Every finding on record at St Anthony Health & Rehabilitation

Based on observation and interviews, the facility failed to ensure proper usage of personal protective equipment (PPE) while sorting soiled linens and personal laundry. This had the potential to affect all 92 residents residing in the facility.Findings include:During tour of the laundry room on 6/16/26 at 3:17p.m. no PPE was observed anywhere in the dirty linen sorting area.On 6/16/26 at 3:17 p.m. housekeeping supervisor (HS) confirmed staff do not wear the required PPE while sorting soiled laundry. HS stated they will wear gloves but no other items. This had been the practice since they started working in the laundry room the previous year.On 6/16/26 at 3:09 p.m. administrator stated their expectation was staff wore full PPE, including gown, gloves, and goggles while sorting laundry.On 6/16/26 at 3:47 p.m. administrator stated the facility did not have a laundry policy.

Based on observation, interview and document review the facility failed to ensure privacy for 1 of 1 resident (R101) reviewed for dignity. Findings include: R101 face sheet indicated admission on [DATE], diagnoses included Urinary Tract Infection, Neuromuscular dysfunction of the bladder, Infection and inflammatory reaction due to indwelling urethral catheter. During observation on 6/17/26 at 10:29 a.m. R101 was ambulating with occupational therapist (OT)-A. An uncovered urinary catheter bag was hanging on the lowest bar of the wheeled walker. R101 and OT-A ambulated down the hallway, past the nurse's station and dining room, to the end of another hall before he sat down to rest. R101 walked past 2 staff and 2 residents. During interview on 6/17/26 at 10:40 a.m. OT-A stated she forgot to move the privacy bag with the catheter bag to the walker. She stated catheter bags should remained covered for resident's privacy. During interview on 6/17/26 at 1:20 p.m. R101 stated preference to have catheter bag covered when in public areas. During interview on 6/17/26 at 1:25 p.m. registered nurse (RN)-A stated catheter bags were to be covered. It's a dignity issue. A catheter policy was requested; however, none was provided.

Based on record review and interview the facility failed to ensure pharmacy recommendations were addressed for 1 of 5 residents (R13) reviewed for unnecessary medications.Findings include:R13's quarterly minimum data set (MDS) dated [DATE], indicated R13 was admitted [DATE], severely cognitively impaired, and had the following diagnoses: hypertension (HTN) (high blood pressure), renal insufficiency, diabetes, thyroid disorder, non-Alzheimer's dementia, and a stroke.R13's Clinical physician orders printed 6/17/26, indicated R13 was currently prescribed the following HTN medications:Metoprolol Succinate extended release (ER)-50 milligrams (MG) tablet- give 50MG by mouth once daily for HTN. Start date-2/26/26Lisinopril 40MG table- give 1 tablet daily for HTN- start date 2/26/26Amlodipine Besylate 10MG tablet- Give 1 tablet by mouth every night at bedtime for HTN- start date-2/25/26R13's monthly pharmacy recommendation dated 3/13/26, indicated the pharmacist had requested hold parameters for the above medication orders. The document also shows the provider responded and ordered parameters for HOLD if systolic blood pressure (SBP) is 100 or less. The order was signed and reviewed by two different nurses on 3/19/26 and 3/20/26.However, R13's medical record had no evidence the parameters were ever added to the orders.On 6/17/26 at 4:27p.m., the regional nurse consultant (RNC) accessed the facility's electronic charting system and confirmed the parameters of HOLD for SBP less than 100 were never added to any of the 3 orders as directed by the physician. The RNC confirmed that even though the pharmacy recommendation was signed off it was never entered as ordered.On 6/18/26 at 09:10 a.m. pharmacist (PHRM) confirmed the parameters were never entered as ordered. PHRM stated their expectation was the facility addressed and completed the pharmacy recommendations and order changes within 30 to 60 days. The PHRM stated the importance of keeping the orders up to date because it could have had a negative effect on the residents.On 6/18/26 at 9:43 a.m. director of nursing (DON) stated the pharmacy emailed the monthly recommendations to the DON and they passed it on to the nurse managers for each wing. Nurse managers were responsible for following up on the recommendations. DON confirmed the parameter orders for R13 were never entered. Their expectation was it would have been completed as ordered. The DON stated the importance of having blood pressure parameter on blood pressure medications as ordered to prevent the residents blood pressure from dropping too low.The Consultant Pharmacist Reports Policy last revised January 2026 indicated the pharmacy recommendations are acted upon and documented by the facility staff and/or prescriber. The DON or designated licensed nurse address and document recommendations that do not require physician intervention, e.g., monitor blood pressure.

Based on interview and document review, the facility failed to ensure binding arbitration agreements were clearly communicated in a form and manner residents understood prior to signing for 1 of 3 residents (R43) reviewed for binding arbitration. This had the potential to affect residents who signed binding arbitration prior to 5/1/26. Findings include: R43's admission Minimum Data Set (MDS) indicated admission on [DATE], intact cognition with diagnoses of non-Alzheimer's dementia, and moderate vision impairment (limited vision: not able to see newspaper headlines but can identify objects), and R43 always needed to have someone help with reading written materials. Exhibit H- Binding Arbitration Agreement undated, included signature of R43. During interview on 6/17/26 at 11:23 a.m. R43 stated he would have not signed a binding arbitration agreement. R43 stated legal issues at the time of his admission would have kept him from signing an arbitration agreement. He would never agree to a mediator. He was not able to read or write and would therefore require assistance. During interview on 6/17/26 at 3:19 p.m. social services (SS)-A stated he completed binding arbitration with R43. He explained binding arbitration as a legal form allowing residents to speed up the process when bringing the facility to court. I [SS-A] would not have stated they were giving up any rights. SS-A stated he had limited training on binding arbitration. He was responsible for all binding arbitration agreements until 5/1/26, when it was transferred to the admission coordinator. During interview on 6/17/26 at 3:29 pm. admission coordinator (AC) stated she had recently been hired and presented binding arbitration upon admission. She stated if a resident did not understand, she would stop and discuss binding arbitration with family. On 6/18/26 at 10:00 a.m. Administrator stated all binding arbitration agreements were grandfathered in. A facility document titled Explanation of Arbitration Agreement Language to Family and Resident/Patient indicated arbitration does not occur in a court. however, the document lacked indication the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. Further, it lacked resident/representative acknowledgement that he or she understands the agreement.

Based on interview and document review the facility failed to ensure 2 of 5 residents (R11, R76) were offered, educated and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations.Findings include: A CDC Adult Immunization Schedule by age topic, dated 08/07/2025, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had not received the complete series of pneumococcal vaccination (i.e., PPSV23, PCV20 and PCV13) or their history is unknown, then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20), 1 dose of PCV-15, or PCV-21. R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was admitted on [DATE], [AGE] years old, severely cognitively impaired, and had the following diagnoses: hypertension (HTN) (high blood pressure), renal insufficiency, diabetes (DM), non-Alzheimer's dementia, depression, malnutrition, and psychotic disorder other than schizophrenia. R11' s undated client information vaccination record indicated R11 was due for their next pneumonia vaccination. R11's immunization informed consent form signed 12/3/25, indicated R11 had given consent to receive the PCV20 vaccination. R11's medical record lacked any evidence the PCV20 was ever provided. R76's quarterly MDS dated [DATE], indicated R76 was admitted on [DATE], [AGE] years old, cognitively intact, and had the following diagnoses: HTN, neurogenic bladder (bladder unable to empty on its own), DM, paraplegia (inability to move one's limbs), seizure disorder, depression, malnutrition, and bipolar disorder. R76's undated client information vaccination record indicated R76 was due for their next pneumonia vaccination. R76's medical record lacked any evidence the PCV20 was ever provided. R76's immunization informed consent form signed 9/23/25, indicated R76 had not been offered the PCV20 vaccination. On 6/16/26 at 3:35 p.m. regional Nurse consultant (RNC) stated she was responsible for infection prevention while the current infection preventionist was on vacation. She confirmed neither R11 or R76 were offered the PCV20, and it had been missed. RNC stated their expectation was for the vaccinations to have been offered and provided upon admission. Furthermore, RNC stated the importance of providing vaccinations according the to the CDC recommendations was to keep the residents healthy. The facility's Pneumococcal policy last revised 2/24, indicated prior to or upon admission to the facility (within 5 days), all residents will be assessed for current immunization status and eligibility to receive the pneumococcal vaccine. Within 30 days of admission, resident will be offered the vaccine, when indicated, unless the resident had already been vaccinated or the vaccine is medical contraindicated.

Based on observation, record review, and interview, the facility failed to follow standards of practice for medication management for 1 of 8 residents (R72) reviewed for medication administration.Findings include:During a medication administration observation on 6/16/26 at 5:20 p.m., it was noted R72's order in the facility's electronic medication administration record (EMAR) indicated R72's Morphine Sulfate order was dispensed as 15 milligram (MG) tablet (TAB) with a dose of 2.5mg to be given sublingually (under the tongue) every (q) 3 hours. However, the Morphine sulfate card from the pharmacy showed the medication was a 2.5mg sublingual tablet to be given q6hrs. Registered nurse (RN)-A confirmed they did not match and tended to happen with sublingual tablet orders.R72's annual minimum data set (MDS) dated [DATE], indicated R72 was admitted [DATE], severely cognitively impaired, and had the following diagnoses: atrial fibrillation (top two chambers of the heart don't pump correctly), coronary artery disease, heart failure, hypertension (high blood pressure), diabetes, Alzheimer's, anxiety, arthritis, and non-Alzheimer's dementia.R72's order summary report printed 6/16/26, indicated R72 had a current order for Morphine Sulfate 15mg tablet- give 2.5mg sublingually q3hr for pain.R72's [provider] Hospice physician orders form dated 6/12/26, indicated the handwritten order from the provider: Morphine 2.5mg solutab: give 1 solutab under the tongue every 3 hours for pain.R72's current medication cards read as follows:-Card #1(lableled #15)-Morphine Sulfate 2.5mg sol tab- 1 tablet orally or sublingually every 6 hours: 1 tablet orally or sublingually every hour as needed. There were no dose change stickers on the card.-Card #2-(lableled #16)-Morphine Sulfate 2.5mg sol tab- 1 tablet orally or sublingually every 6 hours: 1 tablet orally or sublingually every hour as needed. There were no dose change stickers on the card-Care #3-(lableled #17)-Morphine Sulfate 2.5mg sol tab- 1 tablet orally or sublingually every 6 hours: 1 tablet orally or sublingually every hour as needed. There were no dose change stickers on the [NAME] 6/16/26 at 5:20p.m. RN-A confirmed they failed to follow the 5 rights of medication administration, 1-Right person, 2-Right Drug, 3-Right Dose, 4-Right Route, 5-Right time. RN-A confirmed the dose of the tablet and the time on the cards did not match the current order, but as the dose was the same, they continued to use the card. RN-A stated they would normally call the pharmacy and get a card with the correct information sent over, but they had not done that as the dose had matched. Furthermore, RN-A stated they had stickers they can put on the card to alert other staff members to the change in dose, however they had not used the sticker, because they had forgotten.On 6/18/26 at 0910 a.m., pharmacist (PHRM) confirmed R72's orders had a tablet strength of 15mg listed. They stated the wrong dose had most likely been selected when ordering the tablet. PHRM stated they attempted to catch transcription errors during monthly medication review; however, this one had been missed. Their expectation was the cards and the orders matched. It was important to ensure to prevent medication error or overdose.On 6/18/26 at 9:43 a.m. director of nursing (DON) stated the process and expectation for transcribing orders was the order would be written by the provider, given to the health unit coordinator (HUC) to be entered, then reviewed by two nurses to verify the orders. The DON confirmed R72's had been confirmed by two nurses. However, the orders did not match, and they expected staff to have been using the order/dose change sticker. The DON stated the importance of verifying orders were transcribed correctly and the staff were using the 5 rights of medication administration to ensure they provided medications safely and don't have the wrong dose. The facility medication and treatment orders policy dated January 2024, indicated orders for medications and treatments will be transcribed accurately and in a timely manner. Orders must include the following: A: Name and strength of drug B: Number of Doses, start and stop date, and/or specific duration of therapy C: Dosage and frequency of administration D: Route of administration E: Clinical Condition or symptoms for which the medication is prescribed F: Any interim follow-up requirements

Based on interview, observation and document review, the facility failed to update the care plan with specific interventions for 1 of 1 resident (R3) reviewed for falls.Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment, disorganized thinking, and needed extensive assistance with toileting, bed mobility and transfers. The MDS lacked identification of falls for R3. R3's document titled with R3's name undated, indicated after a fall on 6/8/25, an intervention for PRN medications was put in place. Furthermore, the document indicated after a fall on 6/9/25, interventions for frequent rounding and hospice to review side effect monitoring for medications was put in place. R3's care plan revised 6/20/25, lacked interventions for PRN medications after a fall on 6/8/25 and frequent rounding and hospice to review side effect monitoring for medications after a fall on 6/9/25. During an interview on 7/22/25 at 12:03 p.m., nursing assistant (NA)-A stated she would look in the care plan for any fall interventions in place. During an interview on 7/22/25 at 2:18 p.m., licensed practical nurse (LPN)-A stated he would look in the care plan for any current fall interventions. LPN-A stated the management team was responsible for revising and or adding new interventions to the care plan. During an interview on 7/22/25 at 2:58 p.m., registered nurse (RN)-A stated revised or new interventions for R3's falls on 6/8/25, and 6/9/25, should have been added to the care plan by him and he confirmed he did not add any to the care plan. During an interview on 7/22/25 at 3:30 p.m., the administrator stated staff were to refer to the care plan for fall interventions. The management team was responsible for placing fall interventions into care plans as soon as possible. The facility Post Fall Assessment policy reviewed 10/14/24, indicated changes as appropriate would be made on the resident's care plan and communicated to the nursing staff.

Based on interview and document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys in regards to quality of care, care plans and self-administration of medications (SAM) which were also identified during this survey. This had the potential to effect all 74 residents residing in the facility. Findings include: Review of the facility CASPER Report dated 3/17/2025, identified the facility was cited F684 for quality of care, F656 development/implementation of comprehensive care plans, and F554 SAM during the survey exited 3/7/2024. See F684: Based on interview and document review, the facility failed to follow current physician orders and parameters for 2 of 5 residents (R28, R61) reviewed for medications. See F656: Based on observation, interview and record review, the facility failed to ensure a care plan was developed and maintained to ensure appropriate care was provided for 1 of 1 residents (R66) reviewed for increased care needs for a declining resident. See F554: Based on observation, interview and document review, the facility failed to ensure a self-administration of medications assessment was completed to allow residents to safely administer their own medications for 1 of 1 residents (R66) observed with medications at bedside. The facility's QAPI meeting minutes dated 1/27/25, 2/24/25, and 3/24/25, lacked ongoing data related to the above repeat citations. On 4/10/25 at 1:45 p.m., the administrator confirmed the facility had not been tracking previous compliance with surveys, and have recently became aware and began to form a plan to monitor and maintain compliance in the future. The QAPI policy last reviewed 1/11/25, identified the facility will demonstrate the development, implementation, and evaluation of corrective actions or performance improvement activities.

Based on observation, interview and record review, the facility failed to update a care plan 1 of 1 residents (R66) reviewed for a declining resident. Findings include: R66's minimum data set (MDS) dated [DATE], indicated she had intact cognition, did not refuse care or medications and had the following diagnoses: cancer, malnutrition, asthma, chronic obstructive pulmonary disease and/or chronic lung disease. The MDS further indicated R66 was independent with eating, personal hygiene, toileting, dressing, mobility, transfers and received hospice services. R66's face sheet indicated R66 was contracted Hospice of the Midwest to receive hospice cares and services. R66's care plan indicated R66 had a self-care deficit and required assistance with activities of daily living (ADL's) due to terminal lung cancer/respiratory failure. The care plan also indicated R66 received hospice services, and the nurse manager was the designated facility interdisciplinary team (IDT) member to collaborate with hospice to ensure the needs of R66 were being met. R66's order summary report printed 4/10/25 indicated R66 took antidepressant medication with potential side effects of dizziness, fatigue, and anxiety; antipsychotic mediations with potential side effects of blurred vision, postural hypotension(a sudden drop in blood pressure that occurs when a person changes from a lying or sitting position to standing), sedation, confusion, and restlessness; Gabapentin with potential side effects of drowsiness, dizziness, sedation and blurred vision; an opioid medication with potential side effects of dizziness, delirium, over sedation and changes in mental status. R66's medication administration record (MAR) for April 2025 indicated R66 took the following scheduled medications: 100mg quetiapine at bedtime for anxiety, 0.5mg lorazepam twice a day for shortness of breath, 400mg gabapentin three times a day for pain, 30mg morphine three times a day for pain; and the following as needed medications: 15mg morphine tablet every two hours as needed for pain, and 0.75 ml (20mg/ml) every two hours as needed for shortness of breath. The MAR also indicated R66 had not missed any scheduled medications in April 2025 and had been administered as needed morphine three times between April 1st and April 10th, 2025. R66's bedside Kardex dated 4/9/2025 indicated R66 was able to take showers/baths independently with no staff oversight, was able to toilet independently, and was able to transfer independently with no staff oversight. During observation on 04/08/25 at 3:28 p.m. R66 was lying in bed, eyes closed, deep even breathing noted; dressed in light colored top and dark bottoms and did not respond to knocking on door from staff. During observation on 04/09/25 7:28 a.m. R66 was lying in bed on her left side with eyes closed. R66 was wearing same light-colored top and dark bottoms as previous day. R66's hair pulled up into bun on top of head and had a greasy appearance. During interview on 04/09/25 at 10:54 a.m. registered nurse (RN)-C stated R66 was very weak, and the aides had been providing toileting cares to include changing soiled incontinent briefs, assisting with bathing or showering and could no longer dress herself or change her clothes. RN-C could not locate any documentation on R66's bathing record and stated she had been previously independent but was now dependent on staff for assistance with 'basically everything'. RN-C stated R66 did not have a hospice aide to assist with personal cares and she had been updated by the nurse manager that R66 was declining, and staff would have to start doing more cares for her. During interview on 04/09/25 at 10:57 a.m. certified nursing assistant (CNA)-C stated R66 received assistance with toileting, bathing and sometimes repositioning in bed. CNA-C stated R66 had been able to do her own shower previously but had been steadily declining and now needed assistance for all her personal cares. CNA-C stated staff would look to the Kardex for instructions on how to care for residents. CNA-C opened R66's Kardex, stated it was incorrect and did not reflect the cares R66 was currently needing. During observation on 04/10/25 at 11:07 a.m. R66 was observed lying in bed with her eyes closed, wearing what appeared to be the same light-colored top and dark bottoms she had been wearing the previous two days. R66's hair was unkept and had stringy strands hanging loose from a ponytail on the top of her head. R66 did not respond to verbal stimulation. During interview on 04/10/25 at 11:51 a.m. registered nurse case manager (NM)-C stated care plans and Kardex's were updated with changes after a fall, beginning or ending therapy, hospitalization s or any significant change of condition. NM-C stated she was ultimately responsible for updating resident care plans and the Kardex. NM-C reviewed R66's care plan and stated it had not been updated. R66 was not independent with bathing or toileting, she required oversight. NM-C stated R66 had been steadily declining and agreed the care plan should have been updated to reflect her increased need of assistance with all personal cares. During interview on 04/10/25 at 12:35 p.m. director of nursing (DON) stated care plans were reviewed by using an IDT approach and depending on the topic it could be updated by the MDS nurse or the NM. DON stated care plans were updated with new therapies, after a fall, hospitalization , or a change of condition. DON stated the process would be the same for all residents regardless of their hospice designation. DON acknowledged R66 had been declining and stated she was aware she required more assistance. DON went on to say it was her expectation care plans were updated as soon as a change was identified. This was important to ensure all resident care needs were met. Facility document titled Care Plan Revisions Upon Status Change with a created date of 9/26/2023 indicated the purpose of the procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The policy indicated the following: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. upon identification of a change in status, the nurse will notify the MDS coordinator, the physician and the resident representative b. the MDS coordinator and the IDT will discuss the resident condition and collaborate on intervention options c. the care plan will be updated with the new or modified interventions d. staff involved in the care of the resident will report resident response to new or modified interventions e. care plans will be modified as needed by designated staff f. the unit manager or other designated staff will communicate care plan interventions to all staff involved in the resident's care g. the designated staff member will conduct an audit on all residents experiencing a change in status at the time of the change in status is identified to ensure care plans have been updated to reflect current resident needs

Based on observation, interview and document review, the facility failed to ensure a self-administration of medications assessment was completed to allow residents to safely administer their own medications for 1 of 1 residents (R66) observed with medications at bedside. Findings include: R66's admission minimum data set (MDS) dated [DATE], indicated she had intact cognition, did not refuse care or medications and had the following diagnoses: cancer, malnutrition, asthma, chronic obstructive pulmonary disease and/or chronic lung disease. The MDS further indicated R66 took antipsychotic, antianxiety, antidepressant, opioids and required oxygen therapy. R66's order summary report printed on 4/10/25, included antianxiety medications, antidepressant medications, antipsychotic medications and narcotic pain medications which can cause blurriness, dizziness and sedation. Additionally, R66 required nebulizer breathing treatments 4 times throughout the day and the use of supplemental oxygen. The order summary lacked documentation of an order for self-administration of medications (SAM). R66's medication administration record (MAR) dated 4/1/2025-4/30/2025, indicated R66 had been administered all scheduled doses for the month of April. However, the MAR lacked documentation of an order for self-administration of medications. R66's care plan lacked information regarding self-administration of medications. During observation on 4/8/25 at 8:49 a.m., R66 was in bed resting quietly with eyes closed with her bedside table over the right side of the bed. To her immediate left was another facility bed not in use. At the end of her bed was a walker and a wheelchair. Just inside the door to the immediate right, approximately 8 feet from R66, was shower chair covered with a black and white rug. On top of the rug was a white nebulizer machine. Connected to the machine was green tubing connected to a nebulizer cup. The nebulizer cup was approximately two thirds full of clear liquid. A nebulizer solution cap and empty vial was next to the neb machine. During interview on 4/8/25 at 9:17 a.m., registered nurse (RN)-C stated she had not yet given R66 her morning medications. RN-C picked up the nebulizer cup and confirmed the nebulizer cup was two thirds full and stated it was probably the neb treatment from the night before. RN-C stated R66 wouldn't even be able to reach it where it was located so far from her bed. RN-C went on to say she was unclear if R66 could administer her own medications. During interview on 4/8/25 at 3:46 p.m., registered nurse manager (RNM) stated if a resident wished to administer their own meds they would need to be assessed upon admission and with any significant change of condition. RNM stated the assessment for a nebulizer would include the resident demonstrating they could hold the neb cup during administration and were able to remove it when it was completed. RNM stated without a SAM in place she expected the nursing staff to prepare the medication and stay with the resident during administration. RNM stated if a resident had a SAM order a nebulizer could be left with the resident to self-administer, however, the nurse would be required to come back and complete a respiratory assessment when the nebulizer was completed. RNM reviewed R66's electronic medical record and stated R66 did not have a SAM assessment or an order to self-administer medications and a full neb cup should not have been left in her room to self-administer. Facility policy titled Self Administration of Medications with a last review date of 10/14/24 indicated the following: A resident may only self-administer medications after the facility's interdisciplinary team (IDT) has determined which medications may be self-administered safely. When determining if self-administration is clinically appropriate for a resident the IDT consider the residents physical capacity appropriately administer; the resident's capability to follow directions; the resident's comprehension of instructions for the medications they are taking; and the resident's ability to ensure medication is stored safely and securely. The policy went on to indicate all nurses and aides are required to report to the charge nurse any medication found at the bedside not authorized for bedside storage and the care plan must reflect resident self-administration and storage arrangements for such medications.

Based on observation, interview and document review, the facility failed to provided nail care for 1 of 4 residents (R15) reviewed for dependent activities of daily living (ADLs). Findings include: R15's PPS 5 day scheduled Minimum Data Set (MDS) assessment dated [DATE], included R15 was admitted [DATE] and had moderate cognitive impairment. R15 had impairment on one side and was dependent with bathing. Personal hygiene assessment was not recorded on the MDS submission. R15's undated care plan included a focus of being at risk for excessive bruising and bleeding due to use of coumadin (a blood thinner) with an intervention to remind R15 to use extra caution when shaving. The care plan included R15 had a self care deficit and required assistance with ADLs due to weakness, impaired mobility and having multiple disease processes and had an intervention of needing assistance with all ALDs. On 4/7/25 at 2:52 p.m., R15 was observed to have fingernails that extended past the tips of his fingers on both hands. Fingernails on his dominant left hand were irregular. During interview on 2:52 p.m., R15 stated he does not like his fingernails being as long as they are and that they sometimes get caught on his sheets when he is in bed. R15 stated he preferred to be clean shaven, but is unable to shave at this time due to not having a razor he can use. During observation and interview on 4/8/25 at 11:07 a.m., R15's fingernails remained long and irregular and face unshaven. Facial hair was approximately 1/2 to 1 inch in length. R15 stated he typically would shave his head in addition to his face. R15 stated he spoke with someone at the facility 2 to 3 weeks ago and they said they would get him an electric razor to use. He did not ever receive the electric razor. During interview on 4/8/25 at 11:14 a.m., nursing assistant (NA)-A stated grooming assistance should be completed every morning. A nurse should be updated if a resident refused. During interview on 4/8/25 at 11:35 a.m., registered nurse (RN)-A stated nail care should be completed on bath days or as needed and diabetic residents needed to have nail care completed by a nurse. During interview on 4/8/25 at 4:42 p.m., nurse manager (NM)-D stated fingernail care should have been completed on a resident's bath day but could have been completed another time if the resident refused on bath day. NM-D stated assistance with shaving was available and an electric razor was available if the resident did not have access to one. NM-D confirmed R15 did have long nails that extended about 0.3 centimeters (cm) past his fingertip. NM-D confirmed there was occasionally dark matter visible under the fingernails and the staff should have been assisting R15 with cleaning his nails daily and after meals. NM-D confirmed R15 was on blood thinners and recently had high lab values which put him at a greater risk for bleeding. NM-D stated R15 was at increased risk for bleeding and infection due to his longer fingernails. During interview on 4/9/25 at 2:31 p.m., the director of nursing (DON) stated nail care should have been completed on bath day. A resident should have been reapproached if they refused and a progress note should have been completed. The DON confirmed she was informed R15's fingernails were long and in need of nail care. The DON state routine nail care was important to prevent the nails from getting long and possibly getting caught on something, torn or infected. Facility policy titled Activities of Daily Living dated 10/7/24, included ADLs included bathing, grooming and dressing. The facility would provide necessary services for residents who were unable to complete these tasks. X

Based on interview and document review, the facility failed to follow current physician orders and parameters for 2 of 5 residents (R28, R61) reviewed for medications. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], included R28 had moderate cognitive impairment. R28 had diagnoses of gastroparesis (a disease of the digestive system), malnutrition, fecal impaction (a blockage of stool in the intestine). R28's last signed physician orders dated 3/4/25, included an order for prochiorperazine maleate (a medication to treat nausea and vomiting) 10 mg by mouth every 5 hours as needed for nausea and vomiting, polyethylene glycol (a medication to treat constipation) 17 grams by mouth one time a day, and metoprolol tartrate 25 mg by mouth twice a day with instructions to hold the medication if systolic blood pressure was less than 100. R28's medication administration record (MAR) for April included record of medication being given different than the most recent provider orders. Administration included prochiorperazine maleate 10 mg by mouth every 8 hours for gastroparesis, polyethylene glycol (a medication to treat constipation) 17 grams by mouth two times a day, and metoprolol tartrate 25 mg by mouth twice a day without instructions to hold the medication. R28's hospital discharge orders with admitted [DATE], included order changes for polyethylene glycol 17 grams two times a day, prochlorpherazine 10 mg every 8 hours for gastroparesis, and metoprolol tartrate 25 mg twice a day without instructions to hold the medication. R28's MAR for February, March and April reviewed and failed to include documentation of blood pressure readings. During interview on 4/10/25 at 9:56 a.m., nurse manager (NM)-C confirmed the last signed physician orders do not match the MAR and what was currently being given. NM-C stated the facility takes all written orders, which include hospital discharge orders and process them as current orders. NM-C stated clarification would be requested from the hospital or nurse practitioner if there were questions or discrepancies. NM-C stated it was not practice to compare the most recent signed orders from the regulatory visits with the current MAR. The facility would review the plan section to look for new orders. R61's significant change MDS dated [DATE], included R61 was cognitively intact. R61's diagnoses included neuromyelitis optica (a disorder of the nervous system which can lead to weakness) and diabetes. R61's last signed physician orders dated 2/3/25, included an order for tacrolimus (a medication to prevent rejection of an organ after transplant) 1.5 mg by mouth two times a day and 2 mg at bedtime for kidney transplant, hydralazine (a medication to treat high blood pressure) 100 mg three times a day with instructions to hold for mean arterial pressure (MAP) <65, and carvedilol 12.5 mg by mouth twice a day with instruction to hold if MAP was <65. R61's MAR for April included record of medication being given different than the most recent provider orders. Administration record included tacrolimus 2.5 mg twice a day. Hydralazine was administered 100 mg three times a day with instructions to hold for MAP <65, however blood pressure was recorded instead of MAP. Carvedilol was administered 12.5 mg by mouth twice a day with instruction to hold if MAP is <65, however no vitals (blood pressures) were recorded. R61's hospital discharge orders with encounter date 11/21/24, included an order change for tacrolimus 2.5 mg twice a day. R61's MAR for February, March and April reviewed and failed to include documentation of MAP and pulse prior to administration of medication. During interview on 4/9/25 at 10:01 a.m., licensed practical nurse (LPN)-A stated parameters and instructions for giving mediation was listed on the MAR. After reading R61's orders for carvedilol and hydralazine with parameters, LPN-A stated she would check the pulse if the instructions stated to hold if <65 and would not give the medication if the pulse was below 65. During interview on 4/9/25 at 10:25 a.m., nurse manager (NM)-C stated she had never seen MAP as a parameter in a nursing home before and she was unsure if the staff would know how to calculate MAP. NM-C stated an order with instructions to check MAP should have been followed up on because it is not something that should have been used in a nursing home. During interview on 4/9/25 at 10:23 a.m., registered nurse (RN)-B stated she would check a heart rate for an order that instructed to check MAP and hold if <65 and not give the medication if it was below 65. During interview on 4/10/25 at 11:18 a.m., medical director (MD) stated a typical parameter for carvedilol and hydralazine would be to measure the heart rate and blood pressure. MD stated the facility did not calculate MAP. He stated a resident could be at increased risk for falls if a blood pressure medication was given outside of parameters. During interview on 4/10/25 at 12:33 p.m., CP confirmed she reviewed ordered parameters to ensure they are standard parameters during her monthly med reviews. CP acknowledged she failed to identify the discrepancies during the monthly reviews. CP stated blood pressure and heart rate are often monitored when a resident is on carvedilol. During interview on 4/9/25 at 2:41 p.m., director of nursing (DON) confirmed the last signed physician orders for R21 did not match what was being given by the facility. DON confirmed R61 tacrolimus order was different on the last signed physician orders and what was being given by the facility. DON confirmed medication parameters should have always been followed and if there was a question, a provider should have been contacted for clarification. DON confirmed checking and documenting a blood pressure would not be the same as checking and documenting a MAP. The DON confirmed the facility was not following their policy and procedure for reviewing signed physician orders to recognize discrepancies. Facility policy for medication orders dated 10/14/24, included to enter new orders onto the MAR. The nurse should verify new orders with the current attending physician before the medication is administered if it was unclear.

Based on observation, interview and document review, the facility failed to provide range of motion (ROM) exercises for 1 of 1 residents (R61) reviewed for mobility. Findings include: R61's significant change Minimum Data Set (MDS) dated [DATE], included diagnoses of neuromyelitis optica (inflammation of the nerves of the eye and spinal cord which may cause vision loss and muscle weakness), diabetes, encephalopathy (a disorder of the brain which may cause confusion, memory loss and personality changes). R61's MDS included she was dependent for dressing, eating and oral hygiene. R61's undated care plan, included R61 required assistance with activities of daily living (ADLs) due to impaired or decreased mobility, weakness and multiple disease processes. Interventions included to assist with positioning and mobility as needed. R61's care plan failed to include specific ROM exercises. R61's care conference note dated 3/19/25, included R61's family requested therapy for ROM due to stiffness. R61's medical record indicated she was discharged from physical therapy on 11/18/24 and occupational therapy on 12/19/24. No other referral order was provided. During interview on 4/8/25 at 11:14 a.m., nursing assistant (NA)-A stated ROM instructions would be included on a resident's care sheet if they were ordered. During interview on 4/9/25 at 7:53 a.m., NA-B stated ROM exercises would be documented in a resident's chart if they were completed. During interview on 4/9/25 at 7:56 a.m., nurse manager (NM)-C stated a therapy referral would usually be made if a resident had a change in condition, a decrease in ADL ability, or after a hospitalization . NM-C stated a referral for therapy would be made if a family requested it. NM-C confirmed there had not been a referral for therapy since the last care conference. NM-C confirmed the family did request a referral for therapy for ROM exercises. NM-C stated it would typically be nursing who followed up on a requested from family for therapy. During interview on 4/9/25 at 2:34 p.m., director of nursing (DON) stated a referral for therapy should have been completed after the family requested an evaluation. The DON stated the referral should have been made within 2-3 business days of the care conference and family request. The DON confirmed ROM exercises should have been on the care plan or Kardex. The DON stated ROM was important to prevent pain, pressure ulcers and contractures. Facility policy titled Prevention of Decline in Range of Motion dated 10/14/24, included a licensed nurse will assess a resident's range of motion on admission, quarterly and upon significant change. Residents would be referred to therapy for a focused range of motion as appropriate.

Based on interview and document review, the consulting pharmacist (CP) failed to identify and report irregularities related to resident parameters for 2 of 2 residents (R28, R61) reviewed for physician ordered parameters. Findings Include: R28's quarterly Minimum Data Set (MDS) dated [DATE], included R28 had moderate cognitive impairment. R28 had diagnoses of gastroparesis (a disease of the digestive system), malnutrition, fecal impaction (a blockage of stool in the intestine). R28's last signed physician orders dated 3/4/25, included an order for metoprolol tartrate 25 milligrams (mg) by mouth twice a day with instructions to hold the medication if systolic blood pressure was less than 100. R28's medication administration record (MAR) for April included record of medication being given without documentation of blood pressure having been checked prior to administration. The order on the MAR included metoprolol tartrate 25 mg by mouth twice a day without instructions to hold the medication. R28's previous six months of pharmacy reviews failed to identify blood pressure parameter was not being followed. R61's significant change MDS dated [DATE], included R61 was cognitively intact. R61's diagnoses included neuromyelitis optica (a disorder of the nervous system which can lead to weakness) and diabetes. R61's last signed physician orders dated 2/3/25, included an order hydralazine (a medication to treat high blood pressure) 100 mg three times a day with instructions to hold for mean arterial pressure (MAP) < 65, and carvedilol 12.5 mg by mouth twice a day with instruction to hold if MAP was < 65. R61's MAR for April included record of medication being given without documentation of provider ordered parameters. Administration record included hydralazine 100 mg three times a day with instructions to hold for MAP < 65, however blood pressure was recorded instead of MAP. Carvedilol was administered 12.5 mg by mouth twice a day with instruction to hold if MAP is < 65, however no vitals (blood pressures) were recorded. R61's previous six months of pharmacy reviews failed to identify MAP parameter was not being followed nor did they recommend reviewing the parameter for a standard nursing home parameter. During interview on 4/9/25 at 10:25 a.m., nurse manager (NM)-C stated she had never seen MAP as a parameter in a nursing home before and she was unsure if the staff would know how to calculate MAP. NM-C stated an order with instructions to check MAP should have been followed up on because it is not something that should have been used as a parameter in a nursing home. During interview on 4/9/25 at 2:41 p.m., director of nursing (DON) confirmed medication parameters should have always been followed and if there was a question, a provider should have been contacted for clarification. DON confirmed checking and documenting a blood pressure would not be the same as checking and documenting a MAP. During interview on 4/10/25 at 11:18 a.m., medical director (MD) stated a typical parameter for carvedilol and hydralazine would be heart rate and blood pressure. MD stated the facility would not typically calculate MAP. He stated a resident could be at increased risk for falls if a blood pressure medication was given outside of parameters. During interview on 4/10/25 at 12:33 p.m., CP confirmed she reviewed ordered parameters to ensure they are standard parameters during her monthly medication reviews. CP acknowledged she failed to identify the discrepancy in parameters order and what was being documented by the facility. CP stated MAP was not a standard parameter for a nursing home and a more common parameter would be to check blood pressure and heart rate for a resident on carvedilol prior to administration.

Based on interview and document review the facility failed to thoroughly investigate an allegation of sexual abuse for 2 of 2 residents (R1 and R2) when they failed recognize the need to assess R1 for the ability to consent prior to the incident. Findings include: Review of the report to the State Agency (SA) indicated on 2/05/25, at 5:55 p.m. R1 and R2 were being sexually intimate in R1's room. Staff attempted to separate the two and have R2 go to his room. The report indicated the residents were closely monitored throughout the night to prevent further incident, investigation was initiated, and physician was updated. Review of the 5-day investigation report to the SA indicated on 2/12/25, R1 had BIM's of 4 which was severely cognitively impaired and R2 of 10 mild cognitive impairment both residents have not been deemed needing legal guardian and both make their own decisions with family input. In addition the investigation indicated both residents were seen by Associated Clinic of Psychology (ACP) who noted they were alert and oriented to family and friends, getting to know more peers an staff, orientated to place and time, expresses a preference for his/her peer, can avoid exploitation by being able to say no and he/she has a right to make a decision about physical/sexual contact. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, arthritis, severe cognitive impairment, and no behaviors. The MDS further indicted R1 used a walker or wheelchair, supervision with dressing and transfers and was independent with mobility. R1's Care Plan dated 2/07/25, indicated R1 is a vulnerable adult and staff to assist in removing from dangerous/abusive situations, and assist in reporting of abuse/neglect as appropriate and investigate/report all signs and symptoms or accusations of abuse/neglect as appropriate. R1's Care Plan also indicated the resident has impaired cognitive function/dementia or impaired thought process related to dementia, and directed staff to ask yes/no questions, communicate with resident/family/care givers regarding residents capabilities and needs and keep the residents routine consistent and try to provide consistent care givers consistent in order to decrease confusion. Provide just one thought, idea, question, or command at a time, use task segmentation to support short term memory deficits and break tasks into one step at a time. The Care Plan indicated she had a friendship/relationship with a resident where they eat meals together, watch TV and occasionally can engage in sexual intimacy both residents' consent to this. The Care Plan directed staff to check in with residents quarterly and annually on relationship status, provide resident privacy when resident chooses alone time, residents son is aware and supports relationship, update son if issues arise/changes, update physician with any changes. R1's 2/11/25 psychiatry assessment identified R1's behavior prior to having sex was not indicative of her engaging in sexual intercourse .When considering [R1's] knowledge, voluntariness and historical and current factors, she lacks the capacity to consent to sexual expression. Staff and involved parties may need to make a decision for involved parties based on benefit vs. risk factors. Review of R1's medical record identified it lacked evidence to show R1 was appropriately assessed prior to the incident for her capacity to consent. R2's significant change MDS dated [DATE], indicated R2 had anxiety, depression and had moderately impaired cognition. The MDS indicated R2 used a wheelchair and walker, and was independent with mobility, dressing, and transfers. R2's Care Plan dated 2/07/25, indicated R2 had impaired cognition related to mild cognitive impairment of uncertain or unknown etiology/acute on chronic encephalopathy (brain disease that alters brain function or structure), and benign neoplasm of cerebral meninges (non-cancerous a tumor that grows from the membranes that surround the brain and spinal cord). R2's Care Plan indicated he had a friendship/relationship with a resident where they eat meals together, watch TV and occasionally can engage in sexual intimacy both residents' consent to this. The Care Plan directed staff to check in with residents quarterly and annually on relationship status, provide resident privacy when resident chooses alone time, residents power of attorney (POA) is aware and supports relationship, update POA if issues arise/changes, update physician with any changes. During interview on 2/11/25, at 3:20 p.m. R2 stated he had known [R1] for three to four months and they are not boyfriend and girlfriend. They had sex last week for the first time. R2 stated he blames himself and felt he should not have had sex. R2 said he told R1 when he was younger, he used his wife to rub his back and while we were lying in bed together. R1 started to rub his chest and then down his legs and one thing led to another and then staff walked in. R2 stated he does lay in bed and think about doing it again but has not and asked. If he did it again if he would have to inform the facility nurse manager. R2 stated he thought he did not have inform anyone as long as it is consensual for both of them. During interview on 2/11/25, at 3:53 p.m. R1 stated she is friends with R2, and they make each other laugh, R1 stated R2 is hard of hearing so you must repeat yourself when talking to him. R1 stated she cannot remember when she moved to the facility and time has passed. Her parents took care of her and then her brother. She was married and had a son cannot remember his age and stated she is a bad mom for that. R1 stated she does not have a boyfriend and at this point does not want one. R1 has not had sex or kissed or anyone here and is too old for that. R1 stated she had not been naked with R2 and said, I can't even imagine that oh lord!. During interview on 2/11/25, at 4:15 p.m. administrator stated she received the nurse managers interview on what occurred on 2/05/25, received consent from R1's son, and R2's POA and needed to make sure everyone was safe, had a care conference with the interdisciplinary team. And it was decided by the team R1 and R2 would be able to have relationship and for staff to provide them privacy. During interview 2/12/25, at 10:25 a.m. director of social services (DSS) stated she interviewed R1 the morning following the incident on 2/5/25, and R1 informed her she didn't understand why the staff made such a fuss and told her she was not raped and that she consented. She thanked the DSS for talking with her and wished the staff would have talked with her last evening before things gotten out of control. The DSS stated R1's family member (FM)-A came into the facility the next day after the incident and felt R1 showed no signs of distress, and he felt he did not need to have a conversation with R1 about the incident. The DSS spoke to R2, and his interview was the same. He said they (R1 and R2) were laughing, and it just happened. R2 told me no one was coerced. A follow up interview at 1:25 p.m. with the DSS stated she was not part of the decision of R1's capacity to consent. During interview on 2/12/25, at 11:47 a.m. nurse practitioner (NP)-A stated she was informed by the facilities administrator about the incident between R1 and R2. NP-A stated the administrator informed her R2 stated they had sex. R1 could not recall the incident. NP-A stated she felt R1 with a Brief Interview for Mental Status (BIMS) score of 4 indicated she would not have the capacity to consent for a sexual relationship. NP-A felt additional testing should be completed by therapy or social services to evaluate R1's capacity to consent. NP-A planned to meet with the facility. During interview on 2/12/25, at 12:43 p.m. family member (FM)-A stated he was informed of the incident that occurred between R1 and R2 and knows she had not remembered what occurred and would not be surprised if she said she would never do that. FM-A stated he visits every day and noticed R1 repeats herself three to four times over and over during conversations. FM-A felt she does not have the capacity to be on her own, and even forgets when she eats. FM-A stated he does not blame the facility for the incident and R2 is a nice person. If the situation were to happen repeatedly then I would have concerns. During interview on 2/12/25, at 12:57 p.m. licensed independent clinical social worker (LICSW)-A stated she seen R1 and R2 and found both did not have the capacity to consent due to their BIMS and the St. Louis University Mental Status (SLUMS) test (comprehensive mental capacity test) for identifying cognition indicated both R1 and R2 had Dementia. Although the LICSW-A stated she did feel both did show mutual preferences to one another with no mental or behavioral changes after their sexual contact, she felt the facility should have an interdisciplinary meeting with a psychology approach. She had spoken to the facilities DSS who informed her they had already had a meeting and made a decision they could have a relationship. LICSW-A stated she did send an email to the administrator on 2/11/25, with her suggestion for a meeting after her visit with both R1 and R2. During interview on 2/12/25, at 1:31 p.m. administrator stated the decision was made for R1 to have the capacity to consent to have intimate a relationship with R2 was decided from R1's responses from her interview when she stated she consented to sex, and that she was not raped. In addition, the administrator stated R1's FM-A also had no concerns and felt R1 showed no signs of distress. FM-A knew R2 and was okay with what was going on and both residents are their own legal representatives. There was no legal guardianship. During observation on 2/12/25, at 1:45 p.m. R1 and R2 were observed in the dining room sitting next to each other talking and laughing. During interview on 2/12/25, at 2:00 p.m. registered nurse (RN)-A stated R1 gets confused and cannot remember what she ate an hour after she eats in addition to if she knew which meal she ate, breakfast or lunch. Staff constantly remind her she had already had her meal. RN-A further stated it does not surprise me that R1 does not remember having an intimate relationship with R2. During interview on 2/12/25 at 2:07 p.m. licensed practical nurse (LPN)-A identified R1 was confused and sometimes will ask for meals when she just ate. R1 can appear as if she is okay, but she is not. LPN-A stated he does not think R1 remembers anything about the incident that occurred with R2 and does not believe she had the ability to consent. During interview on 2/12/25, at 2:33 p.m. LPN-B stated she was working the evening of 2/05/25, when the incident occurred with R1 and R2. Nursing assistant (NA)-A was looking for R2 twice, and then went into R1's room and found them both in bed together. LPN-B stated they had a blanket covering each other. R1 asked NA-A to please excuse them per NA-A's report. According to NA-A's report, after she walked in and informed her R2 was lying in bed with the covers on himself, R2 got dressed and left R1's room. During interview on 2/12/25, at 3:20 p.m., the administrator stated she felt the consent between R1 and R2 is a very delicate matter. Where do you draw the line where they can make the decision or not. R1 says she gave consent and can make decisions about daily living .it makes it hard. Protocol for capacity to consent is to have a risk call with-in the company, review each client individually, and connect with family, residents and their physician. The administrator stated they do not have a specific policy on capacity to consent for residents at the facility. No policies related to investigating abuse allegations was received.

Based on observation, interview and document review, the facility failed to ensure 1 of 2 resident (R1) was comprehensively assessed for their capacity to consent prior to engaging in sexual activity with R2. Findings include: Review of the report to the State Agency (SA) indicated on 2/05/25, at 5:55 p.m. R1 and R2 were being sexually intimate in R1's room. Staff attempted to separate the two and have R2 go to his room. The report indicated the residents were closely monitored throughout the night to prevent further incident, investigation was initiated, and physician was updated. Review of the 5-day investigation report to the SA indicated on 2/12/25, R1 had BIMMS of 4 which was severely cognitively impaired and R2 of 10 mild cognitive impairment both residents have not been deemed needing legal guardian and both make their own decisions with family input. In addition the investigation indicated both residents were seen by Associated Clinic of Psychology (ACP) who noted they were alert and oriented to family and friends, getting to know more peers an staff, orientated to place and time, expresses a preference for his/her peer, can avoid exploitation by being able to say no and he/she has a right to make a decision about physical/sexual contact. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, arthritis, severe cognitive impairment, and no behaviors. The MDS further indicted R1 used a walker or wheelchair, supervision with dressing and transfers and was independent with mobility. R1's Care Plan dated 2/07/25, indicated R1 is a vulnerable adult and staff to assist in removing from dangerous/abusive situations, and assist in reporting of abuse/neglect as appropriate and investigate/report all signs and symptoms or accusations of abuse/neglect as appropriate. R1's Care Plan also indicated the resident has impaired cognitive function/dementia or impaired thought process related to dementia, and directed staff to ask yes/no questions, communicate with resident/family/care givers regarding residents capabilities and needs and keep the residents routine consistent and try to provide consistent care givers consistent in order to decrease confusion. Provide just one thought, idea, question, or command at a time, use task segmentation to support short term memory deficits and break tasks into one step at a time. The Care Plan indicated she had a friendship/relationship with a resident where they eat meals together, watch TV and occasionally can engage in sexual intimacy both residents' consent to this. The Care Plan directed staff to check in with residents quarterly and annually on relationship status, provide resident privacy when resident chooses alone time, residents son is aware and supports relationship, update son if issues arise/changes, update physician with any changes. R1's 2/11/25 psychiatry assessment identified R1's behavior prior to having sex was not indicative of her engaging in sexual intercourse .When considering [R1's] knowledge, voluntariness and historical and current factors, she lacks the capacity to consent to sexual expression. Staff and involved parties may need to make a decision for involved parties based on benefit vs. risk factors. Review of R1's medical record identified it lacked evidence to show R1 was appropriately assessed prior to the incident for her capacity to consent. During interview on 2/11/25, at 3:20 p.m. R2 stated he had known [R1] for three to four months and they are not boyfriend and girlfriend. They had sex last week for the first time. R2 stated he blames himself and felt he should not have had sex. R2 said he told R1 when he was younger, he used his wife to rub his back and while we were lying in bed together. R1 started to rub his chest and then down his legs and one thing led to another and then staff walked in. R2 stated he does lay in bed and think about doing it again but has not and asked. If he did it again if he would have to inform the facility nurse manager. R2 stated he thought he did not have inform anyone as long as it is consensual for both of them. During interview on 2/11/25, at 3:53 p.m. R1 stated she is friends with R2, and they make each other laugh, R1 stated R2 is hard of hearing so you must repeat yourself when talking to him. R1 stated she cannot remember when she moved to the facility and time has passed. Her parents took care of her and then her brother. She was married and had a son cannot remember his age and stated she is a bad mom for that. R1 stated she does not have a boyfriend and at this point does not want one. R1 has not had sex or kissed or anyone here and is too old for that. R1 stated she had not been naked with R2 and said, I can't even imagine that oh lord!. During interview on 2/11/25, at 4:15 p.m. administrator stated she received the nurse managers interview on what occurred on 2/05/25, received consent from R1's son, and R2's POA and needed to make sure everyone was safe, had a care conference with the interdisciplinary team. And it was decided by the team R1 and R2 would be able to have relationship and for staff to provide them privacy. During interview 2/12/25, at 10:25 a.m. director of social services (DSS) stated she interviewed R1 the morning following the incident on 2/5/25, and R1 informed her she didn't understand why the staff made such a fuss, and told her she was not raped and that she consented. She thanked the DSS for talking with her and wished the staff would have talked with her last evening before things gotten out of control. The DSS stated R1's family member (FM)-A came into the facility the next day after the incident and felt R1 showed no signs of distress and he felt he did not need to have a conversation with R1 about the incident. The DSS spoke to R2, and his interview was the same. He said they (R1 and R2) were laughing, and it just happened. R2 told me no one was coerced. A follow up interview at 1:25 p.m. with the DSS stated she was not part of the decision of R1's capacity to consent. During interview on 2/12/25, at 11:47 a.m. nurse practitioner (NP)-A stated she was informed by the facilities administrator about the incident between R1 and R2. NP-A stated the administrator informed her R2 stated they had sex. R1 could not recall the incident. NP-A stated she felt R1 with a Brief Interview for Mental Status (BIMS) score of 4 indicated she would not have the capacity to consent for a sexual relationship. NP-A felt additional testing should be completed by therapy or social services to evaluate R1's capacity to consent. NP-A planned to meet with the facility. During interview on 2/12/25, at 12:43 p.m. family member (FM)-A stated he was informed of the incident that occurred between R1 and R2 and knows she had not remembered what occurred and would not be surprised if she said she would never do that. FM-A stated he visits every day and noticed R1 repeats herself three to four times over and over during conversations. FM-A felt she does not have the capacity to be on her own, and even forgets when she eats. FM-A stated he does not blame the facility for the incident and R2 is a nice person. If the situation were to happen repeatedly then I would have concerns. During interview on 2/12/25, at 12:57 p.m. licensed independent clinical social worker (LICSW)-A stated she seen R1 and R2 and found both of them did not have the capacity to consent due to their brief interview for mental status( BIMS) and there St. Louis University Mental Status (SLUMS) test (comprehensive mental capacity test) for identifying cognition indicated both R1 and R2 had Dementia. Although the LICSW-A stated she did feel both of them did show mutual preferences to one another with no mental or behavioral changes after their sexual contact, she felt the facility should have an interdisciplinary meeting with a psychology approach. She had spoken to the facilities DSS who informed her they had already had a meeting and made a decision they could have a relationship. LICSW-A stated she did send an email to the administrator on 2/11/25, with her suggestion for a meeting after her visit with both R1 and R2. During interview on 2/12/25, at 1:31 p.m. administrator stated the decision was made for R1 to have the capacity to consent to have intimate a relationship with R2 was decided from R1's responses from her interview when she stated she consented to sex, and that she was not raped. In addition, the administrator stated R1's FM-A also had no concerns and felt R1 showed no signs of distress. FM-A knew R2 and was okay with what was going on and both residents are their own legal representatives. There was no legal guardianship. During observation on 2/12/25, at 1:45 p.m. R1 and R2 were observed in the dinning room sitting next to each other talking and laughing. During interview on 2/12/25, at 2:00 p.m. registered nurse (RN)-A stated R1 gets confused and cannot remember what she ate an hour after she eats in addition to if she knew which meal she ate, breakfast or lunch. Staff constantly remind her she had already had her meal. RN-A further stated it does not surprise me that R1 does not remember having an intimate relationship with R2. During interview on 2/12/25 at 2:07 p.m. licensed practical nurse (LPN)-A identified R1 was confused and sometimes will ask for meals when she just ate. R1 can appear as if she is okay, but she is not. LPN-A stated he does not think R1 remembers anything about the incident that occurred with R2 and does not believe she has the ability to consent. During interview on 2/12/25, at 2:33 p.m. LPN-B stated she was working the evening of 2/05/25, when the incident occurred with R1 and R2. Nursing assistant (NA)-A was looking for R2 twice, and then went into R1's room and found them both in bed together. LPN-B stated they had a blanket covering each other. R1 asked NA-A to please excuse them per NA-A's report. According to NA-A's report, after she walked in and informed her R2 was lying in bed with the covers on himself, R2 got dressed and left R1's room. During interview on 2/12/25, at 3:20 p.m., the administrator stated she felt the consent between R1 and R2 is a very delicate matter. Where do you draw the line where they can make the decision or not. R1 says she gave consent and can make decisions about daily living .it makes it hard. Protocol for capacity to consent is to have a risk call with-in the company, review each client individually, and connect with family, residents and their physician. The administrator stated they do not have a specific policy on capacity to consent for residents at the facility. A policy was not received on dementia care.

Based on interview and document review, the facility failed to ensure long term residents received routine physician visits (every 60 days) for 1 of 3 residents (R3) reviewed for routine physician care. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included cerebrovascular accident (stroke), diabetes, anemia, malnutrition, and epilepsy. R3's clinical record indicated R3's physician completed routine physician visits on 2/5/24 and 5/22/24, greater than 60 days between visits. However, R3's clinical record lacked evidence a physician visit had been provided between 2/5/24 and 5/22/24. On 10/4/24 at 1:28 p.m., the administrator provided an email which contained the entire chart from the provider for R3. The provided chart indicated physician visits had been completed on 2/5/24 and 5/22/24, with no evidence of a physician visit within 60 days of 2/5/24. On 10/7/24 at 12:19 p.m., director of nursing (DON) and infection preventionist (IP) stated the medical records department only found physician visits for 2/5/24 and 5/22/24. The DON and IP confirmed R3's clinical record lacked evidence routine physician visits had been completed every 60 days between 2/5/24 and 5/22/24. The DON stated routine physician visits were important to ensure residents were taken care of properly. The facility's Physician Visitation and Monitoring and Notification policy, reviewed 2/5/24, indicated the attending physician, at a minimum, would visit residents every 30 days for the first 90 days after admission and every 60 days thereafter. A physician visit would be considered timely if performed no later than 10 days after the required visit date. At no time may the visitation period extend beyond 60 days.

Based on interview and document review, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 3 of 3 residents (R3, R4 and R5) reviewed for hospitalization . This had the potential to affect all residents transferred to hospital. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included cerebrovascular accident (stroke), diabetes, anemia, malnutrition, and epilepsy. R3's progress notes indicated R3 was hospitalized from 4/28/24 to 5/17/24. R3's record lacked evidence the Ombudsman for LTC was notified of R3's transfer to the hospital. R4's discharge Minimum Data Set (MDS) dated [DATE]/24, indicated diagnoses which included peripheral vascular disease or peripheral arterial disease (impaired circulation to the peripheral (distant arteries) of the hands and feet), methicillin resistant staphylococcus aureus (MRSA) (an antibiotic resistant organism) infection, pressure ulcer of unspecified joint, and local infection of the skin and subcutaneous tissue (the tissue which lies beneath the skin and above the muscle). R4's progress notes indicated R4 was hospitalized from 3/28/24 to 4/2/24. R4's record lacked evidence the Ombudsman for LTC was notified of R4's transfer to the hospital. Additionally, the document faxed to the Ombudsman for LTC titled Admit/Discharge To/From Report for March 2024, faxed by the social services director (SSD)-A lacked indication of the transfer to the hospital. R5's discharge assessment Minimum Data Set (MDS) dated [DATE], indicated diagnoses which included debility related to cardiorespiratory conditions, atrial fibrillation or other dysrhythmia, cirrhosis, diabetes mellitus, aphasia, malnutrition or at risk for malnutrition, anxiety disorder, respiratory failure, cataracts/glaucoma, or macular degeneration, and tricuspid valve insufficiency. R5's progress notes indicated R5 was hospitalized [DATE]. The progress notes lacked indication the Ombudsman for LTC was notified of hospitalization . Additionally, the document faxed to the Ombudsman for LTC, titled Admit/Discharge To/From Report for April 2024, faxed by the social services director (SSD)-A lacked this information as well. R5's progress notes indicated R5 was discharged from the facility on 5/8/24. Although the record identified R5 was discharged from the facility on that date, the progress notes lacked indication the Ombudsman for LTC was notified of the discharge. Additionally, the document faxed to the Ombudsman for LTC, titled Admit/Discharge To/From Report for May 2024, faxed by the social services director (SSD)-A also lacked indication of facility discharge. During interview on 10/3/24 at 11:33 a.m., the social services director (SSD-A) indicated although she was aware of the need to the notify the Ombudsman for LTC of discharges from the facility, she was unaware of the need to notify the Ombudsman of any transfers to the hospital. The facility policy, Transfer and discharged , last reviewed on 10/24/23, identified the Ombudsman would be notified of discharges from the facility. The policy lacked indication for notification of the Ombudsman of resident transfers to the hospital. 44645

Based on interview and document review, the facility failed to provide a written notice of a bed hold upon transfer for hospitalization for 3 of 4 residents (R3, R4, and R5 ) reviewed for hospitalization . Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included cerebrovascular accident (stroke), diabetes, anemia, malnutrition, and epilepsy. R3's progress note dated 4/28/24 at 6:27 p.m., indicated licensed practical nurse (LPN)-A found R3's gastrostomy tube (G-tube) had been pulled out, the on-call nurse practitioner (NP) was contacted and ordered R3 to be transported to emergency department (ED) for G-tube replacement. LPN-A notified family member (FM)-B of the situation via phone. R3's progress note dated 4/28/24 at 9:42 p.m., indicated R3 was admitted to Hennepin County Medical Center hospital (HCMC) due to a fever and the need for further testing. R3's progress note dated 5/17/24 at 9:46 p.m., indicated R3 returned to the facility from HCMC on 5/17/24 at 5:28 p.m. Review of R3's records lacked evidence of a written notice of bed hold for R3's 4/28/24 to 5/17/24 hospitalization . R4's discharge Minimum Data Set (MDS) dated [DATE]/24, indicated diagnoses which included peripheral vascular disease or peripheral arterial disease (impaired circulation to the peripheral (distant arteries) of the hands and feet), methicillin resistant staphylococcus aureus (MRSA) (an antibiotic resistant organism) infection , pressure ulcer of unspecified joint, and local infection of the skin and subcutaneous tissue (the tissue which lies beneath the skin and above the muscle). R4's progress notes indicated R4 was hospitalized from 3/28/24 to 4/2/24. R4's record lacked evidence a written notice of bed hold for R4's 3/28/24 to 4/2/24 hospitalization s. R5's discharge assessment Minimum Data Set (MDS) dated [DATE], indicated diagnoses which included debility related to cardiorespiratory conditions, atrial fibrillation or other dysrhythmia, cirrhosis, diabetes mellitus, aphasia, malnutrition or at risk for malnutrition, anxiety disorder, respiratory failure, cataracts/glaucoma, or macular degeneration, and tricuspid valve insufficiency. R5's progress notes indicated R5 was hospitalized [DATE]. The progress notes lacked documentation of notification of the bed hold policy of the facility to either the resident, or the responsible party. On 10/3/24, at 4:25 p.m., the executive director (ED) stated she had reviewed the medical record and verified there were no documents to reflect a bedhold notifications were provided. On 10/3/24, at 4:36 p.m., the social services director (SSD)-A stated bedhold notifications were to be given when someone goes to the hospital. SSD-A went on to state that once the notification was provided, they should be uploaded to the electronic medical record. On 10/7/24, at 9:34 a.m. the director of nursing (DON) stated bedhold notifications were given to either the resident of the responsible party at the time of transfer/hospitalization . The bedhold notification was part of the medical record and was uploaded to the EMR. Further, the director of nursing (DON) and infection preventionist (IP) confirmed R3's record lacked evidence a written notice of bed hold had been provided for the 4/28/24 to 5/17/24 hospitalization . The facility policy, Transfer and Discharge, last reviewed 10/24/23, identified the notice of bed hold policy and readmission policy was to be provided before the facility transfers a resident to a hospital, or go on therapeutic leave. The policy identified if the transfer was an emergency, this notification, and subsequent documentation was to be provided within 24 hours of the transfer. 44645

Based on interview and document review, the facility failed to ensure 2 of 4 residents (R3, R9) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3's date of birth was 2/10/1948 ([AGE] years old), and diagnoses included cerebrovascular accident (stroke), diabetes, anemia, malnutrition, and epilepsy. R3's immunization report dated 10/3/24, indicated R3 received PPSV23 on 1/16/2014. The record lacked evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence R3 was offered or received PCV20. R9's quarterly MDS dated [DATE], indicated R9's date of birth was 6/28/1951 ([AGE] years old), and diagnoses included acute and chronic respiratory failure and chronic kidney disease. R9's immunization report dated 10/3/24, indicated R9 received PCV13 on 8/15/2016 and PPSV23 on 2/12/2018. The record lacked evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence R9 was offered or received PCV20. On 10/7/24 at 12:19 p.m., director of nursing (DON) and infection preventionist (IP) confirmed R3's record lacked evidence R3 was offered, declined, and/or received PCV20. Additionally, DON and IP confirmed R9's record lacked evidence R9 was offered, declined, and/or received PCV20. The IP stated immunizations should have been reviewed during care conferences to determine if a resident was eligible and offered PCV20, and PCV20 was important to fight against pneumonia and/or lessen the effects of infection. The facility's Pneumococcal Vaccine (Series) policy, reviewed 10/16/2023, indicated the facility would provide immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.

Based on interview and document review, the facility failed to provide transportation to two scheduled [CONDITION(S)] appointments for 1 of 2 residents (R1) who required [CONDITION(S)] for [CONDITION(S)]. Facility failed to notify the physician and coordinate care with the [CONDITION(S)] clinic. In addition, the facility failed to adequately monitor/assess for signs and symptoms of fluid overload which resulted in admission to the ICU related to fluid overload resulting in an immediate jeopardy (IJ). The IJ began on 4/30/22, when the facility failed to transport R1 to a [CONDITION(S)] appointment resulting in a missed [CONDITION(S)] treatment. The facility failed to notify R1's physician coordinate care with R1's [CONDITION(S)] clinic and failed to monitor and assess for signs and symptoms of fluid overload, these failures resulted in R1 being sent to the emergency room (ER) for emergency treatment which resulted in admission to the intensive care unit (ICU) for an immediate [CONDITION(S)] treatment. The administrator and the director of nursing (DON) were notified of the IJ on 6/6/22, at 6:16 p.m. The IJ was removed on 6/7/22, at 2:29 p.m. However, non-compliance remained at the lower scope and severity of a 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) on 4/22/22, indicated she was cognitively intact. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's orders printed on 6/7/22, indicated she was to receive [CONDITION(S)] on Tuesday, Thursday, and Sunday at Davita at Hennepin County Medical Center (HCMC) in Minneapolis. R1's baseline care plan did not include a [CONDITION(S)] plan of care with goals and interventions. On 5/3/22, at 4:38 p.m. R1's hospital ICU admission paperwork indicated R1 was being admitted to the ICU on 5/3/22 due to chronic hypoxemic hypercapnic respiratory failure, hypervolemia, pulmonary [CONDITION(S)], and end stage renal disease ([CONDITION(S)]). It also indicates the respiratory failure was likely secondary to the hypervolemia from missing two [CONDITION(S)] sessions. On 4/25/22, at 11:21 a.m. dietician (D)-A's progress note indicated no weight had been taken for R1 since admission on 4/22/22. R1's weight log did not have documented weights from her admitted , 4/22/22, through 4/27/22. The first facility documented weight for R1 was on 4/28/22, at 184.2 pounds (lbs) which was the dry weight (weight after excess fluid is removed because of [CONDITION(S)]) obtained at Davita [CONDITION(S)]. On 4/30/22, at 2:23 p.m. licensed practical nurse (LPN)-A's progress note indicated R1 missed her [CONDITION(S)] appointment due to transportation issues. The transport service was contacted multiple times and informed LPN-A R1's ride was running approximately one hour late. R1 waited at the facility's front door for at least one more hour and transportation did not arrive. R1's record from between 4/30/22 to 5/3/22 was reviewed. The record lacked evidence of ongoing monitoring and assessment of fluid volume status. On 5/3/22, at 5:57 a.m. RN-A's progress note indicated R1 started having difficulty breathing. RN-A raised R1's head of the bed to promote better air exchange. R1 was encouraged by RN-A to use breathing techniques to reduce anxiety. R1 kept asking to either sit up in her wheelchair (w/c) for a few minutes and then back into bed interchangeably which had gone on throughout the night with little effect in helping relieve her symptoms. R1's anxiety rather increased causing panic and distress all night with a respiratory rate of 24 breathes per minute (standard respiratory rate for an adult is 12-20 breathes per minute at rest.) RN-A spent most of the night calming and encouraging R1 to reduce stress and anxiety level. R1's doctor was to be updated during his visit on the unit later in the day regarding increased anxiety. On 5/3/22, at 4:08 p.m. RN-B's progress note indicated R1's lung sounds were clear, shortness of breath (SOB) upon exertion, no noted cough, and on 3 liters of oxygen. R1 was on continuous oxygen. On 5/3/22, at 5:20 p.m. LPN-B's progress note indicated a rapid antigen COVID-19 test was performed and came back negative. The test was performed due to an increase in SOB. R1's transportation arrived to transfer R1 to [CONDITION(S)], but they were unable to accommodate her w/c and could not transfer her in time for her [CONDITION(S)]. R1's doctor sent her to the ER via non-urgent medical transport to receive her [CONDITION(S)]. On 5/3/22, at 8:46 p.m. RN-B's progress note indicated R1 was not able to go to her regular [CONDITION(S)] due to issue with transportation. R1 was taken by ambulance transport to the hospital for her [CONDITION(S)] treatment. RN-B received an update from the hospital, R1 was admitted to the ICU and had 3 kilograms (kg) of water removed. On 5/5/22, LPN-B's typed statement indicated R1 missed her [CONDITION(S)] treatment on 4/30/22. R1 was set up with a new transport company for future [CONDITION(S)] treatments. On 5/3/22, at 9:15 a.m. the transportation company arrived on time but did not have w/c transport capability. The driver left and did not come back. LPN-B contacted the company and LPN-B was told R1 was a no-show, LPN-B explained to the transport company that was incorrect and that the driver had arrived however could not accommodate w/c. The transport company stated they could have someone back out with a w/c accessible vehicle in 1-3 hours. LPN-B contacted Davita [CONDITION(S)] and informed them of the transportation situation, and they stated they could still do her [CONDITION(S)] treatment if R1 arrived by noon. LPN-B contacted transport at 11:45 a.m. and they stated they would not be able to provide w/c accessible transportation. (The statement indicated there was not communication with the [CONDITION(S)] company when R1's transportation did not arrive) R1's MD saw her the same day on 5/3/22, and gave orders for R1 to be sent to the ER because she could not miss her [CONDITION(S)]. Non-emergent transport came and took R1 to HCMC. R1 was admitted to the ICU. LPN-B stated she spoke to someone at Davita [CONDITION(S)] to see what they would recommend if the facility was unable to provide transport for R1 going forward and she advised R1 would need to be sent to the emergency room . R1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R2 R2's annual MDS on 5/20/22, indicated she was cognitively intact R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's orders printed on 6/7/22, indicated she was to receive [CONDITION(S)] on Tuesday, Thursday, and Saturday at Davita [CONDITION(S)] University R2's care plan did not address emergency protocols related to [CONDITION(S)] and did not identify R2's risk or plan of care for fluid overload. R2's weight record was reviewed between 2/17/22 to 6/5/22. Although the record included R2's [CONDITION(S)] run records that identified R2's dry weight R2's record indicated R2's weight had not been obtained by the facility between [CONDITION(S)] days. R2's record lacked evidence of monitoring and assessments for hypervolemia (fluid volume overload) including but not limited to weight monitoring, intake and output (if applicable), [CONDITION(S)] monitoring, and respiratory function. R2's weight log reviewed back to 2/17/22, only contained dry weights provided by Davita [CONDITION(S)], the facility was not obtaining weights. R2's care plan did not include monitoring R2 for fluid overload. During an interview on 6/6/22, at 10:33 a.m. R1's medical doctor (MD) who stated he was aware of transportation problems at the facility. MD stated the facility did not notify him of R1's missed [CONDITION(S)] treatment on 4/30/22. MD stated he was notified on 5/3/22, of the missed [CONDITION(S)] treatments on 4/30/22 and 5/3/22, and he ordered for R1 to be sent to the hospital for her [CONDITION(S)] treatment. MD stated neither he, nor his triage line, were notified of R1's change in condition (COC) which occurred early in the morning on 5/3/22. During an interview on 6/6/22, at 11:30 a.m. interviewed LPN-A who indicated 4/30/22 was a hectic day. R1's appointment for [CONDITION(S)] was at around 9:00 a.m. and typically the health unit coordinator (HUC) sets up appointments and transportation. LPN-A indicated on 4/30/22, 30 minutes after the scheduled pickup time R1 was still sitting at the facility front door, her ride had not arrived. LPN-A called the transport company and they told her they were running late but her transportation would arrive soon. LPN-A stated another 30 minutes passed and the transport still had not shown up, she called the company again who said they did not have a w/c accessible vehicle to pick up R1. Eventually it was lunch time and R1's ride still had not arrived, LPN-A took R1 back to the unit to eat lunch. She did vital signs before R1 ate and she was stable. LPN-A stated it felt like a war trying to get the company to pick up R1 for her [CONDITION(S)] treatment and it had happened multiple times in the past. LPN-A stated she did not contact R1's MD to notify him of the missed [CONDITION(S)] treatment. LPN-A stated she did not contact Davita [CONDITION(S)] to notify them R1 would miss her [CONDITION(S)]. LPN-A stated she continued to monitor R1 throughout the remainder of her shift. LPN-A stated she should have contacted the MD and Davita [CONDITION(S)]. During an interview on 6/6/22, at 12:23 p.m. RN-A indicated he had worked the overnight shift of 5/2/22 and was R1's nurse. RN-A stated R1 was having anxiety, but it had nothing to do with SOB (shortness of breath). RN-A stated R1's vital signs were normal; she was on oxygen as well. RN-A stated he did deep breathing with R1 and it went well. RN-A stated R1 did not want to be left by herself but did not feel it required a call to the MD. RN-A stated he did not check R1's weight or check for [CONDITION(S)]. RN-A stated he was not aware of R1's missed [CONDITION(S)] treatment on 4/30/22. RN-A stated he knew the MD was coming to the facility later in the day so he passed onto the oncoming morning nurse to let him know R1 may benefit from an as needed (PRN) medication to help R1's anxiety. During an interview on 6/6/22, at 2:20 p.m. Davita [CONDITION(S)] administrator (DDA) stated she knew R1's facility was having issues getting transportation for R1. DDA stated Davita was not notified R1 would be missing her appointment on 4/30/22. DDA stated on 5/3/22, the facility did contact Davita to inform them of issues with transportation for R1. DDA stated eventually Davita had to reach out to the facility because R1 was a no-show for her appointment. DDA stated in general if a patient misses one treatment they would try and reschedule preferably on the following day. DDA stated under normal circumstances Davita would contact the police for a wellness check if a patient missed a [CONDITION(S)] treatment and were unable to be contacted, but since R1 was a resident at a skilled nursing facility (SNF) they would typically reach out after a 2nd [CONDITION(S)] appointment was missed. DDA stated on 5/3/22, the facility contacted Davita and wanted to know what they were supposed to do if a resident misses their [CONDITION(S)] appointment, Davita advised the facility to call them to try and reschedule or have her sent to the ER. DDA stated R1 was in a SNF and was under the direct care of nursing and providers and it was the responsibility of the facility for the safety and care before and after [CONDITION(S)] treatment, transportation was the facility's responsibility. During an interview on 6/6/2022, at 3:30 p.m. director of Nursing (DON) stated LPN-A should have contacted the MD and Davita [CONDITION(S)] on 4/30/22. DON stated when a resident returns to the facility after [CONDITION(S)] they are returned with a report and those reports would let them know if more fluid was taken off than usual during the treatment. DON stated fluid restrictions would be in the orders if there were some, but she did not believe it was done frequently. DON stated she did not see fluid restrictions in the orders or care plans for R1 and R2. DON stated they do not do weights for their [CONDITION(S)] residents, rather they follow the dry weights provided to them by Davita after returning from their treatment. The facility did do daily weights with patients in the transitional care unit (TCU) but not in their long-term care. DON stated if something were to be abnormal with a resident then they would check their weight, she did not think it was necessary for daily weights if they are at a steady baseline weight and the MD would give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated LPN-A recognized her error. The DON stated RN-A did not seem to equate SOB to fluid overload rather to anxiety. DON stated RN-A should have contacted the on-call doctor on 5/3/22, notifying them of the COC. DON stated [CONDITION(S)] should always be contacted with a COC, missed [CONDITION(S)] treatments, and guidance but the on-call doctor should be contacted first. DON stated she feels R1's situation occurred largely because staff did not recognize how serious it was for someone to miss [CONDITION(S)] and the seriousness of fluid overload. DON stated after R1's hospitalization they started education for the staff which included in-person education on how to respond to missed [CONDITION(S)] treatment and an online training through HealthcareAcademy.com addressing chronic kidney disease which included signs and symptoms of fluid overload and [CONDITION(S)]. The online education was required to be completed by nursing staff by 5/23/22. DON provided a copy of three reminders which were sent to the staff to complete the training by 5/23/22. DON stated LPN-B contacted Davita [CONDITION(S)] to ask them what they wanted them to do if someone missed [CONDITION(S)] again and they told her to send them to the ER if they miss a run. On 6/6/22, at 4:07 p.m. interviewed RN-C who stated she had not received any training regarding [CONDITION(S)] or fluid overload after 4/30/22. RN-C stated weights for [CONDITION(S)] patients should be performed daily. On 6/6/22, at 4:18 p.m. interviewed LPN-C who stated he had not received any training regarding [CONDITION(S)] or fluid overload after 4/30/22. LPN-C stated their policy was to do weights and vital signs before they leave for [CONDITION(S)] and after they return as well. LPN-C stated they do not track input and output as far as he knows for [CONDITION(S)] residents. On 6/6/22, at 4:24 p.m. interviewed LPN-D who stated the facility did daily weights for [CONDITION(S)] residents. LPN-D was only able to identify [CONDITION(S)] and weight as concerning signs and symptoms of fluid overload. LPN-D stated they do track input and output for patients on [CONDITION(S)] and it was in the computer, he stated he would not know where to find it in the computer. LPN-D had not had any training regarding [CONDITION(S)] or fluid overload after 4/30/22. Healthcare Academy online training completion log, provided by the DON on 6/6/22, indicated only 9 out of the 23 LPNs and RNs listed on the staff phone roster and training completion log had completed the training. The due date for completion of the training was 5/23/22. The facility [CONDITION(S)] Communication and Site Monitoring policy, last reviewed on 10/24/21, indicated the facility will assist with transportation to offsite [CONDITION(S)] centers. The policy did not address missed [CONDITION(S)] appointments or how to respond and communicate missed [CONDITION(S)] appointments. The facility Weight Monitoring policy, last reviewed on 10/24/21, indicated newly admitted residents were to be weighed weekly for 4 weeks. The policy did not address [CONDITION(S)]. The IJ was removed on 6/7/22, at 2:29 p.m. when the facility implemented corrective action including updating weight and [CONDITION(S)] policies on 6/7/22. Care plan updates for R2 on 6/7/22. Obtaining baseline weight and vital signs for R2 on 6/7/22. Education for nursing staff including [CONDITION(S)] protocol, notification of physician, coordination of care with [CONDITION(S)], and monitor/assessment of signs and symptoms of fluid overload; the majority of education was completed on 6/6/22 and 6/7/22 with a plan to continue education for staff prior to the start of their next shift. Obtaining daily weights for [CONDITION(S)] residents and notify provider of a 3lb or more weight gain. Audits will be conducted by the DON and/or designee daily through daily weights of [CONDITION(S)] residents starting on 6/7/22. Knowledge check audits to be completed by the DON and/or designee 3 times per week on random shifts

Based on interview and document review, the facility failed to develop a system to ensure residents cardiopulmonary resuscitation (CPR) status was accurately reflected throughout the medical record and 2 of 2 resident's (R26 and R74) whose wishes would not had been honored in the event of cardiopulmonary arrest (cessation of heart beat and breathing). This resulted in an immediate jeopardy (IJ) situation for R26 who would not had received CPR in the event of a cardiopulmonary arrest and was at risk for death. The IJ began on [DATE], at 1:10 p.m. when R26's Health Care Directive Summary (HCDS) reflected do-not-resuscitate status, which was contrary to the physicians order and R26's wishes for CPR. Facility staff verbalized they would had utilized R26's HCDS to identify her code status which put R26 at risk to not receive CPR and subsequent death. The administrator was notified of the IJ on [DATE], at 4:30 p.m. The IJ was removed on [DATE], at 2:57 p.m. but noncompliance remained at the lower scope and severity level of D-isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R26's Face Sheet dated [DATE], indicated R26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's comprehensive Minimum Data Set (MDS) dated [DATE], identified R26 had moderately impaired cognition. R26's HCDS dated [DATE], revealed initials were over a box which indicated, I wish to have DNR/DNI code status. To the immediate left of the initialed box the form indicated, I wish to have FULL CODE Status. The document was signed by R26 and a facility witness. The document lacked a physicians signature. R26's EMR had an order dated [DATE] at 1:38 p.m. which indicated R26 was a full-code (CPR). During an interview on [DATE], at 4:35 p.m. registered nurse (RN)-A verified R26's initials were over the DNR/DNI box of the HCDS and stated R26 was DNR/DNI and would not had performed CPR. RN-A stated nurses would look in either the paper chart or EMR. RN-A verified there was a discrepancy in R26's code status on the HCDS which indicated DNR and R26's EMR physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE], at 4:44 p.m. licensed practical nurse (LPN)-B stated he would go to the paper chart and look for the HCDS to determine a resident's code status if a resident was found unresponsive and not breathing During an interview on [DATE], at 5:18 p.m. LPN-C stated that she would go to the paper chart because it would be faster to look for someone's code status. LPN-C stated that she would look for the HCDS sheet if someone was found unresponsive and not breathing to determine a resident's code status. During an interview on [DATE], at 6:45 p.m. director of nursing (DON) stated staff were expected to follow the advance health care directive in the paper chart. The DON further stated the paper chart and the EMR should match. During an interview on [DATE], at 9:04 a.m. R26 indicated she wanted CPR performed by stating yes when asked if she wanted chest compressions completed if she was found unresponsive and not breathing. During an interview on [DATE], at 12:33 p.m. the DON stated R26 went to the hospital in November of 2020, and was a DNR/DNI. The DON stated upon returning to the facility R26 had a changed her code status to full-code. During an interview on [DATE], at 11:17 a.m. R26's nurse practitioner (NP)-F stated R26 could make her own decisions. NP-F stated R26 was full-code since arriving to the facility. During the review of the CPR policy reviewed on [DATE], revealed the policy lacked direction and process staff were to follow when completing or changing a resident's advanced directive wishes. The IJ was removed on [DATE], at 2:57 p.m. when the facility developed and implemented a systemic plan which was verified interview and document review: The plan included: - The facility provided staff education regarding changes in policy related to advanced directives and honoring residents' health care wishes on [DATE]. Nursing personnel who were not working were notified education needed to be completed prior to their next scheduled shift. - An audit of all resident charts was completed on [DATE], to ensure code statuses were consistent throughout the medical record. - R26 was interviewed by facility staff and it was verified she wished to be a full-code on [DATE]. R74's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MDS identified R74 had severely impaired cognition. R74's hospital history and physical (H&P) and discharge orders dated [DATE], indicated R74 code status was, Do Not Resuscitate (DNR)/Do Not Intubate (DNR). R74's medical record lacked a copy of the Health Center Health Care Directive Summary (HCDS) which was supposed to be completed upon admission to identify a resident code status wishes. R74's electronic medical record (EMR) on [DATE], revealed R74's ordered code status was full-code with a date of [DATE]. R74's medical record lacked documentation from the physician and the resident/representative on the change. During interview on [DATE], at 6:46 p.m. the LPN-A reviewed R74's chart and verified R74's chart did not have a paper copy of the facility HCDS. LPN-A stated he was not certain what happened to R74's facility HCDS as R74 transferred from another unit at the facility. LPN-A stated in case of an emergency, the nurses were supposed to review advanced directive wishes in the paper chart because it was the most current, but R74 did not have one. LPN-A stated he would review the advanced directive in the EMR. During interview on [DATE], at 2:03 p.m. RN-A confirmed R74 was a, no code per discussion with R74's wife in a care conference. RN-A reviewed R74's medical record including the hospital discharge discharge orders and history and physical. RN-A verified R74 was a DNI/DNR. RN-A reviewed the EMR and verified R74 status was listed as full-code which was updated on [DATE]. During interview on [DATE], at 3:03 p.m. family member (FM)-C stated, R74 was DNR/DNI. During an interview on [DATE], at 3:57 p.m. the director of nursing (DON) stated she was made aware of the issue regarding R74's code status. The DON stated the expectation was if a resident's code status was changed staff were supposed to have obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated since the concern was brought forward the facility R74's code status was changed back to DNI/DNR on [DATE].

Based on observation, interview, and document review, the facility failed to ensure adequate supervision was provided during meals for 1 of 3 residents (R75) identified to be at risk for choking. This resulted in an immediate jeopardy (IJ) situation for R75, who was eating unsupervised in the facility dining room and staff was not aware the resident began to choke. Further, the facility failed to implement interventions as directed by the care plan or ensure a resident wore appropriate footwear to prevent a fall for 2 of 3 residents (R1, R22) reviewed for falls. This resulted in actual harm for R1 when only one staff person assisted R1 with incontinence cares, she rolled out of bed and on the floor, and suffered three rib fractures and a dislocated finger. The IJ began on 5/21/21, at 8:57 a.m. when it was identified R75 ate unsupervised in the facility dining room on. R75 began choking and turned a bluish/purple color. Staff did not recognize R75 had began choking and surveyor intervention was required to prompt staff to assist R75. R75 suffered a choking episode which put R75 at risk for death. On 5/21/21, at 4:12 p.m. the administrator, director of nursing (DON), and regional staff were notified of the IJ for R75. The IJ was removed on 5/24/21, at 10:08 a.m., however, non-compliance remained at an isolated scope and severity which indicated no actual harm with potential for more than minimal harm (Level D). Findings include: CHOKING R75's Face Sheet dated 5/20/21, indicated R75 had a cerebral infarct (stroke), dysphasia (difficulty swallowing foods or liquids), Alzheimer's disease, [CONDITION(S)] (loss of ability to understand or express speech), and [CONDITION(S)] (paralysis of one side of the body) affecting left side. R75's annual Minimum Data Set (MDS) indicated R75 had a BIMS score of 7 which indicated a severe cognitive impairment, and required extensive assistance for eating with one person physical assistance to provide weight bearing support. R75's Care Area Assessment (CAA) indicated R75 required extensive assistance with bed mobility and eating. R75's care plan dated 5/20/21, indicated R75 had difficulty swallowing related to the CVA with [CONDITION(S)], dysphasia, and history of choking. R75's Speech Therapy Evaluation and Plan of Treatment dated 4/28/21, indicated R75 had dysphasia of the oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). The speech language pathologist (SLP) indicated recommendations of close supervision during oral intake, seated in an upright position for meals, mechanical soft solids, and nectar thick liquids for safety. R75's Nutritional assessment dated [DATE], indicated R75 had a history of choking episodes and was downgraded to mechanical soft diet textures and seemed to tolerate mechanically altered textures. The Nutritional Assessment further indicated R75's current diet orders were a dysphasia level 3 mechanically advanced diet with nectar thick liquids. Nutrition interventions and recommendations included to monitor intake of food and fluids. R75's Nutritional Assessment lacked recommendations for supervision during meals. R75's nursing assistant report sheet dated 5/21/21, indicated R75 required supervision at meals and needed to be up in wheelchair at meal. R75's physician order dated 5/20/21, indicated R75 was ordered to have assistance with all feeding and monitoring of intake related to diagnosis of choking during meals. R75's physician order indicated a level 3 dysphasia diet, with nectar thick liquids. On 5/18/21, at 9:55 a.m. R75 was observed lying in bed when the dietician brought in R75's breakfast tray and placed it on the over the bed table. At the time R75's bed was at a 30-degree angle. The dietician set up R75's meal tray which contained scrambled eggs, toast, oatmeal, and drinks, shut the R75's room door, and left R75 alone and unsupervised. Staff did not check on R75 while eating his meal. On 5/20/21, 8:50 a.m. to 9:01 a.m. during continuous observations, nursing assistant (NA)-A brought a breakfast tray into R75's room which contained two bowls of oatmeal and orange juice. NA-A uncovered cups,and left the room with R75 unsupervised. R75 was observed coughing while eating his breakfast. -At 9:04 a.m. NA-A returned to R75's room and was overheard giving R75 verbal cues to take a bite of the oatmeal. NA-A assisted R75 take two bites of the oatmeal and then lowered the head of bed to approximately 30-to-40 degree angle. -At 9:05 a.m. NA-A exited R75's room and left the nursing unit. No staff were observed in the hallway to supervise R75. -At 9:40 a.m. NA-B went into R75's room and removed R75's clothing protector and meal tray and exited the room. During interview on 5/19/21, at 8:44 a.m. trained medication aide (TMA)-A stated due to staffing there was a delay in breakfast which was supposed to be served at 8:00 a.m. TMA-A further stated residents were supposed to be assisted with morning cares and be at the dining room an hour ago, however, due to staffing this had not happened. TMA-A further stated the facility management was aware of concerns and staff had expressed the need to have two nursing assistants (NA) in the unit's Garden Court. During an interview, on 5/20/21, at 10:30 a.m. RN-A stated her expectation was for nursing assistants to provide supervision during meals. RN-A stated R75 was to be up in his wheelchair during meals. RN-A stated supervised means supervised or watching the resident during meals. RN-A stated she expected nursing assistants to be supervising residents during mealtimes and nursing assistants probably should not take breaks or leave the floor without another staff member covering the residents. During an interview on 5/20/21, at 1:07 p.m. the director of nursing (DON) stated her expectation was R75 needed to be supervised during meals. The DON stated supervision was watching residents until the meal was done. The DON further stated if a nurse or aide left the floor a replacement needed to be found to provide supervision. On 5/21/21, at 8:57 a.m. during an observation, R75 was sitting in a wheelchair in the dining room. R75 was seated at a table alone and was positioned with his back to the other six other residents who were all eating. Licensed practical nurse (LPN)-A was seated at a nurses' station, which was located across the from the dining room, and approximately 27 feet away. No staff were located in the dining room at this time. LPN-A had his back turned to the residents and was working on a computer. -At 8:59 a.m. R75 was eating in the dining area and dropped a fork on his plate. R75's plate was observed to have scrambled eggs, cut up French toast covered with a red strawberry topping. R75's face turned a deep blue/purple color. R75 was unable to cough, speak, or spit. LPN-A, remained at the nurses' station with his back turned and did not recognize R75 was choking. At this time, the surveyor alerted LPN-A who then immediately approached R75, shook R75's right shoulder, and asked if the resident was okay. R75 did not respond verbally and gestured with his right hand to his throat. LPN-A then used his right fist and pressed into R75 lower sternum/upper abdomen area and compressed R75 chest in roughly two inches twice. R75 immediately started to cough and spit. R75 continued to cough and spit out a light brownish/red colored piece of food roughly ¾ inches in diameter. During an interview on 5/21/21, at 9:06 a.m. LPN-A stated he was documenting at the computer in the nurse's station on another resident's chart when R75 began choking. LPN-A stated R75 choked on French toast and he performed [MEDICATION(S)] maneuver because R75 was choking. LPN-A confirmed R75 needed be supervised during meals. LPN-A confirmed no one was supervising the residents in the dining room and stated he was unsure why. During an interview on 5/21/21, at 9:20 a.m. the registered dietitian (RD) stated R75 was served French toast, scrambled eggs, and a strawberry topping for breakfast when R75 had an incident of choking. The registered dietitian further stated R75 was given dietary directions, or orders, from either the physician or SLP. During an interview on 5/21/21, at 9:50 a.m. the SLP stated R75 had a significant history of dysphasia and was admitted with a modified soft textured diet and level 3 dysphasia advanced diet. SLP stated she wanted to ensure R75 was doing well and tolerating his diet with no episodes of choking because he was not getting up in his wheelchair. SLP stated that it was important for people with dysphasia to sit up in a chair or bed at a 90-degree angle. SLP stated residents with dysphasia have a higher chance of choking. SLP stated she was informed by the dietitian R75 turned blue and choked on French toast. SLP stated the kitchen used Texas toast which was a thick piece of bread and had a hard crust on the edges and made it a risk for a resident with dysphasia. SLP stated French toast was too firm for R75's diet, he should have no tough meats, meat should be able to cut with a fork not a knife. SLP defined supervision as a staff person in the dining room with eyes on the residents. SLP stated a nurse at the nurse's station with their back to residents was not considered supervision. SLP stated she completed an in-service on 5/13/21, with kitchen staff on modified diets. During interview on 5/21/21, at 10:07 a.m. NA-D stated, we are not able to provide supervision with meals because sometimes we have to leave the residents in the dining room to go to a room to help the residents and sometimes the nurse is busy and we are not able to do it and this is for both downstairs and upstairs. During interview on 5/21/21, at 10:27 a.m. NA-M stated, staffing is horrible and sometimes she was in rooms to get residents ready while other residents were served food and would eat. NA-M stated staff was unable to be in the dining room due to getting residents ready for the day. During an interview on 5/21/21, at 12:44 PM the medical director stated, I am not aware of any choking incident. The medical director stated his expectation for supervision was, I do not think my expectation is that they don't need to have eyes on the patient every second. The medical director further stated, One of the problems with COVID is there less people in the dining room. Someone is available to monitor, but not hands on every second. The medical director stated with six people in the dining room someone should have been responsible to monitor the situation and if the surveyor had not come and he did not know how long it would have taken someone to respond. The medical director stated there was always a risk for someone to choke and thought someone needed to be available nearby to hear and respond, but not visibly. The medical director stated if the speech therapist recommended someone be with a resident, then the order was not followed. The medical director also stated if the patient was already purple, they should had been monitored a little bit more closely. During an interview with DON on 5/21/21, at 2:28 p.m. The DON stated all the residents in the dining area were supposed to be supervised and would expect someone to be in the dining area to watch the residents. The DON also stated if the nurse was at the nurses' station and positioned at a certain angle, she would consider it supervision, but if the residents were not in eyesight from the nurses' station then it would not had been considered supervision. During an interview on 5/21/21, at 2:40 p.m. nurse practitioner (NP)-C stated she was informed of the incident of R75 choking. NP-C stated R75 had a history of dysphasia after his CVA and a history of aspiration pneumonia, but was unsure of when it last occurred. NP-C stated R75 was treated with inhalers after a respiratory illness which was possibly related to aspiration in January 2020. NP-C stated she expected R75 is to be monitored in the dining room with staff in dining room or at nurses' station facing residents. Facility policy Activities of Daily Living dated 3/11/15, revised on 10/25/20, directed staff to provide necessary services for residents who were unable to carry out activities of daily living. The IJ which began on 5/21/21, was removed on 5/24/21, 10:08 a.m when the facility developed and implemented a systemic plan which was verified by observation, interview, and document review: The plan included: - Education on the need to supervise residents identified at risk for choking was provided to nursing personnel on 5/21/21. Nursing personnel who were not working were notified education needed to be completed prior to their next scheduled shift. - An audit was completed on 5/21/21, which identified residents who were at risk for choking. - The Supervision of Residents At Risk for Choking and Foods Brought in by Family/Visitors policy and procedure for was reviewed and revised on 5/21/21. - Residents at risk for choking who prefer to eat in their room were evaluated by speech therapy on 5/24/21. - Nursing staff were assigned as a dining room monitor for each dining room and each shift daily and verified on 5/24/21. FALLS R1's Face Sheet printed 5/21/21, indicated R1's diagnosis included [CONDITION(S)], generalized muscle weakness, and [CONDITION(S)]. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and required two staff physical assistance for bed mobility, transfers, and toilet use. R1 was frequently incontinent of urine and bowel and the MDS indicated no fall history. R1's care plan dated 5/12/21, directed R1 required assistance of two staff for bed mobility, and toileting. The care plan further indicated R1 was at risk for falls due to impaired mobility. R1's activities of daily living (ADL) Care Area Assessment (CAA) dated 5/20/21, indicated R1 required extensive assistance for bed mobility and transfers, and had impaired mobility and balance. R1's nursing assistant task sheet dated 5/20/21, indicated R1 required assistance of two staff for ADL's. R1's progress notes dated 5/20/21, at 11:41 p.m. indicated at 8:50 p.m. nursing assistant (NA)-I reported R1 had fallen out of bed. R1 was lying on the floor on her right side. R1's right hand was tucked under her body and was bleeding. NA-I's statement was, I turned [R1] to her left side, giving peri care, then she said 'I am having a BM', then I feel the heaviness of her body going over to the ground, I try to pull her back but I couldn't. R1's bed was at waist height. R1 was assisted off the floor with Hoyer and two staff assist. R1 obtained a skin tear to the back of right-hand measuring 10 cm [centimeters] by 7 cm, and a skin tear to the right elbow measuring 10 cm by 3 cm, both secured and dressing applied. R1 was able to wiggle fingers and complained of [C/O] burning sensation to skin tear. Range of motion (ROM) was intact to extremities, neurological examination was normal for R1. R1 C/O difficulty breathing to right side (while holding right rib area). Staff applied oxygen and contacted the on-call provider who stated to provide comfort cares, apply ice to ribs, if needed, and monitor until R1 was seen tomorrow by in house provider. R1's progress notes dated 5/21/21, at 6:00 a.m. indicated R1 complained of right sided pain and stated, It's hard to breathe on my right side. R1's progress notes dated 5/21/21, at 1:39 p.m. indicated R1 was an assist of two staff with a Hoyer lift. R1 complained of pain on right hip and legs due to fall. R1's doctor ordered a x-rays of R1's right rib, hand, and wrist. The progress note further indicated R1 was able to move both of her arms and expressed some pain; R1 was able to move both legs without pain. Multiple bruises were noted on R1's abdomen and left thigh. R1 also had one bruise to her right inner thigh. R1's Post Fall Evaluation dated 5/21/21, indicated R1 did not have a history of falls and nursing interventions included assistance of two staff. R1's x-ray results dated 5/21/21, indicated she suffered fractures of the third, fourth, fifth, and sixth ribs and also had a partial dislocation of her fifth finger at metacarpophalangeal joint (where the hand bone meets the finger bones). When interviewed on 5/21/21, at 12:10 p.m. family member (FM)-F stated on 5/20/21, R1 had a fall out of bed when a staff was providing incontinence care. FM-F stated there was only one staff-person who assisted R1 and there was supposed to be two. FM-F stated R1 received an x-ray of her hand and was notified on 5/19/21, R1's bed was elevated at the time of the fall. FM-F stated, The one gal was changing her and rolled her over and she fell right out of bed. FM-F also stated R1 had sustained a skin tear to her hand. When interviewed on 5/21/21, at 12:28 p.m. R1 stated, They were taking care of me and only one person tried to change me. It is ridiculous. R1 was observed to have a skin tear about the size of a quarter on the back of her elbow with bruising which extended down the forearm towards the wrist. R1 had a dressing midway down forearm wrapped with gauze and tape with visible blood on the dressing. R1 had an ace wrap on her arm with gauze below with the wrap holding visible dried blood. All fingers on R1's right hand were bruised with dark blue, dark red, and dark purple coloration, up to the knuckles before the nail. R1 was able to move all fingers upon command. R1 verified she required the assistance of two staff for incontinence care and positioning needs. R1 stated, It's two always. R1 stated she felt 10/10 pain immediately after the fall and stated, it felt like I was being tortured. When interviewed on 5/21/21, at 12:56 p.m. registered nurse (RN)-E verified R1's fall occurred and the plan of care was not followed and stated, NA-I was doing cares for her and there was only one aid and she rolled out of bed, she is actually assist of two for transfers and ADL's. When interviewed on 5/21/21, at 1:36 p.m. NA-I confirmed she provided incontinence care for R1 5/20/21, and stated, I know I shouldn't have done her myself, but the floor was very busy, call lights were going off. NA-I stated she removed R1's brief, turned R1 on her side when R1 began having a bowel movement. NA-H stated she had her left hand on R1's hip when cleaning R1 with her right hand. NA-I stated she felt R1's weight stating to shift, and, The next thing I know she was on the floor. NA-I stated R1's bed was elevated slightly above her hip height and about three-to-four feet above the ground. NA-I verified R1 required two staff for incontinence care and stated, When I looked there was no one to help me. NA-I stated after the fall, R1 complained of pain on her right side and her right hand where she sustained a skin tear. When interviewed on 5/21/21, at 2:25 p.m. the director of nursing (DON) stated she expected staff to follow the plan of care, and NA-I would receive retraining. When interviewed on 5/24/21, at 8:03 a.m. R1 laid in bed and stated her arm, hurts horribly and, I am so sore, I have some ribs, I can tell that they are broken. R1 recounted her fall and further stated, I've never had something so terrifying in my life. When interviewed on 5/25/21, at 8:15 a.m. nurse practitioner (NP)-A verified R1's fall and stated her injuries were consistent with a fall from bed. NP-A verified R1's required level of assistance and stated, I would expect that they would have two people. Facility policy titled Comprehensive Care Plans, revised 10/28/20, directed qualified staff were responsible for carrying out interventions specified in the care plan and would be notified of their roles and responsibilities for carrying out the interventions initially and when changed were made. R22's diagnoses included abnormal gait and mobility, weakness, history of falls with a displaced intertrochanteric fracture left femur, closed fracture with routine healing and dementia obtained from the quarterly MDS dated [DATE]. The MDS also identified R22 had severely impaired cognition, required extensive physical assistance two staff for bed mobility, transfers, and did not walk in the room or in the corridor during the assessment period. The MDS identified for balance R22 was not steady during transitions, and walking, and moving on and off the toilet. In addition, the MDS indicated R22 had a fall in the last two to six months with a fracture. R22's care plan effective 11/16/20, identified R22 had the potential for falls related to dementia and history of falls. Interventions included: staff to anticipate R22's needs and promote safety. During interview on 5/17/21, at 2:20 p.m. family member (FM)-D stated R22 had no recent falls, however, two to three days after R22 was admitted at the facility, R22 had a fall and sustained a fracture. FM-D stated during a companion visit she had noticed R22 was wearing regular non-skid shoes. FM-D stated R22's non-skid shoes were missing from his room. During the interview, R22 was observed laying in bed on his back and was wearing long black with gray soles socks. On 5/17/21, at 12:11 p.m. nursing assistant (NA)-C was observed wheeling R22 into the dining room. R22 was observed not wearing appropriate footwear. On 5/19/21, at 7:16 a.m. R22 was observed seated in a wheelchair in the TV lounge. R22 stated he was not assisted to walk that morning. R22 was not wearing no shoes or other non-skid footwear. -At 8:35 a.m. R22 wheeled himself out of the dining room, down the hallway, and went back to his room. R22 self-transferred himself to bed. R22 was not wearing shoes or non-skid footwear to prevent a fall. On 5/20/21, at 7:55 a.m. R22 was observed propel his wheelchair down the hallway towards the dining room and when he got to the dining room entrance, the environmental service director wheeled R22 to the table. During the observation R22 was not wearing shoes or non-skid footwear. -At 8:37 a.m. R22 was wheeled himself out of the dining room. At this time registered nurse (RN)-D approached R22 and asked him to wait for her as she was going assist him to his room and into bed as she did not want R22 to fall. -At 8:43 a.m. RN-D assisted R22 to his room and cued R22 to set the wheelchair next to bed. R22 stood up and was not wearing shoes or non-skid footwear as he pivoted and sat in his bed. During the transfer R22 was observed to be unsteady, but was able to stabilize himself without RN-D's assistance. R22 was not offered shoes or other non-skid footwear prior to the transfer to reduce the risk of a fall. -At 8:44 a.m. RN-D stated, He should wear gripper socks because he is a high fall risk. I have never seen him with shoes R22 then stated he used to have shoes, but they were missing. RN-D stated R22 would self-transfer if staff were not present to assist him. RN-D stated R22 also self-transferred himself on-and-off the toilet. RN-D offered resident non-skid footwear and this time. R22 accepted the non-skid footwear. During interview on 5/21/21, at 8:11 a.m. the director of nursing stated staff should ask R22 if he would allow them to put on gripper socks.

Based on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R1) reviewed for accidents was transferred according to the plan of care. R1 had been assessed to transfer with assistance of two staff and a mechanical lift. R1 sustained actual harm when during a transfer with two staff, without a mechanical lift, R1 sustained a deep laceration that required sutures. Although noncompliance was present at the time of the event, the facility had implemented appropriate corrective action by 5/14/19, resulting in a finding of past-noncompliance harm for R1. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified the resident's [DIAGNOSES REDACTED]. In addition, the MDS indicated the resident had severely impaired cognition and required total dependence of staff assistance with all transfers. R1's care plan dated 1/26/15, indicated R1 was at risk for falls, and had been downgraded to transfer with two staff assist with a Hoyer lift (a mechanical lift). During review of the 2 North NA (nursing assistant) Report Sheet updated 4/9/19, it was revealed R1 was a 2 (staff) assist Hoyer lift for transfers. A facility 24 Hour Report indicated on 4/18/19, at 8:45 p.m. R1 was sent to the hospital to be assessed due to a deep skin tear on the right lower calf. The report indicated the injury was a laceration of 8.4 centimeter (cm) by 4.0 cm which had occurred during bedtime cares. The 24 Hour Report indicated NA-A had told the writer, that R1 had been transferred with two staff assist using a gait belt from the wheelchair to the bed. The report further indicated the another NA was pulling the wheelchair back as NA-A was laying R1 in bed. At that time, R1's right leg crashed against the edge of the bed resulting the laceration. The 24 Hour Report indicated the writer had provided first aid and had notified the on-call physician who gave orders for R1 to be sent to the hospital for evaluation, and family member (FM)-A was updated. During interview and observation on 8/12/19, at 9:16 a.m. when asked about the injury from 4/18/19, R1 stated, I don't remember anything. I'm tired. When asked how staff transferred her, R1 stated, They use the machine. During a telephone interview on 8/14/19, at 10:21 a.m. FM-A stated at the time of the incident, the nurse had called him to notify him of the injury and had reported R1 was being sent to the hospital because she had sustained the skin tear (laceration) and staff were unable to stop the bleeding at the time. FM-A stated the nurse had not told him how the skin tear had occurred, but he had assumed it was due to R1's fragile skin, and that she had bumped on something while using the lift. FM-A verified R1 required sutures to close the laceration. On 8/14/19, at 3:23 p.m. NA-A was interviewed by telephone and stated, We usually transferred her with two staff using a transfer belt. I worked in the group regularly and I was not aware she had been changed to use a Hoyer lift. The nurse manager told me she had been changed like a week before. When NA-A was asked how she would be made aware of changes to the assignment sheet NA-A stated, We are supposed to look at it, but I didn't know it was changed. When asked how the laceration happened NA-A stated, Her leg got caught on the bed when we were laying her down. On 8/12/19, at 1:05 p.m. the director of nursing (DON) stated, (NA-A) was the aide assigned to (R1) and he had approached another aide (NA-B) for assistance to transfer her. He (NA-A) was not using the assignment sheet, and was not following the care plan to use the Hoyer to transfer (R1). The DON stated NA-B had not received discipline because she was just following NA-A who was assigned to R1 at the time, and who should have known R1's care needs. The DON further stated, (NA-A) received a 'Corrective Action Notice' and had reviewed the facility's Mechanical lift Transfer Safety policy, and a Competency Skill Checklist had also been completed for NA-A to make sure he was proficient. Although the facility staff failed to follow the plan of care on 4/18/19, the facility was able to verify corrective action had occurred, including a corrective action notice given 4/19/19, review of the mechanical lift transfer safety policy 4/22/19, and a competency skill checklist completed with the staff 5/14/19, following the incident. The facility completed an investigation timely, and the interdisciplinary team had reviewed the incident which the team identified as isolated. The corrective action was verified as completed 5/14/19, during the onsite survey 8/12/19. Therefore, this deficient practice is being cited at Past Noncompliance.

Based on interview and document review, the facility failed to supervise and comprehensively assess the elopement risk for 1 of 3 residents (R1) who was identified as an elopement risk upon admission. A wander guard alarm was placed on R1 after admission and the facility failed again to assess R1's elopement risk and identify approaches and interventions. This resulted in actual harm when R1 eloped out of the building on [DATE], was brought back into the building approximately 20 minutes after being outside, R1 became unresponsive, went into [MEDICAL CONDITION], was brought to the hospital and died . Findings include: R1's admission face sheet identified R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. R1's admission Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment needed 2 person extensive assistance with bed mobility, transfers, and locomotion on the unit, the admission MDS identified R1 did not wander. The prospective payment system (PPS) 60 day MDS dated [DATE], identified R1 had severe cognitive impairment, was a two person extensive assist for transfers, a one person physical assist with supervision for walking in his room, the corridor and locomotion on and off the unit. The 60 day MDS also indicated R1 wandered daily. The Treatment Administration Record order (TAR) for (MONTH) 2019 identified R1 had a wander guard (started [DATE]). Staff were to ensure wander guard was on the left wrist at all times due to cognitive impairment. The clinical admission assessment dated [DATE], at 7:13 p.m. revealed R1 had a moderate elopement risk based on the recent move to the facility and had a history of [REDACTED]. Preventative action included: identification band on resident, frequent room checks, social services, family and staff visits. Review of the care plan with effective date of [DATE], did not reveal any identification that R1 wandered or was at a moderate risk for elopement. A resident plan of care summary (undated) listed R1 with safety concerns/risks of falls and elopements. Review of clinical notes for R1 included the following: [DATE], at 7:25 a.m. R1 admitted on [DATE], at 5:00 p.m. R1 identified as impulsive and wandered. Staff kept R1 in the common area to monitor closely until 9:30 p.m. when he was assisted to bed. [DATE], at 1:09 p.m. R1 was a high fall risk related to his cognitive impairment regarding safety, impulsivity and lack of safety awareness. New intervention included staff to check on R1 frequently at the beginning of the night shift and through out the shift for safety. Continue to monitor and adjust per R1's needs. [DATE], at 6:05 a.m. Staff put R1 to bed and R1 attempted to get out of bed. Staff brought R1 to the common area for close monitoring. Needed to be monitored one to one. Will continue to monitor. [DATE], at 8:18 p.m. R1 needed one to one supervision. [DATE], at 2:11 p.m. R1 wandered by the nurses' station and tried to go inside other residents' rooms. [DATE], at 5:24 p.m. R1 attempted to enter other residents' rooms, staff was able to re-direct. [DATE], at 5:43 a.m. R1 spend the whole night in his wheel chair and slept. Staff attempted to assist R1 to bed and R1 self transferred out of bed. R1 brought back to the nurses' station for close supervision through out the shift. Will continue to assess. [DATE], at 1:30 a.m. R1 sat in a wheelchair by the nurses' station for close observation. [DATE], at 5:19 a.m. R1 was up in his wheel chair in the common area. R1 slept in the recliner at 12:00 a.m. At 2:00 a.m. R1 wandered the unit and attempted to enter other residents' rooms but was redirected. At 3:00 a.m. R1 grabbed things from the nurses' station, attempted to open locked medication carts and attempted access to locked medication cart computers. Continued to self transfer and attempted to enter other residents' rooms. [DATE], at 8:53 p.m. R1 wandered around the unit. Wander guard placed on left wrist to be monitored by staff. [DATE], at 5:47 p.m. R1 repeatedly packed and unpacked and rearranged his belongings. Talked about moving once I get the clearance code. [DATE], at 6:38 a.m. R1 paced on the floor and exhibited exit seeking behavior. R1 eloped out of the building at the beginning of the shift. R1 was seen at the exit of the building and was redirected back by staff upon hearing the wander guard alarm activated. Staff will continue to monitor [DATE], at 3:14 p.m. R1 was alert and oriented times 2, risk of elopement, had a wander guard on his left wrist. R1 wandered around the unit and looked for an exit, staff tirelessly kept redirecting. Will continue to monitor. [DATE], 10:50 a.m. R1 walked and wandered around the unit early in the morning and packed and unpacked his personal belongings. R1 said, I am going home. R1 was redirected. [DATE], at 10:42 a.m. R1 wandered around the unit and other residents' rooms. R1 was re-directed. [DATE], at 10:47 a.m. R1 wandered around the unit and other residents' rooms. R1 was re-directed. [DATE], at 9:36 p.m. R1 continued to wander from room to room/other floors and needed continuous staff re-direction and supervision. [DATE], at 9:40 p.m. R1 was restless after dinner and picked up items from the nurses' station and other residents' rooms, wandered to other units and wanted to go outside. R1 was not easy to redirect and staff had to stay with him continuously. Later R1 got exhausted and say by the TV area next to the nurses' station. Will continue to monitor and redirect as needed. [DATE], at 12:03 a.m. R1 was his normal self this afternoon and ambulated to all places on the unit. After dinner R1 paced in the hallway, he tried to open the exit door by the subacute dinning room and the alarm went off. A barrier was placed by the exit and staff supervised his moves. Medications were administered at 7:45 p.m. At 8:05 p.m. R1 was brought back to the receptionist desk by a good Samaritan. According to the receptionist, the person that brought R1 back to the facility found R1 by the apartments across from the facility's parking lot. When R1 was brought back to the facility, he complained of trouble breathing as he walked with staff back to the unit. R1 sat at a couch next to the nurses' station and oxygen was immediately applied at 5 liters(L)/minute using an oxygen concentrator. R1's fingers were very cold and staff was unable to get a saturation level. There was a brief oxygen saturation (levels that measure the degree to which the hemoglobin contained in the red blood cells has bonded with oxygen molecules) reading of 40 (A range of ,[DATE] is normal) but it immediately went blank. Code blue was paged via the overhead pager to alert staff of the emergency. At 8:10 p.m. 911 called and family was notified of R1's condition. R1's fingers were cold, which made it difficult to read oxygen saturations, warm blankets were placed on resident. R1 started to foam at the mouth and oral suctioning was initiated as paramedics arrived at 8:20 p.m R1 was still breathing when the paramedics arrived. R1 became unresponsive and cardiopulmonary resuscitation (CPR) was initiated with paramedics present. At 8:55 p.m. R1 was taken to the hospital. On [DATE], at 10:39 registered nurse (RN)-B said a resident needed to be assessed for the placement of a wander guard. If staff notice that a resident has tried to open exit door or wants to go home there is a standing house order for wander guard placement and a nurse can asses a resident has a risk for elopement and place a wander guard on a resident. After a wander guard is placed, nursing staff will check it every shift to make sure that it works and document the check in the Medication Administration Record [REDACTED]. On [DATE], at 11:27 p.m. licensed practical nurse (LPN)-A stated after the incident the facility management had staff go through a flyer about the wanderguard and residents at risk for elopement. LPN-A stated also with the training they were to check the wanderguards on residents to make sure they functioned properly. When asked about the exit door where R1 had gone through, LPN-A stated after the incident a sensor was then installed on the door to alert the staff if someone was opening the door which was not in place before. LPN-A stated she did not think the time frame from the time the sensor went off which was 30 seconds was enough as at times staff was in residents rooms and if staff was not in the common areas they would not be able to respond to it timely. LPN-A further stated R1 was at risk for elopement as at times he would disappear when all the staff was in other residents' rooms and when they came out and did not see him we had to stop everything to find him. On [DATE], at 11:38 a.m. the director of social services (DSS) said social services would assess a resident's elopement risk quarterly with the MDS, and as needed, and update the care plan to reflect the elopement risk. DSS said when a resident is first admitted there is an initial elopement assessment that is connected to the clinical admission evaluation assessment that nursing completes. If there was a change since admission and a resident started to wander as a new behavior, nursing staff would let social services know and an elopement assessment would be completed by social services and the care plan would be updated to reflect the elopement risk. DSS verified the clinical admission evaluation assessment dated [DATE], identified R1 as a moderate elopement risk, which should have triggered an assessment and care plan development and there was not an elopement assessment completed or care plan developed. DSS was unable to find an elopement assessment for R1 after the wanderguard was placed on [DATE], and was not aware if nursing staff notified social services about the wanderguard placement. On [DATE], at 11:42 a.m. anonymous staff stated had not received any training following the elopement incident. Staff stated after the incident when getting report it had been brought up R1 had eloped and was brought back to the facility by a neighbor but had a [MEDICAL CONDITION] and had passed away. Staff indicated on the day of the incident during the morning shift R1 had been exit seeking and had the usual wandering behaviors. Staff also stated during R1's stay at the facility all staff during her shift made sure they all knew the whereabouts of R1, If we don't see him we have to stop what we are doing to find him and re-direct him back to a common area. On [DATE], at 12:01 p.m. the social services assistant (SSA) said that she was aware that a wander guard was placed on R1 on [DATE], however, at that time SSA did not know it was the responsibility of social services to complete the elopement assessment or update the care plan when a wander guard was placed on a resident. On [DATE], at 12:10 p.m. nursing assistant (NA)-A stated she had not received any training regarding the wanderguard but she was aware R1 had eloped and was brought back. When asked if she was aware of the anything being installed to the exit door R1 had gone through NA-A stated, No. The nurses check them. On [DATE], at 12:29 p.m. an interview was completed with the director of nursing (DON) and the regional clinical nurse. When asked about the incident, the DON stated the facility staff had called her that evening initially and had stated a neighbor had brought R1 back to the building then the receptionist had the transitional care unit (TCU) nurses to get R1 back to the unit. The DON stated after R1 returned to the unit he was noted with shortness of breath then oxygen was applied and then he became unresponsive and staff nurses initiated cardiopulmonary resuscitation (CPR) as the nurses called 911. The DON stated the staff continued to administer CPR until the paramedics arrived and during that time the nurses had not been able to obtain an oxygen saturation level via the finger probably due to R1 being to cold. The DON stated the nurse assigned to R1 on the evening of the incident had stated he had given R1 his evening medications around 7:45 p.m. and had gone on with the medication pass for other residents until when they were made aware R1 had been brought back to the facility. When asked if the staff was supposed to know R1's whereabouts, the DON stated R1 was not on one to one supervision but the staff had encouraged him to stay by the desk so the staff could keep close eye on R1. When asked why the exit door did not have an alarm like other doors in the building she stated after the incident that was when the facility identified the door never had an alarm to it. The DON stated after the incident then signs were put on the door and a exit alarm which was supposed to be on for 30 seconds after someone exited the door to alert staff and the alarm was loud. When asked how the staff were notified and trained following the incident, the DON stated an e-mail was sent out to the nurses to alert them. Then other training information was provided to all the staff through the facility training platform platinum service. In addition, the DON stated the training was usually posted in the break room for staff for four days and after was taken down. When asked how the facility made sure all staff had received the training provided following the incident, the DON stated she did not have a signing sheet or any way of knowing that instead for her she thought she needed to get the information out immediately and thought after the door alarm was installed it was loud to alert staff. The DON said when R1 first was admitted , he wandered around the unit and then his behavior started to change and R1 said he wanted to leave. Staff put a wander guard on R1 and put it on the treatment sheet to check the wander guard each shift. The DON acknowledged she would have expected an elopement assessment to be completed and a care plan developed upon admission and R1 should have been re-assessed when the wander guard was added and his care plan to be updated. The policy for elopement risk (last reviewed [DATE]) indicated residents would be assessed for elopement risk on admission and throughout their stay by the interdisciplinary team. Under the procedure section staff was directed to observe residents determined to be at risk for elopement or elopement sign and/or attempts and interventions will be included in their comprehensive plan of care to address the potential for elopement. The policy for wander guards (last reviewed [DATE]) indicated an elopement evaluation is completed upon admission, re-admission, quarterly with the MDS process, when a resident is moved in or out of a memory care and PRN (as needed) when the resident may exhibit a change in condition where they might be a wander risk and have the need for a wander guard alarm.