 at 11:18 a.m., RN-C stated it is best practice to have equipment designated for use in a contact precautions room, but if that is not possible then it should be sanitized after removed from the room to prevent infection spread.During an interview on 8/27/26 at 11:32 a.m., RN-B stated equipment taken out of a contact precautions room should be sanitized with the appropriate wipes and left to dry for the entire dwell time to prevent the spread of infection.During an interview on 8/27/26 at 12:05 p.m., the director of nursing (DON) stated equipment should not go from a contact to non-contact isolation room without being sanitized because it could expose other residents to infection. Staff should use the appropriate wipes and dwell time assigned to sanitize all shared equipment after use to protect residents and staff from infection.The Centers for Disease Control and Prevention facility door sign titled Contact Precautions instructed: Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.The facility policy Infection Prevention and Control - Contact Precautions dated 7/13/23, directed if equipment must be shared between residents, it should be properly cleaned and disinfected before use from one resident to another resident.

Based on observation, interview and document review, the facility failed to ensure the nurse staff posting was posted daily. This had the potential to affect all 89 residents residing in the facility and/or visitors who may wish to view the information.Findings include:On 8/23/26 at 3:27 p.m., the nurse staff posting was posted in a hallway across from the director of nursing's office. The posting was dated for 8/21/26, which was Friday.On 8/23/26 at 5:17 p.m., the nurse staff posting was now dated for 8/23/26. The director of nursing (DON) verified she updated the posting when she arrived in the building at 4:25 p.m. on 8/23/26. The DON stated it was important to have the posting current so anyone could see how many nursing staff were scheduled for the day. The DON stated it was the responsibility of the night charge nurse to change the posting daily. A policy on staffing was requested but not provided.

Based on observations, interviews, and document review the facility failed to ensure medications were stored securely to ensure residents, staff and guests could not access medications in 2 of 2 medication carts observed, potentially affecting two units of the facility, with 43 residents. Findings include:During a continuous observation on 6/10/26 from 4:07 p.m. to 4:15 p.m., the medication cart at the crosswalk of the Parkside nurses' station, was left unlocked and unattended. Staff walked by the medication cart five times, and one resident wheeled by in a wheelchair. During an interview on 6/10/26 at 4:15 p.m., the registered nurse (RN)-E stated he walked away from the medication cart to administer a treatment to a resident and forgot to lock it. The RN-E acknowledged he could not see the medication cart from the resident's room and the medication cart was supposed to be locked when he walked away from it. The RN-E stated it was a risk to patients because their medications could be taken from the cart and also staff could steal medications. During an observation on 6/12/26 at 3:01 p.m., the medication cart on the Southside unit adjacent to the day room was unattended and unlocked. Three residents and six staff walked by. During an interview on 6/12/26 at 3:05 p.m., the RN-F stated she was just in another room counting medications with another nurse while the medication cart was left unattended and unlocked. The RN-F acknowledged she could not see the cart from the other room and knew staff and residents had walked by the cart. RN-F stated the cart was supposed to be locked when she walked away from the cart or someone could steal medications. During an interview on 6/15/26 at 10:55 a.m., the director of nursing (DON) stated nurses were expected to lock medication carts any time they were not directly in front of the medication cart to prevent theft. Further, the DON stated medications in a capsule required a provider order to open the capsule and administered the contents without the capsule, and medications in a capsule could not be divided equally and accurately. The Medication Storage in the Facility policy dated May 2022 indicated the medication supply was accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. Medication carts were locked when not attended by people with authorized access.

Based on observation, interviews, and document review, the facility failed to ensure skin assessments were performed as ordered for 1 of 3 residents (R3) reviewed for wound care.Additionally, the facility failed to ensure medication orders were followed for 2 of 2 residents (R4, R5) when saccharomycin (a probiotic yeast used to support digestive health and treat gastrointestinal - stomach and intestine- issues) was not administered as prescribed. Findings include:R3R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 was dependent on staff for activities of daily living (ADLs), and was at risk of developing additional pressure ulcers. R3's diagnoses included cancer, heart failure, malnutrition, diabetes, arthritis, end stage kidney disease, and respiratory failure. R3's care plan indicated the following:3/11/26, monitor for skin breakdown and for signs and symptoms of infection4/22/26, an alteration in skin integrity related to abrasion on buttock R3's provider orders dated 3/31/26, indicated starting 4/6/26 at 2:30 p.m., licensed nurses to perform weekly skin inspections every Monday evening. R3's Monarch Health Management (MHM) Weekly Skin Assessments in the electronic health record (EHR) indicated weekly skin assessments were completed 4/6/26, 4/21/26, 5/3/26, 5/4/26, 5/11/26, 5/18/26, 5/25/26, and 5/31/26. The EHR lacked indication weekly skin assessments were completed the weeks of 3/29/26, 4/12/26, 4/26/26, and 6/8/26, and R3 refused the skin assessment on 3/28/26 and 5/4/26. R3's April 2026 Treatment Administration Record (TAR) indicated weekly skin inspections by a licensed nurse were to be completed every Monday evening shift, complete MHM Weekly Skin Inspection form in the medical record. The TAR indicated the skin inspections were omitted 4/13/26 and 4/27/26. R3's May 2026 TAR indicated weekly skin inspections by a licensed nurse were to be completed every Monday evening shift, complete MHM Weekly Skin Inspection form in the medical record. The TAR indicated the skin inspection was omitted 5/18/26. R3's June 2026 TAR indicated weekly skin inspections by a licensed nurse were to be completed every Monday evening shift, complete MHM Weekly Skin Inspection form in the medical record. The TAR indicated the skin inspection was omitted 6/8/26. During an interview on 6/11/26 at 1:50 p.m., the licensed practical nurse (LPN)-C stated skin assessments were performed once weekly, and if the resident refused, the nurse was supposed to tell the subsequent shift nurse. If the assessment still was not completed on the scheduled day, the nurses could ask a nurse manager for assistance. The LPN-C stated she did not recall R3 ever refusing care. The LPN-C acknowledged she did not see a skin assessment for R3 in the admission assessment, and R3 was missing weekly assessments the weeks of 3/29/26, 4/12/26, 4/26/26, and 6/8/26. The LPN-C further acknowledged on 6/8/26, the TAR referred to a nursing note for explanation, but there was no nursing note to explain why the skin assessment was not completed. The LPN-C stated staff should have been monitoring R3's skin for breakdown. During an interview on 6/11/26 at 2:08 p.m., the registered nurse (RN)-C stated R3 had weekly skin assessments, or more frequently if skin issues were noted by a nursing assistant (NA) and then the nurse was required to assess the skin to observe what the NA found. The RN-C acknowledged R3 had a wound on her bottom, was incontinent, frail, slid around in her bed, had poor nutritional intake and could have skin changes as a result. During an interview on 6/11/26 at 2:20 p.m., the RN-D stated when skin assessments were not completed as ordered, the resident could have skin breakdown and wounds that were not noticed timely. On 6/11/26 at 3:00 p.m., the RN-H stated the purpose of weekly skin assessments was to observe a resident's skin to ensure there were no new skin issues, and to document the findings. The purpose of the weekly wound rounds was to assess the skin issues that were already known. The weekly skin assessments and weekly wound rounds were not used interchangeably. During an interview on 6/12/26 at 12:06 p.m., the RN-B stated R3 was supposed to have weekly skin assessments. If R3 wasn't getting weekly skin assessments she could have undiagnosed skin issues or unseen evidence of abuse. The RN-B stated she was not aware of any instance in which R3 refused the weekly skin assessments. During an interview on 6/15/26 at 10:55 a.m., the director of nursing (DON) stated weekly wound rounds were utilized weekly to assess for and monitor for skin integrity and acknowledged R3's weekly skin assessments were not completed as ordered. The Skin Assessment and Wound Management policy dated 2/2025 indicated licensed staff would perform a weekly skin inspection. R4 R4's quarterly MDS dated [DATE], indicated intact cognition, and dependence upon staff for ADLs. R4's diagnose included trauma from a motor vehicle accident, a traumatic brain injury, and altered mental status. R4's care plan indicated the following:12/19/25, alteration in elimination related to diarrhea and malnutrition with an intervention to monitor bowel movements as they occurThe care plan lacked mention of the use of saccharomycin to treat diarrhea. R4's provider orders dated 4/20/26, indicated saccharomycin oral capsule 250 mg (milligrams), give by mouth two times daily related to enterocolitis (inflammation of the intestines) due to clostridium difficile (C-Diff - a bacterium that causes severe, watery diarrhea and inflammation of the colon). R4's May 2026 Medication Administration Record (MAR) indicated administer saccharomycin 250 mg twice daily in the morning and at bedtime. The MAR indicated the medication was not administered as ordered on 5/28/26 and 5/30/26 at bedtime. R4's progress notes dated 5/28/26 at 8:00 p.m., and 5/30/26 at 7:46 p.m., indicated saccharomycin was not administered because the medication was not available. R4's June 2026 MAR indicated administer saccharomycin 250 mg twice daily in the morning and at bedtime. The MAR indicated the medication was not administered as ordered on 6/2/26, 6/3/26, 6/8/26, and 6/9/26 at bedtime. R4's progress notes dated 6/2/26 at 8:35 p.m., 6/3/26 at 8:44 p.m., 6/8/26 at 9:41 p.m., and 6/9/26 at 7:26 p.m., indicated saccharomycin was not administered because the medication was not available. R5 R5's annual MDS dated [DATE], indicated moderate cognitive impairment, dependence upon staff for assistance with ADLs. R5's diagnoses included heart failure, dementia, stroke, malnutrition, an indwelling urinary catheter, and frequent incontinence of bowel. R5's care plan dated 11/12/25, indicated an alteration in elimination related to a history of C-Diff. The care plan lacked mention of the use of saccharomycin to treat diarrhea. R5's provider orders dated 3/12/26, indicated saccharomycin oral capsule 250 mg, give by mouth two times daily related to enterocolitis due to recurrent clostridium difficile. R5's May 2026 MAR indicated administer saccharomycin 250 mg twice daily in the morning and at bedtime. The MAR indicated the medication was not administered as ordered on 5/28/26 and 5/30/26 at bedtime. R5's progress notes dated 5/28/26 at 7:49 p.m., and 5/30/26 at 7:06 p.m., indicated saccharomycin was not administered because the medication was not available. R5's June 2026 MAR indicated administer saccharomycin 250 mg twice daily in the morning and at bedtime. The MAR indicated the medication was not administered as ordered on 6/2/26, 6/8/26, and 6/9/26 at bedtime. R5's progress notes dated 6/2/26 at 6:43 p.m., 6/8/26 at 10:26 p.m., and 6/9/26 at 9:26 p.m., indicated saccharomycin was not administered because the medication was not available. During an interview on 6/11/26 at 3:09 p.m., the DON stated the carts did contain the correct dose of saccharomycin. The bottle was labeled to give 1-2 capsules, and the total unit dose was 500 mg, meaning each capsule contained 250 mg. The DON acknowledged the packaging on the bottle was confusing for some of the nurses, and stated she would provide education to nurses about the packaging and dosing. The DON acknowledged R4 and R5 each missed doses of saccharomycin, perhaps due to the confusion with the medication label. During an interview on 6/12/26 at 2:54 p.m., the RN-G stated she did not have the correct dose of saccharomycin for R4. R4 was supposed to get 250 mg twice a day, and the bottle in the cart was 500 mg capsules, which could not be crushed. The RN-G stated she took one capsule, opened it, divided the contents into two medication cups, mixed one cup with applesauce and administered it to R4, and then discarded the second cup. The RN-G stated she did not need an order to open the medication capsule for administration and had been doing it that way for ten years, so she knew it was all right to do that and stated the dose was easily divided by looking at the quantity of the contents in the dose cups. During an interview on 6/12/26 at 2:33 p.m., the LPN-A stated the facility did not have the correct dose of saccharomycin for residents. Residents typically had orders for 250 mg twice daily but the stock medication came in 500 mg capsules instead of 250 mg. The LPN-A stated it appeared some staff were giving the medication anyway, but it was not the correct dose if they were. The LPN-A further stated she asked other nurses who showed her they were giving the 250 mg doses from the stock medication bottles labeled 500 mg, and sometimes the LPN-A found 250 mg doses that came in bottles from the pharmacy and would administer those when they were available. During an interview on 6/12/26 at 1:17 p.m., the LPN-B stated two residents, R4 and R5, did not get saccharomyces doses because the facility did not have the correct doses on hand, the bottles were labeled 500 mg, not 250 mg, and the medication was not available in the facility medication bank. The LPN-B stated she noticed the residents were administered the medication on other dates and didn't know why she did not have the correct medication in the medication cart when other nurses had administered it previously. The LPN-B acknowledged she asked other nurses about the medication and was told it was in her cart, but she did not find it and did not give saccharomyces as ordered for R4 and R5. During an interview on 6/15/26 at 11:57 a.m., the medical director (MD) stated if a medication was ordered, it should have been administered. If staff had a question about the label on a medication, they should have asked a nurse manager or the pharmacist. The MD also stated if a nurse opened a capsule and administered half of the contents, that would be a medication error and should be recorded as such. The Medication Administration Guidelines policy dated 5/22 indicated the right dose would be administered for each medication ordered. Opening capsules may require a physician's order, according to facility policy. If it is safe to do so, capsules may be emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines. An individualized approach should be used when altering dosage forms opening capsules. Working with the resident or representative and appropriate clinicians (e.g., the consultant pharmacist, attending physician, medical director) the facility should determine the most appropriate method for administering medications which considers each resident's safety, needs, medication schedule, preferences, and functional ability.

Based on observations, interviews, and document review, the facility failed to maintain an effective infection prevention and control program by ensuring staff utilized proper hand hygiene during wound care treatments for 1 of 1 resident (R3) observed for wound care. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 was dependent on staff for activities of daily living (ADLs) was was at risk of developing additional pressure ulcers. R3's diagnoses included cancer, heart failure, malnutrition, diabetes, arthritis, end stage kidney disease, and respiratory failure. R3's care plan indicated the following:3/11/26 an alteration in skin integrity related to abrasion on buttock with an intervention to monitor for skin breakdown and for signs and symptoms of infection3/19/26 enhanced barrier precautions (EBP-an infection control strategy that requires staff to wear gowns and gloves during high-contact care to prevent the spread of drug-resistant organisms) related to the coccyx wound with an intervention to don and doff personal protective equipment per EBP precautions R3's wound care orders indicated the following: 4/22/26 staff to follow enhanced barrier precautions for wound care5/22/26 wound care to the coccyx moisture associated skin damage (MASD): cleanse with wound cleanser, pat dry, apply calmoseptine (barrier cream to prevent moisture on the skin) twice daily and as needed During an observation on 6/10/26 at 11:39 a.m., the registered nurse (RN)-A provided wound care for R3. Afterwards, The RN-A doffed her gloves, donned a clean pair and applied barrier cream to R3's bottom. The RN-A doffed her gloves again, donned a clean pair of gloves, and repositioned R3 in bed and arranged items on R3's tray table. The RN-A did not perform hand hygiene between either glove change. During an interview on 6/10/26 at 11:50 a.m., the RN-A acknowledged she knew she was supposed to perform hand hygiene between both glove changes to prevent the spread of infection but had not because she forgot. During an interview on 6/15/26 at 10:55 a.m., the director of nursing (DON) stated when performing wound care, the nurses were required to perform hand hygiene between gloves changes to prevent infection or the spread of germs. The Handwashing policy dated 2/24 indicated when conducting a procedure requiring the use of gloves, proper hand washing shall be completed before donning gloves and afterremoving gloves.

Based on interview and document review, the facility failed to ensure orders for oxygen use were clarified and documented in the medical record to ensure continuity of care; and failed to ensure physician orders for continuous oxygen use were implemented for 1 of 1 resident (R1) reviewed who used continuous oxygen for comfort. R1's oxygen concentrator machine was not transferred over during a room change and then his portable oxygen tank ran out during the night, causing R1 to go without oxygen for several hours.Findings include: R1's Interagency Referral Form, dated [DATE], identified R1 had multiple medical conditions including obstructive sleep apnea (OSA), high blood pressure, chronic obstructive pulmonary disease (COPD), atrial fibrillation (irregular heartbeat), and acute-on-chronic heart failure. The document included R1's discharge orders from the hospital to the care center which included, Oxygen inhalation gas . 2 L/min [liters per minute] at bedtime. Indications: Heart failure. However, R1's Oxygen & Equipment Order Form, dated [DATE], was completed at the care center and signed by health unit coordinator (HUC)-A. This form identified a fax communication sent to the outside oxygen supplier and contained a section labeled, Prescription Information, which marked R1 as having a prescription for 6 L/min continuous oxygen and needing an oxygen concentrator and portable gas tank(s). R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 5/2026, identified R1's administered treatments and medications for the month. This included an order which read, Oxygen 6L via nasal cannula continuously every shift. This had a start date of [DATE], and recorded staff initials for 10 of 11 opportunities as administered. The TAR continued and listed an order which read, Check Portable Oxygen/Stroller every shift and fill if needed. This also had a start date of [DATE], and had staff initials recorded as last completed on [DATE] for the night shift by registered nurse (RN)-B. R1's medical record was reviewed and lacked evidence of a signed physician's order for 6 L/min of oxygen until [DATE] (following death; see below); nor did the record have evidence this discrepancy was identified or clarified to ensure the correct L/min would be administered to R1 despite him having COPD (over-oxygenation in COPD could cause carbon dioxide retention). When interviewed on [DATE] at 12:44 p.m., HUC-A stated orders upon admission were usually sent via email from the director of nursing (DON) and if oxygen was listed, a form was completed and sent to the outside oxygen vendor. HUC-A reviewed R1's medical record and verified they signed R1's Order Form which had 6 L/min written on it. HUC-A then reviewed the discharge orders from the hospital and verified those directed oxygen at 2 L/min. HUC-A stated they thought the 6 L/min directive came from the nurse-to-nurse report but was not sure. HUC-A stated the nurse manager, RN-F, had entered the orders for 6 L/min into the record system (EMR) and verified they were unable to locate a signed physician order for 6 L/min prior to [DATE]. HUC-A stated it was important to ensure oxygen orders were correct and matched for patient safety. R1's MHM (Monarch Healthcare Management) Admission/Initial Data Collection V-9, dated [DATE], identified R1 admitted to the care center from the hospital and had oxygen saturation of 94% on oxygen via nasal cannula. R1 was recorded as having intact cognition, needing extensive assistance with transfers, and having frequent urinary incontinence. The evaluation listed a section labeled, Respiratory Status, which identified R1 had a cough and shortness of breath (SOB), and he used oxygen. R1's progress notes, dated [DATE] to [DATE], identified the following information: On [DATE], R1 was stable and had sustained a fall earlier without injury. R1 denied pain and the note added, . is on 6L of oxygen. On [DATE], R1 had hallucinations and was worried people were bugging his telephone. R1 was moved to a different room. On [DATE] at 7:11 a.m., a note identified, Writer called Moment's Hospice . updated Nurse [Name] that patient had expired. A subsequent note identified, After Medicare Nurse spoke with Hospice, writer and she went to [old room] and observed a concentrator in the corner of a closet in the room. Writer later revisited [old room], and the concentrator was sitting outside of the closet, and attached to the electrical outlet. On [DATE] at 9:25 a.m., a note entered by registered nurse (RN)-A identified two night shift nursing assistants (NA) alerted RN-A that R1 was not on oxygen, and that his concentrator was not in the room and the portable tank was empty. RN-A directed another NA to go fill the tank immediately and RN-A responded to R1's room. R1 was seated on the toilet with the PALS (mechanical standing) lift loops attached but he could not be aroused. R1 did not have a heartbeat and was deceased . The two NAs were no longer on shift, and the sequence of events was documented. The director of nursing (DON) and hospice were notified of the death. The note identified the oncoming NA for the morning shift was not notified R1 had been helped to the toilet, and that the aide-to-aide report happened before the two night shift NA alerted RN-A to R1 not having oxygen in his tank. When interviewed on [DATE] at 10:24 a.m., NA-A verified they had worked with R1 during his stay at the care center. NA-A stated the nurse manager or HUC was responsible for clarifying orders for oxygen use upon admission and if a resident used oxygen, it was communicated to the staff using the care plan sheets. NA stated the nurse was allowed to adjust oxygen flow settings, but the NA staff were allowed to change the devices when needed (i.e., change from portable to concentrator). NA-A stated the portable oxygen tanks were filled onsite by the NA staff members usually, and training was reviewed on it annually during a skills fair. NA-A stated it would most likely be me and the more experienced aides who checked the portable oxygen tanks throughout the shift to ensure they still had oxygen available in them as there was not a designated person to do this. NA-A stated they personally tried to check the tanks multiple times a shift, however, they were unsure what other staff did. NA-A stated they were told prior that the night shift was supposed to fill each of the portable tanks for residents; however, that was not happening. NA-A recalled working with R1 on the morning of [DATE] and explained they received report from NA-B who had worked the night shift while NA-C was seen going into R1's room. NA-A was then abruptly asked by RN-A to run and fill [R1's] portable right away. NA-A returned minutes later with the filled tank and saw R1 seated on the toilet and overheard someone say R1 had died. NA-A stated there was not an oxygen concentrator in the room when they observed R1 on the toilet, and the tubing for his cannula was connected to nothing and just lying on the ground. When interviewed on [DATE] at 10:51 a.m., NA-D stated if a resident is in their room, then they should use their oxygen concentrator and not a portable tank as the tank will deplete quicker depending on how many L/min are used. NA-D stated they personally tried to check the portable tanks for their level each time they helped a resident leave their room; however, the overall frequency of when to check it depended on how many L/min the resident used. It was left to each aide to know the L/min being used and how quickly each tank would deplete. NA-D stated when a resident moved rooms, it was everyone's responsibility to ensure equipment got moved to the new room but there was no checklist or documentation completed to track the equipment being moved. On [DATE] at 11:56 a.m., the director of social services (DSS) was interviewed. DSS stated the social worker who oversaw R1's room change was not available; however, explained the social worker typically helped to spearhead the move and ensure equipment is changed over between the rooms. The housekeeping staff was then a second check to ensure items were all moved. If on a weekend, then the floor staff would be responsible for moving the equipment. DSS verified there was no checklist or other documentation to show all equipment was moved to the new room and reiterated it was the staff's responsibility to ensure items got moved. DSS stated they vaguely recalled R1 and were aware of a facility investigation in process about him potentially not getting oxygen because the oxygen equipment had not moved rooms with him. DSS stated they had not yet done any re-education with the social worker who was involved with R1's room change as they were on leave adding, We are going to when she returns. DSS verified there had not been any re-education with the other social worker staff, either, adding, Not at this time. When interviewed on [DATE] at 12:04 p.m., NA-B stated the aides were the ones responsible to fill the portable oxygen tanks, when needed, but nobody from the care center had ever directed or told them how often to check the tanks to ensure oxygen remained. NA-B stated, They never told me anything [about that]. NA-B explained someone would likely know the oxygen had run out as it simply would stop working adding it was between the nurse and aide working to check the tank, but nobody had ever discussed or covered a L/min rate or how to know when a tank would be depleted. NA-B recalled working the night shift into [DATE] and had worked with R1 alongside NA-C who was in training at the time. NA-B stated they complete a safety check every hour during the night on each resident, but this was just a quick peek into the room to ensure their chest was rising. It did not include any check of the oxygen equipment to ensure it was functioning. NA-B stated nobody had ever directed or told them to check oxygen equipment during the night before. Shortly after 6:00 a.m., NA-B stated they sat down with the oncoming NA (NA-A) and gave verbal report. R1 activated his call light and needed to use the bathroom, so NA-C then entered R1's room to assist. NA-B stated NA-C then asked a question about R1's portable oxygen tank, however, NA-B could not recall exactly what was asked. NA-B stated there was only a single portable oxygen tank in the room and no visible oxygen concentrator was present. NA-B made a comment about the lack of concentrator to RN-A who was also present, and RN-A stated they had just moved his room the day prior. NA-B stated nobody from the previous shift (evenings) had mentioned anything about R1's oxygen equipment or where it was located which was abnormal in hindsight. NA-B stated that since the incident with R1 happened, there had been no formal re-education on oxygen use or new direction on how to ensure oxygen doesn't run out while a portable tank is used. There had just been a telephone call from the administrator asking what had happened and some form sent to them via email. NA-B stated they had not yet had a chance to review it. A telephone call was attempted with RN-A on [DATE], however, they were unable to be reached. When interviewed on [DATE] at 12:20 p.m., NA-C stated they had been shown once briefly how to fill an oxygen tank by other staff members but had never been told how often to re-check the tank to ensure it had oxygen still available. NA-C stated, I don't remember ever being told a specific number [when to check], but added they tried to remember to check it at least three times a night. NA-C recalled working with R1 on the night shift into [DATE]. NA-C helped R1 with a bed change around 3:00 a.m. due to incontinence and R1 seemed fine. NA-C had oxygen in place connected to a portable tank, however, NA-C stated they did not check the tank at that time to see its level of remaining oxygen adding, It didn't cross my mind. Shortly after 6:00 a.m., R1 then used his call light and wanted to go to the bathroom. NA-C retrieved a PAL lift and helped R1 to the bathroom when his oxygen tubing became disconnected from the portable tank. That is when NA-C noticed the tank had run out of oxygen and was at zero. NA-C stated they told R1 they were going to fill the tank and to activate the call light when he was done using the bathroom. NA-C then went to the oxygen room and attempted to re-fill the tank but could not get it work, so the other NA then came to help but also couldn't get it to work. By this time, the next shift had arrived so they told them they were going to leave and asked someone else to fill the tank which they said they would do. NA-C recalled checking in on R1 while he was on the toilet but noticed he wasn't looking good so they told someone to make sure the oxygen got filled quickly. Then, later on [DATE], the director of nursing (DON) called them and explained R1 had died that morning. NA-C stated they did not recall ever checking R1's portable oxygen tank throughout the entire night shift until they noticed it was empty when helping him to the toilet adding, It slipped my mind. Since the incident, NA-C stated they were given a survey about oxygen which had a few questions on it; however, they had not gotten any feedback on it yet. During interview on [DATE] 1:18 p.m., RN-B verified they had worked the overnight shift into [DATE] with NA-B and NA-C on R1's unit. RN-B recalled R1 and explained both the NA and nurse should be checking the portable tank to ensure it had oxygen. RN-B stated there were no specific times to check it rather just throughout the shift. RN-B stated the TAR order, which directed to check and fill the portable tank every shift, was signed off by them when they completed an oxygen level check on the patient using a pulse oximeter. It did not mean to check the actual tank for its oxygen level. RN-B verified they did not at any point check the actual portable oxygen tank adding, I did not check that. RN-B then stated, Mostly the aides do that. On [DATE] at 1:33 p.m., a group interview was held with the DON, RN-F and the administrator. RN-F explained a nurse-to-nurse report, which happened when R1 admitted to the center, identified him as using 6 L/min of oxygen, so they contacted the hospitalist and obtained a verbal order. However, this was not ever written or dictated in the notes adding there was no signed physician order they could provide for 6 L/min of oxygen. RN-F stated a verbal order would typically have a note entered to support it but that was a note that I did miss. RN-F stated oxygen tanks should be checked at least every two hours like other tasks such as repositioning. This was something covered in the skills fair training each NA is provided and the DON added they expected staff to check the oxygen level in the tanks anytime you're hooking them up to portable [tanks]. The administrator stated each tank should be tracked when filled using a log in the oxygen room but RN-F then stated they had noticed some mishaps with that lately. The DON stated the tank R1 had been using was no longer at the campus or available to inspect. R1 admitted on hospice care and due to behavioral issues, had two room changes happen with the last change on [DATE]. If a move happened during the work week, then it was a collaborative effort between the managers and social workers to get equipment changed over. DON stated they expected the social worker team and managers to move the equipment, however, R1's oxygen concentrator did get left behind and not moved. RN-F stated they did not help with R1's room changeover on [DATE] and did not check the prior room at any point to ensure all equipment had been moved. The administrator stated they recalled the social worker involved with R1 had asked the NA staff to finish moving the items. RN-F explained when they left work on [DATE] in the later evening hours, R1's tank was full, and he was still using 6 L/min. The EMR showed R1's pulse oximeter was entered at 9:56 p.m. and it was 96% at the time (above 90% is normal). The log system showed R1's portable tank last being filled around the same time. The EMR then showed RN-B entered R1's pulse oximeter at 2:36 a.m. and it was 95% then. On the morning of [DATE], DON stated they received a telephone call that R1 had died. The DON then contacted the Minimum Data Set (MDS) nurse and asked them to assist the team working. Following that, the DON then contacted NA-C and discussed the situation. DON stated they recalled NA-B stating they had filled the tank around 2:30 a.m. but it was not logged. RN-F reiterated the staff were always told to check the portable tanks every two hours. The DON stated they were still investigating the situation and had the medical director (MD)-A involved who expressed the oxygen was likely just for comfort and not life-sustaining adding MD-A felt the death was likely a sudden cardiac-event and not due to hypoxia (lack of oxygen). Following, on [DATE] at 2:22 p.m., a subsequent telephone interview was completed with NA-B. NA-B verified they never checked or re-filled R1's portable oxygen tank on the night shift prior to R1's passing away. NA-B stated they didn't even know R1 was on portable oxygen until the morning of [DATE], when the incident happened. NA-B stated they just did the hourly safety checks where they peek inside the room to ensure the resident is alive and in bed. A Northwest Respiratory Services Oxygen Cylinder Duration (In Hours), flowsheet, undated, identified approximate times a liquid oxygen tank would last on various L/min of use. This identified a portable tank would last approximately 2.8 hours at 6 L/min of continuous use. NA-B's Nursing Assistant Facility Orientation Checklist, dated [DATE], identified checkmarks adjacent to areas which were signed off as educated and completed. This included, Demonstrates components of oxygen use, with bullet points for the location or oxygen closets, demonstration how to re-fill portable tanks, how to know when the tanks are empty, filling the tanks prior to a resident appointment, and turning on the oxygen flow on a portable tank. The orientation checklist lacked any direction on how often to check the tanks when in use to ensure they had remaining oxygen inside. NA-C's Nursing Assistant Facility Orientation Checklist, dated [DATE], identified checkmarks adjacent to areas which were signed off as educated and completed. This identified the same areas of oxygen use as NA-B's checklist, however, again, lacked any direction on how often to check the tanks when in use to ensure they had remaining oxygen inside. A facility policy on oxygen use was requested; however, none was received.

Based on observation, interview, and document review, the facility failed to protect 1 of 3 resident's (R74) right to be free from mental and physical abuse by staff. Findings include: R74's admission minimum data set (MDS) dated [DATE], indicated moderate cognitive impairment, did not have inattention, disorganized thinking, or an altered level of consciousness. R74 had delusions and hallucinations and verbal behavior symptoms for 4 to 6 days but not daily. Further, the behavior symptoms significantly interfered with activities or social interactions and significantly disrupted care or living environment. R74 wandered 1 to 3 days and behaviors symptoms were the same compared to prior assessment. R74 did not have impairment in range of motion, (ROM) used a walker and wheelchair and required partial to moderate assist with toileting hygiene, showering and bathing, lower body dressing, required substantial assistance with transferring, and supervision with walking 50 feet. R74's significant change MDS dated [DATE], indicated moderate cognitive impairment, was able to recall after cueing, did not have a change in mental status, did not have inattention, disorganized thinking, or an altered level of consciousness, did not have hallucinations or delusions, physical, verbal, or other behavioral symptoms, and did not reject care. Further, R74 had an improvement in behavior status compared to a prior assessment. R74's MDS indicated no impairment in ROM to upper extremities, used a walker, and a wheelchair, required substantial to maximal assistance with toileting hygiene, partial to moderate assistance for showering and bathing, set up assistance for upper body dressing, and supervision or touching assistance for personal hygiene. R74's Medical Diagnosis form indicated the following diagnoses: metabolic encephalopathy, Alzheimer's disease with late onset, chronic diastolic congestive heart failure, unspecified atrial fibrillation, unspecified dementia moderate with other behavioral disturbance, cognitive communication deficit, Parkinson's disease, and long-term use of anticoagulants. R74's Clinical Resident Profile, saved 6/10/25, indicated R74 was [AGE] years old. R74's care plan revised on 4/9/25, indicated R74 was hard of hearing and had bilateral hearing aids. Interventions indicated to speak clearly, repeat conversation as needed, assist resident with placing, removing, and storing of hearing aid. R74's care plan dated revised on 4/25/25, indicated R74 had an alteration in skin integrity due to weakness, advanced age, Parkinson's, impaired mobility, and anticoagulation. Additionally, R74 had thin skin that was prone to bruising due to anticoagulation usage and frequently bumped arms into his wheelchair and other items and interventions indicated to document on skin condition and keep the physician or physician assistant informed of changes, monitor skin integrity daily during cares and weekly skin inspections by the nurse. R74's care plan revised 5/2/25, indicated R74 was a vulnerable adult and was at risk for decreased cognitive and physical abilities related to dementia with moderate behavioral disturbance and R74 experienced sundowning. Further R74 expresses feeling like he is having a nightmare but is awake and has become violent and swung objects at staff and is difficult to calm down and redirect. R74's goal was to remain free from abuse and or neglect and interventions included: allow space when R74 is upset, remove other residents from the surrounding area, remove objects of potential harm from residents nearby area, allow resident to express his frustrations, validate emotions, if resident becomes a danger to himself, residents, or staff call 911 to help deescalate the resident, monitor for signs of emotional distress or mood and behavior changes, resident will become agitated when he cannot hear. Ensure resident has his hearing aides in to allow for appropriate communication, safety monitoring will be implemented as needed to ensure resident's safety, staff will follow the facility vulnerable adult and abuse reporting policy, the local ombudsman, adult protection, police, and or state financial agencies will be notified of any suspected abuse or financial exploitation as needed, utilize de-escalation techniques with the resident. R74's care plan revised on 5/2/25, indicated R74 had an alteration in mood and behavior related to insomnia, cognitive communication deficit, urinary tract infection, as evidenced by anger at having to be in the facility, history of swearing, yelling, making statements of wanting to leave, putting self on the floor intentionally. Further, most behaviors seemed related to not wanting to be a resident at the facility. Interventions indicated to monitor and document mood, approach in a calm manner and provide resident with choices as appropriate, if resident becomes anxious remove from the crowded area. R74's Nursing Home Incident Reporting (NHIR) form dated 4/25/25, indicated R74 was combative and agitated, was swinging a foot pedal and metal shovel at staff and the nurse reported staff handled the situation unprofessionally and were unable to deescalate R74. Further, registered nurse (RN)-D and nursing assistant (NA)-G were immediately suspended and removed from the facility and immediate education to staff regarding abuse prohibition was completed among other interventions such as a full body skin assessment, monitoring orders for distress, and progress note every shift, hourly safety checks, notification of family, and R74 was evaluated by emergency medical services (EMS) and transferred to the hospital. Further, the form indicated R74 had old bruising noted to his hand, but had no signs or symptoms of physical injury. R74's 5 day Investigation Report form dated 5/2/25, indicated R74 told the director of nursing (DON) he could not hear the staff because he did not have his hearing aids in and told the DON he felt like he was in a nightmare. The report indicated according to witness, NA-H, R74 was aggressive, swearing, hitting, and punching and going back and forth between units and screamed, Get me the fuck out of this place and would not calm down. The form indicated NA-H stated they tried to talk to R74 and get him to let go of the foot pedal but was swinging and hitting them with it and then R74 came back with a metal shovel. NA-H went back to her unit and let the nurse and the other NA handle the situation and R74 told EMS he was having a bad dream. The report further indicated licensed practical nurse (LPN)-E heard yelling and R74 was cussing at the nurse and swinging his foot pedal at staff and RN-D was trying to get the foot pedal away from R74 and was egging him on and wondering whether R74 would hit RN-D with the foot pedal. LPN-E stated RN-D swore at R74 and kept saying, You are going to jail, you are going to jail. LPN-E stated NA-G kept trying to get R74 back to his unit and threw a blanket over R74's head and grabbed the foot pedal away and shoved R74's head away from her to grab the foot pedal. Furthermore, RN-D stated R74 was angry and upset and swinging, yelling, and verbally abusing staff and kept going back and forth between stations. RN-D tried to do a pressure point on R74's wrist to get the foot pedal away and tried to lift his fingers off. RN-D called the police and denied touching other parts of R74's body and stated that was the aide. RN-D stated she did not engage in verbal arguments or call R74 names. Further, the form indicated NA-G stated R74 was screaming, loud, and combative and was hitting staff with something and R74 took the foot pedal that was on his wheelchair and was hitting staff with it. NA-G held R74's hands down and attempted to take away the foot pedal and shovel and threw a blanket over R74's head and NA-G was frustrated with the lack of immediate action from the nurse. The form indicated an allegation of abuse was substantiated against both RN-D, and NA-G who were immediately suspended at the time of the incident and ultimately terminated. A form, RN-D's Statement dated 4/24/25 at 12:15 a.m., completed by the director of nursing (DON) and the administrator indicated RN-D's statement. The form indicated R74 got into his wheelchair and wanted to get out of the facility and took off his foot pedal and started swinging it back and forth and knicked RN-D and they got it away from him. Further, RN-D lifted R74's fingers off the footrest by trying a pressure point that wasn't very successful and called the police about 11:30 p.m. The form further indicated RN-D tried to call the on call provider but there were issues with the phones and RN-D demonstrated on the DON's hand a pressure point and showed the actions of peeling her fingers off a pen and the form indicated RN-D used significant effort to get R74's hand off. Further the form indicated RN-D denied engaging in verbal arguments, or calling R74 a fucker. A form, NA-G's Statement dated 4/25/25 at 12:40 a.m., completed by the DON and administrator indicated NA-G's statement. The form indicated NA-G stated a guy was hitting staff and NA-G held his hands down and pushed him back to his unit and then the guy was back on their unit and had a shank or sharp shovel and there was a resident in a chair and NA-G grabbed it from behind and took it from him and then he took the leg off his chair and felt like he was going to hurt someone so through up like it over him and took the leg a chair. NA-G felt like she de-escalated the situation. Further, the form indicated NA-G got the item from behind so he couldn't hurt her and grabbed the leg of the chair. further, NA-G told the resident she may have to call the police if he didn't calm down and the resident wasn't calming down and denied calling resident a fucker, but the form indicated NA-G threw a blanket over R74's head and grabbed the foot pedal. A form, LPN-E Statement Regarding the Incident, undated, indicated LPN-E reported an incident with a resident with a foot pedal where RN-D stated, I wonder if he will hit me with it and kept getting close to the resident and trying to grab it and the resident hit RN-D. Later, LPN-E heard a crash and the resident had a shovel and was yelling saying they were abusing him. The form further indicated LPN-E kept telling them to leave the resident and call an officer, but they kept engaging the resident and would not leave him alone. Additionally, NA-G grabbed the shovel and ripped it out of the resident's hands and the resident turned around and had the foot pedal and swung it at NA-G. LPN-E stated NA-G yanked it out of the resident's hand and grabbed the resident's head and forced his head down and stated the resident's middle finger was starting to bruise and looked swollen. Further, the statement indicated the resident kept stating stop abusing me and RN-D kept egging the resident on and the RN-D was stating you're going to jail and the resident said to call them and RN-D grabbed the residents shirt and said you little fucker. Further, the form indicated LPN-E stated they were antagonizing the resident. Additionally, the form indicated LPN-E stated NA-G threw a blanket over the resident's head. LPN-E could not recall if she saw bruises on R74's hands before the incident but thought they were already there except for the one on R74's middle finger on the right hand that was purplish. A form, NA-H Statement, undated, indicated R74 was aggressive and swearing, hitting, and punching and screaming get me out of the fucking place. The form indicated R74 was swinging it and hit himself too. The form further indicated maybe it looked worse than when it really was. NA-H stated they pulled R74's hands away and did not remember if anybody shoved R74's head and took away a foot pedal and put it at the nurses station. NA-H was on north when staff got the metal shovel and saw LPN-E, RN-D, and NA-G arguing amongst themselves and LPN-E stated it was getting abusive but NA-H did not know what happened because she wasn't present. Further, the form indicated NA-H was asked whether R74 was taunted and NA-H did not know and added they might have been, but could not identify who was talking in a way that sounded like they were taunting and further the document indicated NA-H stated, I think the other two were in heat at the moment, you know, I don't think anybody meant too many things. NA-H later in the statement indicated she thought there may have been swearing and that it was both of them. RN-D's personnel file was reviewed and indicated a letter from the facility to RN-D dated 5/9/25, indicating RN-D was suspended on 4/25/25, and the facility was not able to reach RN-D and requested RN-D contact the facility by 5/23/25, or would take the no communication as a voluntary resignation. An additional letter dated 5/19/25, indicated a discussion occurred indicating RN-D's employment was terminated due to substantiated abuse. NA-G's personnel file was reviewed and indicated a letter from the facility to NA-G dated 4/30/25, that indicated NA-G was terminated immediately due to substantiated abuse of a vulnerable adult. R74's progress notes from 3/25/25, indicated R74 yelled and swore and was easily agitated, climbed out of his chair and was transported out of the facility for suicidal ideations while throwing himself out of the wheelchair. R74's progress notes from 3/26/25, indicated R74's physician indicated R74 had behavior changes due to prednisone use and ordered to discontinue current prednisone (a steroid medication used to reduce inflammation) order. R74's progress notes from 3/27/25, indicated R74 had increased confusion and restlessness, and agitation and a one time dose of seroquel (an antipsychotic) was ordered. R74's progress notes from 4/5/25, indicated R74 yelled and screamed and pounded on the wall, punching out, resisted cares, was physically aggressive. R74's progress note dated 4/10/25, indicated a urine culture was pending. RN-D's progress note dated 4/25/25 at 12:09 a.m., indicated R74 was yelling out and wanting out and was swinging at RN-D with his fist and verbally abusive. RN-D's note indicated R74 was left in bed and then R74 got up on his own and came out to the nursing area and hallways yelling he was kept against his will and grabbed a wheelchair pedal and started swinging it. The note further indicated they took the pedal away but R74 hit a staff person's wrist. R74 was brought down to the Park area and R74 grabbed a plant that had a garden tool in it and stated, now I am going to get you. RN-D was concerned R74 may hurt other residents and called 911 and was taken to the hospital to be evaluated. R74's progress notes following the incident on 4/25/25 at 12:09 a.m., indicated R74 was calm and had no further behaviors on 4/25/25. R74's progress notes on 4/26/25 at 1:51 a.m., indicated R74 was agitated and irritated and declined neuro and vital sign checks. R74's progress notes were reviewed following 4/26/25, to 6/10/25, and no further behaviors were documented. R74's Weekly Skin Inspection form completed by the director of nurse dated 4/25/25 at 2:21 a.m., and locked on 4/25/25 at 4:07 a.m., indicated, Patient has redness to right side of groin with moist area, house stock powder applied. Patient has 2+ pitting edema in top of bilateral feet. Bruising to 1 x 3 & 3 x 2 to right antecubital, 3 x 2 & 2.2x 1.2 & 2.3 x 1.4 to right wrist. 1.3 x 1.1 and 1 x 0.3 on right forearm, 3.5 x 2.5 & 0.5 x 0.5 & 0.8 x 0.4 left hand. A Fairview Health note dated 4/24/25 at 3:10 p.m., indicated from 3/27/25 to 3/29/25, R74 had a couple of falls and had possible dactylitis (an inflammation of the joints causing them to swell and appear sausage shaped) of the right middle finger and prednisone was discontinued. R74's After Visit Summary form dated 4/25/25, indicated R74 was seen for agitation and a history of dementia and quetiapine (an antipsychotic) was given on 4/25/25 at 12:43 a.m., and instructions indicated to continue with normal cares. During interview on 6/9/25 at 6:32 p.m., R74 stated he made a lot of friends at the facility and stated the help was doing their duty and further stated if you were decent with them, you received much better care. R74 further stated he wasn't satisfied at first and added he was [AGE] years old and had freedom all those years. R74 stated early spring time he had to go to the bathroom and pressed the button to get service, but nobody came and then a lady came and asked what he wanted and R74 stated he had to go to the bathroom. R74 stated the lady wouldn't help him by herself and had to get somebody else. R74 stated he blew up at her and they were going down the hall throwing things at each other. R74 stated he ended up at the police department, but didn't get held and stated there were two staff persons and they were no longer at the facility. R74 stated they were trying to get him to shut up and further stated all he wanted to do was get some help. R74 stated that night she pushed too far and hit him and was throwing stuff at him and R74 stated he threw right back. R74 stated he did not know their names and stated he felt safe and since she's out of here, R74 stated he was back to living in heaven again. During observation on 6/10/25 at 12:36 p.m., R74 was with family member (FM)-A down the hallway and no behaviors were observed. During observation on 6/11/25 at 8:53 a.m., R74 was in his wheelchair in his room next to his television and did not have any behaviors. Phone calls were placed and messages left to NA-H on 6/10/25 at 3:43 p.m., 6/11/25 at 8:04 a.m., and again on 6/11/25 10:44 a.m., however was not able to interview NA-H. During interview on 6/10/25 at 3:57 p.m., LPN-E stated she was working on a different unit on 4/24/25, and stated about 10:45 p.m., the pharmacy dropped off medications and she heard yelling from Park station and was yelling at the aide stating you guys abused me enough tonight. LPN-E stated NA-H was trying to talk to R74 and R74 was not violent. Further, NA-H asked to close the doors to keep R74 contained on their unit and R74 went through the doors about 11:00 p.m., had a foot pedal and was screaming and RN-D stated she wondered if R74 would hit her with the foot pedal and went up to R74, put her hand close to the foot pedal and R74 hit RN-D and she grabbed the foot pedal. R74 was fine with NA-H, but then 10 minutes later, LPN-E stated she heard yelling again and a loud bang and RN-D was in the hallway and LPN-E stated RN-D stated, I don't care we can do this all night and walked off. LPN-E stated there was a flower pot that had a gardening shovel and R74 was holding it and was backed up against the wall and looked petrified and LPN-E stated this was not R74's normal behavior and said to call an officer and RN-D walked off. R74 came to LPN-E's unit and LPN-E stated she walked with him and again told RN-D to call 911 and RN-D walked off and R74 still had the gardening shovel and they came around the north station and NA-G came out of the nurse's office. LPN-E stated to NA-G to be careful and not approach and let R74 cool off and NA-G insisted this was her unit and reached over and pulled the shovel from behind and yanked it back wards. LPN-E stated R74 got the foot pedal and started swinging it at her and NA-G backed up and threw a blanket on R74 and NA-G pushed his head down to the right. LPN-E stated NA-G was about to start fighting R74 and R74 was so worked up he was starting to hyperventilate. LPN-E stated she told R74 he was safe and R74 broke down crying and then RN-D came back and tried pushing R74 in his wheelchair and LPN-E told RN-D to call 911. LPN-E stated RN-D and NA-G kept coming back and attacking R74. LPN-E stated RN-D was trying to push R74 and LPN-E stated RN-D told R74 he was going to fucking jail and RN-D grabbed R74's shirt and LPN-D stated RN-D told R74 he was fucking going to jail and yanked R74 back in his chair and pushed him forward with his shirt and called him a fucker. LPN-E stated R74 kept screaming they abused him and LPN-E stated R74 was abused. LPN-E stated R74 had behaviors prior, but not like this and added that R74 was so happy now. LPN-E stated the director of nursing (DON) called her that night and both the DON and the administrator came in to the facility. LPN-E stated she worked through an Agency and stated the facility conducted training for the staff and had staff sign papers and thought she had signed paperwork on the night the incident occurred. A call was placed to NA-G on 6/11/25 at 8:28 a.m., and initially the call seemed to connect but then ended. A call was placed back to NA-G on 6/11/25 at 8:30 a.m., and went to voicemail and a message was left requesting a return call, but did not receive a return call. A call was placed to RN-D on 6/11/25 at 8:36 a.m., and a message was left, but did not receive a return call. During interview on 6/11/25 at 9:43 a.m., NA-I stated signs of abuse included hitting, leaving bruises, or taking things from residents and added they do Med Trainer online and don't have a strict meeting or learning. NA-I stated she had not heard anything from R74 and stated R74 was a sweet guy and kept to himself and had behaviors when he first came and now was the best person in the building. RN-I stated the facility comes around with pieces of paper they sign and discuss and stated she hadn't signed anything the last couple of months related to abuse that she could remember and then later stated she signed something a few months prior, but could not recall what it was for. During interview on 6/11/25 at 10:02 a.m., NA-A stated R74 did not tell her he was abused and normally liked to joke around and was sweet. NA-A stated for abuse training the facility has them complete a questionnaire and answer questions and sign a paper form and if there was an incident put something in Med Trainer. NA-A stated she had to do a couple by the end of this month and thought about a month or two ago she had to sign something but could not recall what. NA-A stated R74 had behaviors in the beginning when first admitted for the first week or so and now has been a different person. During interview on 6/11/25 at 11:42 a.m., the administrator and director of nursing (DON) stated they completed immediate education and assigned online education as well including for staff who received the immediate education. The administrator stated the DON received the call and then called her and stated the staff members did not provide care and were sitting in the lobby and were pulled in for statements and RN-D, and NA-G were suspended. R74 was sent to the hospital and told EMS he had a nightmare. The DON stated R74 received seroquel (an antipsychotic) in the hospital. The administrator stated they interviewed RN-D first at 12:15 a.m., and R74 was agitated and yelling and swinging a foot pedal. The administrator stated both RN-D and NA-G admitted to not de-escalating the situation and egging R74 on. The administrator stated NA-G and RN-D both forcefully grabbed the foot rest and NA-G threw a blanket over R74's head and when NA-G said that, that was abuse to us and explained that was not ok and suspended NA-G. The administrator stated R74 did not have any injuries and the DON completed a skin check and determined R74 didn't have any injuries. The administrator stated RN-D egged R74 on and called R74 a fucker and dared him to hit her and with the egging behavior both RN-D and NA-G were walked out of the facility and they completed a full skin check on R74 and checked other residents. RN-D had not interacted with anyone else. The administrator further stated they completed immediate education and facility wide education. The facility wide education assigned contained caring for residents with dementia and elder abuse training and assigned it for the whole assisted living facility and nursing home. The first training was person centered care for persons with dementia and the second education was identifying and reporting elder abuse. The administrator stated they did not have video monitoring and another resident was watching television and went into their room and did not witness anything. During interview on 6/11/25 at 1:39 p.m., the administrator stated she brought in a list of employees and the course name that indicated completed, however there was no date of completion on the form of the list of employees who received training. The administrator stated everyone was trained and they completed verbal education and assigned training to all staff. The administrator stated she would provide the education staff completed along with the dates education was completed. During interview on 6/11/25 at 2:50 p.m., the administrator stated they had a new system through Med Trainer and had used Google Sheets and they ran the reports and identified a handful of staff that needed to complete their education and would be calling all those staff members today to educate them and further stated they would not be using Med Trainer and would go back to Google Sheets. The administrator stated they needed to call and get ahold of NA-J and a few other people for education. During interview on 6/11/25 at 3:30 p.m., the administrator provided a form, that indicated at the top, Course due Employee full name, Course Name, Assignment date, Assignment Status, Completion Date, and Google Sheets Education and Education. The administrator stated the employees in red were new hires and hadn't worked yet but all the staff on the top of the form with a 6/11/25, date had been educated today on Elder Abuse. The form indicated there were 11 employees who were assigned the course, Identifying and Reporting Elder Abuse on 4/25/25, and had a pending assignment status and were educated on 6/11/25. The form indicated NA-J had not yet received education among other staff. Later, the administrator provided an updated form that indicated 42 employees including seasonal and on-call employees were provided education on 6/11/25. During interview on 6/11/25 at 4:13 p.m., RN-A stated she heard R74 had talked about being abused through hearsay and added R74 states he feels safe and was sweet and gave bear hugs. RN-A stated R74 was never combative with her. During interview on 6/12/25 at 2:02 p.m., the administrator stated she expected staff who were assigned education to complete the education or do an alternative education like reviewing the policy and completing a verbal education and further stated they completed immediate education and contacted staff 6/11/25, and completed a verbal education. The regional director of operations (RDO)-G stated unfortunately they used a new system and would be going back to the old way. A policy, Abuse Prohibition/Vulnerable Adult Policy, dated 4/2025, indicated the purpose of the policy was to protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members, or legal guardians, friends or other individuals, or self-abuse. Further, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish and includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Further, under a heading, Investigation/Protection indicated corrective action based on the investigation will be completed such as change of procedure, training, discipline or discharge of staff.

Based on interview and document review, the facility failed to comprehensively assess and monitor for signs of injury after a fall, resulting in delayed diagnosis and treatment for injuries for 1 of 3 residents (R1) reviewed for delay in treatment. This resulted in an immediate jeopardy (IJ) for R1 who required emergent care and hospitalization as a result of their injuries. The immediate jeopardy began on [DATE], when R1was not assessed for any injuries after a witnessed fall, that resulted in displaced rib fractures, chest wall hematoma (blood collection outside of large vessels) and hemothorax (blood accumulation between the chest wall and lungs). The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 2:45 p.m. The IJ was removed on [DATE] at 2:35 p.m., but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, required extensive assistance with one person and a walker for mobility and had a history of falls. Furthermore, R1's MDS indicated R1 received an anticoagulant (blood thinning medication) and had diagnoses of spinal fusion, arterial flutter (rapid heartbeat), and cerebral hemorrhage (brain bleed). A review of R1's provider orders indicated the following: -an order on [DATE], indicated R1 required Eliquis (anticoagulant medication) 5 milligrams (mg) twice daily for arterial flutter. -an order on [DATE], indicated R1 required monitoring for black tarry stools, severe headache, nausea, vomiting, lethargy, and bruising every shift related to R1's anticoagulant use. -an order on [DATE], indicated R1 required immediate provider notification for falls and head strikes every shift related to R1's anticoagulant use. A review of R1's electronic medication administration record (EMAR) progress notes indicated: -on [DATE] at 11:05 p.m., R1 was administered Tylenol for general pain. -on [DATE] at 5:18 a.m., R1 requested Tylenol for pain. -on [DATE] at 1:18 p.m., R1 was administered Tylenol for back pain. -on [DATE] at 7:54 p.m., R1 was administered Tylenol for headache/neck pain. -on [DATE] at 12:36 a.m., R1 was administered Tylenol for back pain rated ,d+[DATE]. The EMAR lacked any indication of monitoring for bleeding, bruising, or any injuries. A review of R1's progress notes dated [DATE] to [DATE], lacked any indication a comprehensive assessment for evalution of potenital injuries or any ongoing monitoring for injuries was completed after the witnessed fall on [DATE]. R1's nursing progress note dated [DATE] at 6:48 p.m., indicated the previous shift reported R1 was very tired and sleeping most of the day due to being up all night. R1's wife notified nurse something was wrong. Upon assessment, R1 appeared very lethargic and was slow to respond and unable to open eyes fully. R1's neurological status and vital signs were obtained and the note indicated they were within normal limits. R1 complained of back pain and rib pain related to the fall on [DATE]. R1's provider was notified and R1 was sent to hospital for evaluation due to R1's fall history on [DATE], anticoagulant therapy, and history of brain bleed. R1's chest computerized tomography scan (CT scan) results dated [DATE], (no time) indicated R1 had displaced back left 10th and 11th rib fractures and non-displaced back left 10th -12th rib fractures, chest wall hematoma near the fracture sites, and a large left pleural effusion (accumulation of excess fluid in the space between the lung and chest wall). R1's Emergency department progress note dated [DATE] at 12:52 a.m., indicated R1 was seen in the emergency room due to altered mental status. Per report, R1 had a fall back into a radiator two days ago and had complained of back and rib pain. R1 had a wet sounding cough, was lethargic and slow to answer, but was responding to questions. R1's hemoglobin (lab that determines blood loss) dropped 2 grams (g) from previous result two weeks ago. R1's diagnoses included multiple rib fractures and hemothorax. R1's note further indicated after discussion with R1's family, it was determined a transfer to trauma hospital for chest tube (tube inserted into the chest wall to drain plural effusion and treat hemeothorax) was not desired and R1 would be comfort care and transition to hospice. R1 expired 10 days after hospitalization . The facility's internal investigation dated [DATE], indicated nursing assistant (NA)-B reported walking R1 to the bathroom on [DATE] at 10:30 p.m., and R1 stumbled backwards into a radiator and wall outlet. NA-B was able to guide R1's head to avoid head injury but was unable to prevent the fall. Incident was reported to registered nurse (RN)-C. The internal investigation did not indicate the provider was notified at the time of the fall nor a comprehensive assessment or monitoring for injuries was completed. R1's medical record lacked indication a staff member notified R1's provider of incident, or completed continued monitoring or assessment for injury between the time of the incident on [DATE], until R1 was sent to hospital for evaluation on [DATE]. When interviewed on [DATE] at 1:58 p.m., family member (FM)-A stated they were notified by NA-A when visiting R1 on [DATE] regarding the fall. NA-A told FM-A R1 had fell into the radiator and R1 hadn't been the same with moving around. FM-A stated R1 appeared to be the same except for being crabby because he had back and side pain. FM-A stated R1 had been getting Tylenol and ice packs for the back pain. FM-A further stated she had seen some bruising on the front of R1's body, near his chest and was told there was bruising on his back as well. FM-A asked RN-D about the fall, and RN-D didn't know details, but verified R1 fell as there was a nurse note. When visiting R1 on [DATE] at aproximatly 12:00 p.m., FM-A stated R1 was sleeping in the recliner by the television in the dining room. FM-A wanted to help R1 with lunch but staff stated R1 just fell asleep after being awake most of the night. FM-A left and returned around 4:30 p.m. to assist R1 with dinner. R1 was still asleep in the recliner in the dining room. FM-A went to wake R1 up and found R1 wouldn't wake to voice. FM-A then notified RN-A something was wrong and requested R1 to be sent to the hospital. When interviewed on [DATE] at 3:30 p.m., NA-A stated worked the day of the fall but wasn't in R1's room when the fall happened, but NA-B was and R1's fall was discussed with NA-B and RN-C. NA-A stated the following day, [DATE], R1 was just not the same. R1 had bruising on his back and some on the front and complained of headache and back pain. R1 was also not eating much and had a difficult time transferring. NA-A further stated RN-A was made aware of the changes. On [DATE], NA-A stated R1 was worse when coming on shift. R1 was lethargic and not even taking sips of water. NA-A stated FM-A was more vocal with concerns and R1 was sent to the hospital. When interviewed on [DATE] at 3:08 p.m., RN-A stated the NAs had informed (RN-A) R1 had a fall sometime prior to their shift on [DATE]. RN-A stated R1 had complained of a headache, but RN-A had not noted anything unusual with R1 during the evening shift on [DATE]. On [DATE], RN-A stated NA-A stated R1 was more tired than usual, had bruising, and had complaints of rib pain. FM-A also had concerns after they arrived to visit. RN-A stated she completed an assessment, notified the provider, and sent R1 to the hospital for evaluation. RN-A had not assessed R1's bruising and skin as R1 was seated in a common area. RN-A was not aware of any bruising or back pain on [DATE], and there was no nurse-to-nurse report of back pain or bruising. RN-A verified there was not any physical monitoring of R1 orders in place during her shifts on [DATE] and [DATE] and had not completed any assessments or phyical monitoring after the fall. RN-A further stated monitoring notes only last for a day or two and thought the monitoring was already completed. When interviewed on [DATE] at 3:55 p.m., RN-B stated they cared for R1 on the night shift of [DATE] through 10:00 a.m., on [DATE]. RN-A stated was told R1 fell a day or two ago in RN-to-RN report. R1 had hit his back on the radiator and was having some back pain and had been receiving Tylenol. R1 had complained of back pain during the night and had been given Tylenol and was able to go back to sleep. There were no further concerns that night. The following morning R1 was in the dining room for breakfast and had taken his morning medications. R1 had remained in his recliner through the morning napping or watching television. RN-B had reported off to RN-E around 10:00 a.m. RN-B stated there were no orders for post fall monitoring for changes or injuries in place and was not aware of any bruising as RN-B had not completed any cares for R1. RN-B further stated there was nothing indicating R1 required monitoring for bruising and RN-B was not sure if R1 was on an anticoagulant. When interviewed on [DATE] at 9:17 a.m., medical doctor (MD)-A could not find any documentation of R1's fall when reviewing R1's provider and on call documentation. MD-A further stated there was no provider notes or on call documentaion for R1 from [DATE] until R1's hospitalization on [DATE]. When interviewed on [DATE] at 9:45 a.m., MD-A stated they expected staff to notify providers right away of residents who fall and were also taking an anticoagulant. Staff were also expected to monitor for bruising, pain, and injury post fall. Furthermore, the medical director expected staff to notify providers if any abnormal assessments or changes after a fall. When interviewed on [DATE] at 12:55 p.m., the DON stated initially an internal investigation was started however, was not completed due to a lack in communication. DON had completed further interviews and follow up today after state surveyors entered. DON further stated R1 had a witnessed fall and when the details of the incident are known, a risk analysis wasn't required. DON expected staff to notify the family and provider, on call leader and complete a thorough assessment, including a skin assessment, initiate post fall orders after every resident fall to ensure assessments and monitoring for injury were completed. A facility policy titled Fall Prevention and Management revised ,d+[DATE], directed staff to: -notify the provider in a timely manner for any residents noted to be on an anticoagulation as there was significant risk of bleeding. -document the relevant details of the fall. -observe for delayed complications of a fall (72) hours after an observed or suspected fall and will document in the medical record. Documentation will include vital signs, pain, swelling, bruising, decreased mobility, and overall function. -nursing staff will complete and incident review and analysis. The immediate jeopardy that began on [DATE], was removed on [DATE], when it was verified through staff interviews and document review, the facility reviewed residents who have fallen in the past 14 days were reviewed to ensure provider notification, assessments, and health status monitoring was completed, had educated all licensed nurses and nursing assistants on fall policies and procedures pertaining to monitoring for injuries, and physician notification, before the start of their next shift, and completed a plan for ongoing audits of residents who have fallen.

Based on interview and document review, the facility failed to ensure an International Normalized Ratio (INR a standard lab test used when taking blood-thinning medications) was obtained per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This caused a delay in care and treatment and resulted in an immediate jeopardy (IJ) for R54. In addition, the facility failed to administer an antibiotic medication for 12 days, prior to being identified by the physician, for 1 of 15 (R35) residents, on antibiotic therapy. The IJ began on 2/10/22, when nursing staff failed to obtain an INR and did not administer [MEDICATION(S)] for four days to R54. R54 had history of pulmonary embolism(PE -blood clots in the lung) and was at increased risk of serious harm and/or death. The Administrator and director of nursing (DON) were notified on 2/15/22 at 12:51 p.m. and the IJ was removed on 02/15/22, when the facility's approved removal plan was verified onsite by the state agency (SA). Findings included: R54 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes identified R54 had an INR level of 2.77 (normal range for an INR is 2.0-3.0) and her [MEDICATION(S)] dose was 2.5 milligrams (mg) once daily at 6:00 p.m R54's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/31/22, listed R54 had moderately impaired cognition for daily decision-making and had been administered an anticoagulant medication for seven out of seven days during the assessment period. Review of the facility's Anticoagulation Flow sheet, revealed after R54 was admitted to the facility, an INR was obtained on 1/28/22. The INR level was 1.6 (below the recommended therapeutic level of 2.0 to 3.0) The provider was notified. The provider ordered: [MEDICATION(S)] 7.5 mg today and 2.5 mg on Saturday, and 5 mg on Sunday. Staff were to recheck the INR on 1/31/22. On 1/31/22, the INR was obtained which showed a level of 2.3. The provider was notified and the new order given for [MEDICATION(S)] 2.5 mg today, 5 mg on 02/01/22, 2.5 mg on 2/03/22. Staff were to redraw an INR on 2/03/22. On 2/03/22, the INR was obtained which showed a level of 2.1. The provider was notified, the new order for [MEDICATION(S)] was 2.5 mg on Monday, Wednesday, and Saturday and 5 mg all the other days. Staff were to redraw the INR on 2/10/22. The Anticoagulation Flow sheet did not list documentation of an INR drawn on 2/10/22. Therefore there were no orders for [MEDICATION(S)] from 2/10/22 to 2/14/22 (four days). On 2/14/22, an INR was obtained which showed 1.2 (therapeutic range for R54 was 2.0 to 3.0) and a note which showed, drawn per medical director. The new order read to give [MEDICATION(S)] 5 mg today and a recheck of the INR was for 2/15/22. A review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for the use of anticoagulant medication was not created prior to 2/15/22, however, R54's care plan was developed on 2/15/22, for potential for alteration in blood formation and coagulation, related to use of anticoagulant medication due to history of PE, staff were to administer anticoagulant medication as ordered by the provider and to monitor labs, as ordered. In an interview on 2/15/22, at 8:19 a.m., registered nurse (RN)-A, stated that INR's were done on the night shift, early in the morning. Each resident on [MEDICATION(S)] had a flow sheet, which was then handed off to the day shift in order to obtain orders from the provider. RN-A stated, I don't know why [R54's] INR was not done on 2/10/22. RN-A stated R54's INR should have been entered into the system, the night shift would have done the INR and the day shift would have call the provider to obtain orders. Provider Progress Notes, dated 2/07/22, identified nurse practitioner (NP)-B saw R54 for an episodic visit. NP-B documented R54's hospital course was long and complicated, and she remained very weak. In addition, R54 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R54 was on [MEDICATION(S)], as directed by the Anticoagulation Clinic based on the INR. Her current dose of [MEDICATION(S)] was 2.5 mg on Tuesday, Friday, and Sunday, all other days she was on 5 mg daily. NP-B further documented due for INR recheck 2/9/22. R54's medical record review revealed no actual order was written. In an interview on 2/15/22, at 8:31 a.m., the DON stated she looked at the Anticoagulation Flow Sheet for the whole facility and found the INR for R54 had not been obtained on 2/10/22, and called the Medical Director to get orders. The DON stated the process was for night shift to obtain the INR, day shift to obtain provider orders, and the evening shift would administer the medication. The DON stated what happened for R54 was the recheck on the flow sheet documented 2/10/22, however, the rounding provider had ordered the INR for 2/09/22, but that was not documented on the flow sheet nor entered into the system. The DON verified that R54 had gone four days without having had an INR obtained or [MEDICATION(S)] administered was at risk because R54 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 2/15/22, at 11:48 a.m., the Medical Director (MD) stated when the DON called him on 2/14/22, that was the first he was made aware that R54 had not received [MEDICATION(S)] for four days. The MD stated NP-B saw R54 on 2/07/22, had written a note to obtain an INR on 2/09/22, however, she did not actually write an order. When the unit clerk saw the progress notes, she discontinued the INR for 2/10/22, but technically, there was no order written. The Medical Director stated the expected range for R54's INR was between 2.0-3.0. The MD stated a potential risk for not receiving [MEDICATION(S)] for four days would be the INR would go down and her risk increased for a stroke. The MD further stated that R54 also had an irregular heart rhythm which placed her at high risk for a stroke or PE. The facility's Medication Errors policy dated January 2020 indicated the relative significance of medication errors was a matter of professional judgment. The resident's condition was an important factor to take into consideration. If the resident's condition requires rigid control, a single missed or wrong dose could be highly significant. The policy further indicated if the medication was from a category that usually required the resident to be titrated (measuring to a certain level) to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This was especially important with a medication that has a Narrow Therapeutic Index (NTI). Finally, the frequency of error is important; if an error was occurring repeatedly, there may be more reason to classify the error as significant. For example, if a resident's medication was omitted several times, it may be appropriate, depending on consideration of resident condition and medication category, to classify, that error as significant. R35 Review of R35's Face Sheet, revealed R35 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R35 discharged to the community on 2/06/22. Review of R35's Significant Change in Status MDS with an ARD of 1/05/22, found R35 had a BIMS score 13 of 15, which indicated the resident was cognitively intact. The MDS also indicated the resident had not received any antibiotics in the 7-day look back period. Review of R35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R35's Infectious Disease Physician's Progress Notes, dated 11/24/21, revealed Continue [MEDICATION(S)] 400 mg daily maintenance dose. Duration maintenance dose for at least 6-12 months . Review of R35's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R35's Nurse's Note, dated 12/13/21, revealed Per 11/24[/21] visit with (infectious disease) [provider], [MEDICATION(S)] [antifungal] 400 mg to continue indefinitely. Prior order had been entered with a stop date of 12/1. Medication fell off of active orders and has not been given since 12/1. Message left for [infectious disease physician] for further instruction . [MEDICATION(S)] 400 mg reinstated at this time per [Medical Director], and prior written instruction on after visit summary from 11/24. Review of R35's Nurse's Note, dated 12/13/21, revealed Missed [MEDICATION(S)] [antifungal] 400 mg [milligrams] 12-2 to 12-13. Consult with [Medical Director] and [infectious disease physician]. Continue [MEDICATION(S)] [antifungal] 400 mg [milligrams] daily through next appointment with ID [infectious disease] in January . Review of R35's Nurse's Note, dated 12/13/21, revealed Resident and daughter, notified of resident not receiving [MEDICATION(S)] [antifungal] between 12-1 and 12-13 and circumstances explained. Also updated on consult with [Medical Director] and [infectious disease physician] and decision to continue [MEDICATION(S)] [antifungal] 400 mg [milligrams] QD [daily] through next ID [infectious disease] appointment. They have no further questions or concerns at this time. Review of the Facility's Initial Incident Report, dated 12/13/21, provided by the facility, revealed, On 11/24/21, resident had a phone call visit with Infectious Disease and infectious disease ordered for [MEDICATION(S)] [antifungal] 400 mg [milligrams] daily indefinitely for now for disseminated cryptococcal disease. At that time Nurse Manager looked at order that was in EMAR [electronic Medication Administration Record] and identified [MEDICATION(S)] [antifungal] 400 mg [milligrams] was present. Nurse did not observe an end date to the medication, but it [the medication] did have an end date of 12/1/21 .On 12/13/21 Medical Director rounded and noticed that [MEDICATION(S)] [antifungal] was not in current medication list as ordered. Medical Director restarted [MEDICATION(S)] [antifungal] and Nurse Manager notified Infectious Disease and they ordered it to be restarted as well .No side effects were identified due to this medication not being administered. Resident to follow up with infectious disease in January. Investigation Initiated. Interview on 2/14/22, at 12:02 p.m. with the Medical Director revealed he rounded in the facility on 12/13/21, and found R35's antifungal medication was not on the medication list as ordered so he restarted the medication. The Medical Director stated that he discussed the medication error with RN- B and told her to report the significant medication error to the State Agency (SA). Interview on 2/16/22, at 10:45 AM with RN- B revealed R35 had a phone visit with the infectious disease provider and [MEDICATION(S)] (antifungal) was ordered for six to twelve months. RN-B stated that after R35's phone visit with the infectious disease provider, she called the provider about the orders in the progress note but didn't request an order from the provider since R35 was already taking the medication at the same dosage. RN-B stated she reviewed the order, but she didn't observe the end date on the order of 12/01/21. RN-B stated that the Medical Director identified the medication was missing from R35's medication list on 12/13/21. RN- B stated that she notified the DON about the medication error on 12/13/21, and that she was educated on the medication administration policy on 12/13/21. RN-B stated that all orders will be entered as a new order, another nurse will verify the order, and the start and stop dates will be verified. Interview on 2/16/22, at 11:06 a.m. with the DON revealed RN-B notified her on 12/13/21, of the medication error, she contacted the Medical Director, and the infectious disease Physician then restarted the medication for R35. The DON stated that she completed a medication error form, educated RN- B to check the end dates on all orders, then reviewed the medication administration policy with her. The DON indicated training with all nursing staff related to the medication administration policy was initiated with all nursing staff on 12/13/21. The DON stated the Health Information Care Coordinator (HICC) would enter the new orders, then the nurse or RN manager would verify/confirm order. The DON also stated the Infection Preventionist (IP) would audit the antibiotic orders now and antibiotic orders would be discussed in stand-up meetings. Interview on 2/16/22, at 1:57 p.m. with the Infectious Disease (ID) Physician revealed that R35 was admitted to the facility after a complicated hospital stay and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ID Physician stated that she ordered [MEDICATION(S)] 400 milligrams (mg) until 12/01/21, to prevent recurrence of the disease. The ID Physician also stated that she had a phone visit with R35 on 11/24/21, and ordered [MEDICATION(S)] 400 milligrams (mg) for six to 12 months to prevent recurrence of the disease. The IP Physician indicated the facility notified her that R35 had missed 12 doses of the antifungal medication. Review of the facility's policy titled Medication Orders, dated August 2019, provided by the facility, revealed E. Documentation of the Medication Order .2) The following steps are initiated to complete documentation and receive the medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Call, fax, or electronically transfer the medication order to the provider pharmacy. c. Transcribe newly prescribed medications on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Enter the new order on the MAR/TAR/electronic medical record. d. After completion, document each medication order entered on the appropriate form with date, time, and signature. The IJ began on 2/10/22, and was removed on 2/15/22, when the facility received physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility reviewed and updated their current INR Process to ensure INR's and [MEDICATION(S)] dosages were not missed. Facility educated appropriate staff on the protocol for physician INR orders and having correct [MEDICATION(S)] dosing. Audits will be conducted by the DON or designee to ensure INR's were completed and [MEDICATION(S)] medicaion was given as ordered. Interviews were conducted with nursing staff on 2/16/22, between 8:30 a.m. and 10:30 a.m. to verify the above plan was in place on 2/15/22.

Based on interview and document review, the facility failed to initiate cardio-pulmonary resuscitation (CPR) and activate the emergency medical system (EMS) when 1 of 1 residents (R82) experienced a [MEDICAL CONDITION] (absence of respirations and pulse) in accordance with the resident's advance directives. This resulted in the death of R82. In addition, the facility's policies and practices placed 22 of 22 residents (R76, R46, R17, R78, R15, R14, P4, R50, R39, R64, R77, R49, R47, R30, R13, R12, R235, R233, R237, R52, R31, and R72) whose advanced directives indicated full resuscitative status, at risk of potential harm or death and was an immediate jeopardy situation. The immediate jeopardy began on [DATE], at 5:00 a.m. when CPR was not initiated for R82 when he was found unresponsive and without pulse or respirations, and staff did not administer CPR according to his advanced directives. The administrator and director of nursing (DON) were informed of the immediate jeopardy on [DATE], at 5:25 p.m. The immediate jeopardy was removed on [DATE], at 2:50 p.m. but noncompliance remained at the lower scope and severity of a G, isolated actual harm that is not immediate jeopardy. Findings include: R82's Admission Record printed [DATE], indicated [DIAGNOSES REDACTED]. R82's 5 day Prospective Payment System (PPS) Minimum Data Set ((MDS) dated [DATE], indicated he was cognitively intact, required extensive assistance will all activities of daily living (ADLs) except walking in his room and on the unit. R82's Provider Orders for Life Sustaining Treatment (POLST) directed, Cardiopulmonary Resuscitation (CPR): Patient has no pulse and is not breathing. Attempt Resuscitation/CPR). The POLST was signed by the R82's spouse on [DATE], with the indication that R82 had capacity, and by the advance practice nurse practitioner on [DATE]. R82's order summary report printed on [DATE], indicated R82 had orders that included a [DATE], order for use of a continuous positive airway pressure ([MEDICAL CONDITION]) (used to treat sleep apnea) every evening and night shift for sleep apnea; a [DATE], order for oxygen by nasal cannula at 5 liters per minutes (LPM) to keep oxygen saturations at greater than 88% to 94%. The oxygen order indicated baseline supplemental oxygen at 2 LPM at rest with increase to ,[DATE] L with activity. R82's order summary report also indicated a [DATE], order for CPR with selective treatment. A [DATE], progress note, indicated an initial care conference was held on [DATE], and R82 planned short term stay with plans to return home after physical therapy (PT) and occupational therapy (OT) were complete. On [DATE], at 2:14 p.m. a progress note indicated R82 wished to transfer to another facility to be closer to home, and the facility faxed a referral. On [DATE], at 10:28 p.m. a progress note indicated R82 had 2 episodes of emesis, had stated he didn't feel well, out of nowhere, and had thrown up in his sleep. On [DATE], at 10:35 p.m. a progress note dated indicated R82's [MEDICAL CONDITION] machine was held due to the 2 episodes of emesis. On [DATE], at 2:52 a.m. a progress note indicated R82 would not wear the [MEDICAL CONDITION] mask. On [DATE], at 5:51 a.m. a progress note indicated, At about 0200 (2:00 a.m.) this writer and NAR (nursing assistant registered) went in to patients room to do complete bed change d/t (due to) large incontinent void. Patient was having significant tachypnea, was anxious, and accelerated heart rate. Oxygen sats checked and were at 72% with NC (nasal cannula) in place. Oxygen was at 5 LPM (liters per minute). This writer switched NC to oxygen mask d/t patient breathing heavily through mouth. This writer sat with patient encouraging slow breathing and to breath in through nose and out through mouth. About 0230 patient was starting to calm down and oxygen sats were at 83%. Patient was able to be roused and was responding appropriately. Patient continued having brief episodes of tachypnea, and this writer talked patient through episodes. At 0300 patient was calmed and oxygen sats had come up to 90% at the 5 LPM. When this writer left room, patient was calm and breathing was stable. NAR had looked into patients room around 0430 and patient did not appear restless. When NAR went into patients room again at 0500, patient appeared to not be breathing, oxygen mask was lying on floor by foot of bed, and covers were lying on floor next to bed. NAR alerted this writer about patient. This writer went into room at 0510 and patient had no respirations, no heart rate, was cool to the touch, and limbs were starting to get stiff. Mottling was significant on back of legs, arms, hands, and back. This writer checked patients code status which was CPR with selective treatment. Based on findings/condition of patient, CPR was not performed. On [DATE], at 8:26 a.m. the assistant director of nursing (ADON) stated if a resident was not breathing and did not have a pulse, she would check their code status, if full code would initiate CPR, unless they, Had that dusky appearance, extreme rigidity, blood pooled in back or are cool to touch. The ADON stated the staff had recent training in code status and when to do CPR or not do CPR. On [DATE], at 11:15 a.m. the Monarch consultant nurse (CN) stated the facility had notified the state agency when they found out an LPN-E, working the night shift had not notified the physician when R82 had a change in condition and subsequently died . CN stated they looked into whether R82 should have received CPR or not and determined that he did not meet the criteria for CPR (however the facility was not following current American Heart Association guidelines for determining when CPR should not be initiated). This was after the human resource director had met with LPN-E to terminate employment and received more explanation from her. The explanation as to why CPR had not been performed was not documented. On [DATE], at 11:23 a.m. the DON stated she had not been working at the facility at the time R82 had resided there. On [DATE], at 11:29 a.m. registered nurse (RN)-A stated CPR should not have been started for R82. RN-A stated signs of death including rigidity of limbs, and blood pooling in a person's back are signs of death that would indicate to not start CPR. On [DATE], at approximately 11:30 a.m. registered nurse consultant (RNC) stated R82 met the criteria for not starting CPR. Licensed practical nurse (LPN)-E was interviewed and stated CPR should not have been started. On [DATE], at 2:38 p.m. LPN-J was interviewed and stated she would perform CPR on someone if they were listed full code, No matter what, but it also depended on if they were cold, or had other signs of not breathing for a long time, such as stiffness. On [DATE], at 2:52 p.m. RN-B was interviewed and stated she would not do CPR on someone if they had rigid joints or if they had blood pooling in their back. On [DATE], at 2:14 p.m. the geriatric nurse practitioner (GNP) stated an on-call provider should have been notified of R82's declining condition. The GNP stated CPR should not be performed if a person was Stiff or Cold, and indicated nursing judgement was involved, and there was a short window of effectiveness when beginning CPR. The GNP also verified R82 was listed as a full code, and CPR was not performed. The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; Part 3: Ethics, included: Criteria for not starting CPR in all OHCA (out of hospital [MEDICAL CONDITION]). While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR might be appropriate, as follows: 1. Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril. 2. Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity (a bluish discoloration of lowest part of body), decapitation, transection, or decomposition). 3. A valid, signed, and dated advanced directive indicating that resuscitation is not desired, or a valid, signed, and dated DNAR (do not attempt resuscitation) order. The facility's Cardiopulmonary Resuscitation Protocol revised ,[DATE], directed a nurse will determine the need for CPR. CPR would be initiated immediately based upon that nurse's and/or the clinical team's determination and evaluation of the resident. The protocol further directed CPR will not be initiated if death is unobserved and obvious clinical signs such as, but not limited to: no response to external stimuli, no BP (blood pressure), no palpable or audible apical pulse, no respirations, pupils dilated and fixed AND in the present of the following irreversible signs of death is present: a. Rigor Mortis: rigidity/stiffening of the muscles and extremities. b. Dependent Lividity: settling/pooling of the blood in a part of the body causing a purplish red discoloration of the skin. c. Decapitation: separation of the head/skull from the body. d. Decomposition: decaying of the body. R76's quarterly MDS dated [DATE], indicated moderately impaired cognition. However, R76's annual MDS dated [DATE], and quarterly MDS dated [DATE], indicated R76 had been cognitively intact prior to the recent MDS. R76's face sheet printed [DATE], indicated [DIAGNOSES REDACTED]. R76's POLST was signed but not dated by the resident. R76's POLST was signed by an RN on [DATE], but the physician signature was not dated. The POLST indicated R76 designated staff to attempt CPR if R76 had no pulse and was not breathing. R76 was at risk of death if s/he went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R46's quarterly MDS dated [DATE], indicated she was cognitively intact. R46's Face Sheet printed [DATE], indicated [DIAGNOSES REDACTED]. R46's POLST was signed by the resident, but not dated. R46's POLST was signed by the nurse practitioner on [DATE]. The POLST indicated R46 designated staff to attempt CPR if R46 had no pulse and was not breathing. R46 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R17's quarterly MDS dated [DATE], indicated she was cognitively intact. R17's Face Sheet printed [DATE], indicated type 2 diabetes, [MEDICAL CONDITION] and [MEDICAL CONDITION] without behavioral disturbances. R17's POLST was signed but not dated by the resident. R17's POLST was signed by the nurse practitioner on [DATE]. The POLST indicated R17 designated staff to attempt CPR if R17 had no pulse and was not breathing. R17 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R78's admission MDS dated [DATE], indicated he had severely impaired cognition. R78's Face Sheet printed on [DATE], indicated [DIAGNOSES REDACTED]. R78's POLST was signed by his daughter and Power of Attorney (POA) on [DATE]. R78's POLST was signed by the nurse practitioner on [DATE]. The POLST indicated R78's POA designated staff to attempt CPR if R78 had no pulse and was not breathing. R78 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R15's admission MDS dated [DATE], indicated she was cognitively intact. R15's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R15's POLST was signed but not dated by the resident. R15's POLST was signed by an RN on [DATE], and by the nurse practitioner on [DATE]. The POLST indicated R15 designated staff to attempt CPR if R15 had no pulse and was not breathing. R15 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff following their policy and practice of not performing CPR. R14's admission MDS dated [DATE], indicated he was cognitively intact. R14's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R14's POLST was signed but not dated by the resident. R14's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R14 designated staff to attempt CPR if R15 had no pulse and was not breathing. R14 was at risk of death if he went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R4's significant change MDS dated [DATE], indicated he had severely impaired cognition. R4's Face Sheet printed on [DATE], indicated [DIAGNOSES REDACTED]. R4's POLST was signed by his son and POA on [DATE]. R4's POLST was signed by the nurse practitioner on [DATE]. The POLST indicated R4's POA designated staff to attempt CPR if R4 had no pulse and was not breathing. R4 was at risk of death if he went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R50's quarterly MDS dated [DATE], indicated she was cognitively intact. R50's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R50's POLST was signed by the resident on [DATE]. R50's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R50 designated staff to attempt CPR if R50 had no pulse and was not breathing. R50 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R39's significant change MDS dated [DATE], indicated she had moderately impaired cognition. R39's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R39's POLST was signed but not dated by her daughter. R39's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R39 designated staff to attempt CPR if R39 had no pulse and was not breathing. R39 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R64's annual MDS dated [DATE], indicated he had severely impaired cognition. R64's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R64's POLST was signed by his wife on [DATE]. R64's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R64 designated staff to attempt CPR if R64 had no pulse and was not breathing. R64 was at risk of death if he went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R77's admission MDS dated [DATE], indicated she was cognitively intact. R77's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R77's POLST was signed but not dated by the resident. R77's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R77 designated staff to attempt CPR if R77 had no pulse and was not breathing. R77 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R49's admission MDS dated [DATE], indicated she was cognitively intact. R49's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R49's POLST was signed and dated by the resident on [DATE]. R49's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R49 designated staff to attempt CPR if R49 had no pulse and was not breathing. R49 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R47's admission MDS dated [DATE], indicated he was cognitively intact. R47's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R47's POLST was signed by his wife on [DATE]. R47's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R47's wife designated staff to attempt CPR if R47 had no pulse and was not breathing. R47 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R30's quarterly MDS dated [DATE], indicated she was cognitively intact. R30's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R30's POLST was signed by the resident on [DATE]. R30's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R30 designated staff to attempt CPR if R30 had no pulse and was not breathing. R30 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R13's admission MDS dated [DATE], indicated she had moderately impaired cognition. R13's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R13's POLST was signed by her daughter on [DATE]. R13's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R13's daughter designated staff to attempt CPR if R13 had no pulse and was not breathing. R13 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R12's quarterly MDS dated [DATE], indicated she was cognitively intact. R12's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R12's POLST was signed but not dated by the resident. R12's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R12 designated staff to attempt CPR if R12 had no pulse and was not breathing. R12 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R235's face sheet, printed on [DATE], indicated he was admitted on [DATE]. R12's Face Sheet further indicated [DIAGNOSES REDACTED]. R235's POLST was signed but not dated by the resident. R235's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R235 designated staff to attempt CPR if R235 had no pulse and was not breathing. R235 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R233's admission MDS dated [DATE], indicated she was cognitively intact. R233's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R233's POLST was signed by the resident on [DATE]. R233's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R233 designated staff to attempt CPR if R233 had no pulse and was not breathing. R233 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R237's Face Sheet, printed on [DATE], indicated she was admitted on [DATE]. R237's Face Sheet further indicated [DIAGNOSES REDACTED]. R237's POLST was signed by the resident on [DATE]. R237's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R237 designated staff to attempt CPR if R237 had no pulse and was not breathing. R237 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R52's quarterly MDS dated [DATE], indicated he had severely impaired cognition. R52's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R52's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R52's POA designated staff to attempt CPR if R52 had no pulse and was not breathing. R52 was at risk of death if he went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R31's quarterly MDS dated [DATE], indicated she was cognitively intact. R31's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R31's POLST was signed by the resident on [DATE]. R13's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R31 designated staff to attempt CPR if R31 had no pulse and was not breathing. R31 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. R72's admission MDS dated [DATE], indicated she was cognitively intact. R72's Face Sheet, printed on [DATE], indicated [DIAGNOSES REDACTED]. R72's POLST was signed by the resident on [DATE]. R72's POLST was signed by a nurse practitioner on [DATE]. The POLST indicated R72 designated staff to attempt CPR if R72 had no pulse and was not breathing. R72 was at risk of death if she went into an unwitnessed [MEDICAL CONDITION] and staff were following their policy and practice of not performing CPR. The immediate jeopardy that began on [DATE], was removed on [DATE], at 2:50 p.m. when the facility took the following action and was verified as implemented. However, the noncompliance remained at the lower scope and severity level of G (isolated actual harm that is not immediate jeopardy) due to the death of R82. -updated their policy which included current standards, -trained staff, -identified residents who had full code status designated in their advanced directives, and placed measures to ensure staff could easily identify who these residents were. -provided information indicating all current licenses nurses had a current CPR certificate.