Every finding on record at St Clare Living Community of Mora

Based on observation, interview, and record review the facility failed to ensure the code alert system (a wander management system to protect residents from elopement) was functioning properly, failed to follow manufacture recommendation for weekly testing, and failed to follow manufacture recommendations for inspection. This resulted in an immediate Jeopardy situation for two residents (R19, R12) who were at risk for elopement and were able to get through the main doors, due to failure of the doors to lock as required per the code alert system. In addition, the facility failed to adequately assess and develop care plans for residents identified at risk for elopement and wandering for 14 of 14 residents (R19, R12, R3, R4, R13, R17, R18, R22, R25, R28, R32, R34, R37, R46) who were assigned code alert devices and had the potential for elopement.The IJ began on [DATE] at 2:18 p.m., when R12 was able to exit the building due to code alert system malfunction. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 7:35 p.m. The immediate jeopardy was removed on [DATE] at 4:36 p.m., however, non-compliance remained at a lower scope and severity, level 2, isolated scope, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include:The manufacturer Code Alert System book in the facility binder recommended:-Weekly testing of the code alert units and instructed replacement of expired devices and/or devices that failed testing.-Testing of each detection zone (doors) on a regular basis, ideally weekly.-Quarterly service inspections by vendor.Logs titled Code Alert Alarm Testing dated between 1/2025, and 4/2025, showed the North internal door/offices, Main Entry/Exit Long Term, South Exit, East Exit, [NAME] Connector Exit, and the [NAME] View Entry/Exit had been tested monthly.Logs titled Wander Guard Monitor sheets dated between 1/2026, and [DATE], listed all residents with a code alert monitor, the monitor location, and the device expiration date. Device checks were documented as completed weekly. The most recent log dated 4/2026, listed 14 residents with code alert devices: R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46.R19 was admitted to the facility on [DATE]. R19' significant change MDS assessment dated [DATE], indicated R19 was severely cognitively impaired with the diagnosis of Alzheimer's disease. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R19 had not exhibited wandering. R19's care plan reviewed [DATE], lacked interventions for elopement and wandering.R19's most recent elopement assessment was completed on [DATE]. The assessment identified R19 as low risk for elopement and interventions included clothing labeled with identification, identification band on resident. The Door Alarm band applied (code alert device) was not selected. R19's progress note did not include an entry regarding R19's attempt to leave the building on [DATE].During an observation on [DATE] at 10:07 a.m., R19 wheeled their wheelchair to the main entrance of the facility. R19 proceeded to wheel self through the first door into the entrance vestibule. The alarm went off, but the door did not lock. NA-J responded and was able to redirect R19 out of the entry and back to the central tv area. R19 was heard telling NA-J I was just thinking about a change of scenery. Oh, sure let's go to the tv area. R19's code alert device was attached above the left wheel of their wheelchair.During an interview on [DATE] at 10:48 a.m., nursing assistant NA-J stated yesterday they had heard the alarm go off and had responded to the main entry. R19 had been partially through the first door when they reached R19. Usually, the door would lock when a resident got withing 3 feet or so, but it had not locked yesterday.R12 was admitted to the facility on [DATE]. R12's quarterly MDS assessment dated [DATE], indicated R12 was severely cognitively impaired with diagnoses of non-Alzheimer's dementia and anxiety. MDS Section P. indicated a wander guard alarm was not in use. Section E900 indicated R12 had not exhibited wandering. R12's care plan last reviewed [DATE], lacked interventions for elopement and wandering.R12 had documented elopement assessments completed by the licensed social worker (LSW-A) on [DATE], [DATE], [DATE].R12's most recent assessment completed on [DATE], indicated R12 was a low risk for elopement and interventions in place included: clothing labeled, and an identification band placed on the wrist. The door alarm band applied (code alert device) was not selected as an intervention.During an observation on [DATE] at 8:40 a.m., R12 set off code-alert alarm attempting to ambulate out the main facility door. R12 went through the inside door into the vestibule where her walker got hung up on the rug pushing it upwards along the legs of the walker. Staff responded and redirected R12 back inside and away from the entrance door.During an observation on [DATE] at 2:18 p.m., R12 walked out of their room with their wheeled walker directly to the main entrance. R12 paused at the main entrance door, stated I think my car is out there and then proceeded through the first door. R12's walker initially got caught up on the rug, but R12 was able to push walker beyond the rug and proceeded outside. Staffing coordinator (SC)-D saw R12 exiting the building and followed R12 out asking that surveyors 1 or 2 get their cell phone and bring it to them. Surveyor 2 notified the DON who was passing down the hallway a resident had made it outside of the building and SC-D had followed and needed their phone. The DON brought the phone out to SC-D and left the area. SC-D and R12 sat on a bench along the driveway. At 2:20 p.m., SC-D and R12 came back inside the facility. R12 returned to their room which was near the main entrance doorDuring an observation on [DATE] at 9:07 a.m., R12 walked out of their room to the main entrance door. R12 made it through the first door and into the vestibule before SC-D redirected R12 back inside and away from the door. The alarm went off once R12 went through the first door. SC-D stated they were keeping a staff at the door 24/7 until the door was fixed.Progress notes entered by LSW-A on [DATE], [DATE], and [DATE], indicated R12's elopement assessments had been reviewed with no change. R12's EMR lacked documentation regarding R12's successful exit of the building on [DATE], or their attempts to exit the building made on [DATE], and [DATE].On [DATE] at 2:20 p.m., the maintenance department responded to a call regarding the door. The director of plant services (DPS)-A stated the door should have locked when R12 got near it, and once R12 made it through the door the door should have alarmed.During an interview on [DATE] at 2:23 p.m., SC-D stated they had seen R12 heading to the door, initially they thought it had locked, but then R12 went through the door, and it didn't alarm so they followed R12 outside. R12 agreed to come back in for coffee so they had brought R12 coffee when they came back in.On [DATE] at 2:30 p.m., DPS-A and maintenance associate (MA-B) started adjusting and testing the main entrance door code alert system. The door continued to fail with testing and readjusting.During an interview on [DATE] at 2:56 p.m., SC-D stated R12 had a history of trying to get out of the facility. Usually when R12 tried to leave, R12 was looking for their car, house, or family. Lately R12 had been attempting to leave more frequently.During an interview on [DATE] at 3:08 p.m., occupational therapist (OT)-C stated R12 was able to walk from her room to the dining room and back again.During an interview on [DATE] at 3:51 p.m., NA-A stated she was familiar with R12 and said she was able to walk around the facility using her walker. NA-A stated R12 could walk to activities using her walker. NA-A stated R12 would try to leave the facility a lot, mostly in the evenings. NA-A stated she would want to go pick up her kids, when this occurred, they would call her son, and he would come over. NA-A stated she was not aware of her ever leaving the building.During an interview on [DATE] at 3:55 p.m., NA-C stated R12 could walk on her own using her walker, stated she was a good walker. NA-C stated R12 would try to leave the building mostly in the evening. NA-C stated she had seen R12 leave the building about a month previously, stated she got between the inner and outside door, the alarm sounded.During an interview on [DATE] at 4:01 p.m., NA-D stated R12 walked independently using a walker. NA-D stated she would try to leave the building and stated the evening before she was crying, trying to find her baby and asking how to get out of the building. She was not successful.During an interview on [DATE] at 4:05 p.m., NA-E stated R12 walked independently using a walker. NA-E was not aware of her trying to leave the building but stated last summer she was wanting to go outside.During an interview on [DATE] at 4:08 p.m., trained medication aide (TMA)-A stated R12 would wait by the door waiting for her son to come and pick her up. TMA-A stated the waiting by the door occurred mostly in the evenings after supper.During an interview on [DATE] at 4:14 p.m., LPN-A stated she had caught R12 a few times trying to leave the building, said she would usually come back in easily and then they would call her son. LPN-A stated R12 could walk independently using a walker, stated she would get between the doors, and the alarm would sound.On [DATE] at 4:19 p.m., MA-B stated the manual identified electronics could potentially interfere with the functioning of the code alert system. All technology was removed from the dining area and the meeting room on either side of the main entrance door. MA-B proceeded to test the door; however, the door did not lock or alarm when approached with a code alert device.During an interview on [DATE] at 4:20 p.m., NA-F stated R12 would get things ready and say someone was coming to pick her up. NA-F stated R12 was able to walk around the building independently using her walker.During an interview on [DATE] at 4:25 p.m., LPN-B said R12 would try to leave the building about four to five times a week. LPN-B stated R12 get around the building independently using her walker.During an interview on [DATE] at 9:02 a.m., SC-D stated on 4/28 they had been at the nurse's station when R12 had set the door alarm off. Normally the door would have locked so R12 couldn't get through the first door. When they responded with another staff, R12 had already made it out between the doors. R12 said they were looking for the salon when we got her.During an interview on [DATE] at 4:29 p.m., SC-D stated Monday through Friday, she would be seated at the desk across from the front door from 8:00 a.m. to 4:30 p.m. The charge nurse would be responsible to lock the front door on the evening shift. SC-D stated R12 will try to leave the building, not usually as much as this week. SC-D recalled last summer R12 got between the two doors. SC-D stated R12 walked independently using a walker.During an interview on [DATE] at 3:38 p.m., the DON stated R12 has had increased confusion and behaviors regarding looking for and being worried about their son. It was a significant change in R12's disease progression for R12 to not know where their apartment was (that was what R12 called their room). The team had discussed R12's inability to navigate to their room and felt it would be beneficial to move R12 to a room where they did not have to pass the main entrance when going to and from their room. They planned to discuss the potential room change with R12's son.R3 was admitted on [DATE]. R3's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with a diagnosis of dementia neurocognitive Lewy body disease. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R4 had not exhibited wandering. R3's care plan last reviewed on [DATE] lacked interventions for elopement and wandering.R4 was admitted on [DATE]. R4's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with diagnoses of Alzheimer's disease and non-traumatic brain dysfunction. MDS. Section P. indicated a wander guard alarm was not in use. Section E900. indicated R4 had not exhibited wandering. R4's care plan last reviewed [DATE], lacked interventions for elopement and wandering.R13 was admitted on [DATE]. R13's quarterly MDS assessment dated [DATE], indicated R13 was moderately cognitive impaired with the diagnoses of dementia, anxiety, and cognitive impairment. Section E900. did not identify wandering behavior. Section P. indicated a wander device was not in use. R13's care plan last revised [DATE], did not include elopement or wandering intervention. On [DATE], R13's elopement assessment was completed and R13's code alert device was removed.R17 was admitted on [DATE]. R17's quarterly MDS dated [DATE], indicated R17 was moderately cognitively impaired with the diagnoses of dementia, and anxiety. Section E900. Indicated R17 had not exhibited wandering behavior. Section P. indicated a wander device was not in use. R17's care plan last updated [DATE], did not include elopement or wandering interventions. An Elopement assessment was completed on [DATE] and R17's code alert device was removed.R18 was admitted on [DATE]. R18's quarterly MDS assessment dated [DATE], indicated R18 was moderately cognitively impaired with a diagnosis of Alzheimer's disease. MDS Section P. indicated a wander guard alarm was not in use. Section E900. indicated R18 had not exhibited wandering. R18's care plan was last reviewed [DATE], did not include interventions for elopement and wandering. R22 was admitted on [DATE]. R22's quarterly MDS assessment dated [DATE], indicated R22 was severely cognitively impaired with diagnosis of vascular dementia with other behavioral disturbances. MDS. Section P. indicated a wander guard alarm was not in use. Section E900. identified R22 had not exhibited wandering. R22's care plan last reviewed [DATE], lacked interventions for elopement and wandering and did not identify the placement location or R22's code alert device.R23 was admitted on [DATE]. R23's admission MDS dated [DATE], indicated R23 was severely cognitively impaired with the diagnoses of anxiety disorder, unspecified head injury and type 2 diabetes. MDS Section E0900. indicated R23 had not exhibited wandering behavior. Section P. did not indicate R23 had a wander guard. R23's care plan last reviewed on [DATE], lacked interventions for elopement and wandering.R28 was admitted on [DATE]. R28's MDS assessment dated [DATE], indicated R28 was severely cognitively impaired with the diagnosis of dementia. MDS Section E0900. indicated R23 had not exhibited wandering behavior. Section P. did not indicate R23 had a wander guard. R28's care plan last reviewed on [DATE], lacked interventions for elopement and wandering.R32 was admitted on [DATE]. R32's annual MDS assessment dated [DATE], indicated R32 was significantly cognitively impaired with the diagnoses of Alzheimer's disease and dementia with behavior disturbances. MDS Section E0900. indicated R32 had not exhibited wandering behavior. Section P. did not indicate R32 had a wander guard. R32's care plan last reviewed [DATE], lacked interventions for elopement or wandering.R34 was admitted [DATE]. R34's quarterly MDS dated [DATE], indicated R34 was significantly cognitively impaired with the diagnoses of Alzheimer's disease and diabetes type 2. MDS Section E0900. indicated R34 had not exhibited wandering behavior. Section P. did not indicate R34 had a wander guard. R34's care plan last reviewed [DATE], lacked interventions for elopement and wandering.R37 was admitted [DATE]. R37's quarterly MDS dated [DATE], indicated R37 was significantly cognitively impaired with the diagnosis of Alzheimer's disease. MDS Section E0900. indicated R37 had not exhibited wandering behavior. Section P. did not indicate R37 had a wander guard. The problem area elopement was not initiated on R37's care plan until [DATE].R46 was admitted on [DATE] and was discharged on [DATE]. R46's significant change MDS assessment dated [DATE], indicated R46 was significantly cognitively impaired with the diagnosis of Alzheimer's disease. MDS Section E0900. indicated R46 had not exhibited wandering behavior. Section P. did not indicate R46 had a wander guard. R46's care plan was requested but not received.On [DATE] at 4:19 p.m., MA-B stated the manual identified electronics could potentially interfere with the functioning of the code alert system. All technology was removed from the dining area and the meeting room on either side of the main entrance door. MA-B proceeded to test the door; however, the door did not lock or alarm when approached with a code alert device.During an interview on [DATE] at 4:20 p.m., NA-F stated R12 would get things ready and say someone was coming to pick her up. NA-F stated R12 was able to walk around the building independently using her walker.During an interview on [DATE] at 4:25 p.m., LPN-B said R12 would try to leave the building about four to five times a week. LPN-B stated R12 get around the building independently using her walker.During an interview on [DATE] at 9:02 a.m., SC-D stated on 4/28 they had been at the nurse's station when R12 had set the door alarm off. Normally the door would have locked so R12 couldn't get through the first door. When they responded with another staff R12 had already made it out between the doors. R12 said they were looking for the salon when we got her.During an interview on [DATE] at 4:29 p.m., SC-D stated Monday through Friday, she would be seated at the desk across from the front door from 8:00 a.m. to 4:30 p.m. The charge nurse would be responsible to lock the front door on the evening shift. SC-D stated R12 will try to leave the building, not usually as much as this week. SC-D recalled last summer R12 got between the two doors. SC-D stated R12 walked independently using a walker.During an interview on [DATE] at 3:38 p.m., the DON stated R12 has had increased confusion and behaviors regarding looking for and being worried about their son. It was a significant change in R12's disease progression for R12 to not know where their apartment was (that was what R12 called their room). The team had discussed R12's inability to navigate to their room and felt it would be beneficial to move R12 to a room where they did not have to pass the main entrance when going to and from their room. They planned to discuss the potential room change with R12's son.During an interview on [DATE] at 1:39 p.m., NA-G stated if a resident had wandering or elopement risks that would be identified on the care plan. All staff watched for and redirected those behaviors. If a resident got too close to the main door, it locked and alarmed to alert staff to respond and redirect. Once the alarm went off it had to be reset to stop alarming and unlock the door.During an interview on [DATE] at 1:46 p.m., NA-B stated as a NA they didn't do anything with the code alert alarm devices on residents. The hydration NA went around once a week and checked to make sure the code alert devices were still working.During an interview on [DATE] at 1:54 p.m., NA-A stated another staff was the primary for testing resident code alert devices, but they had been trained and could do it if asked.During an interview on [DATE] at 2:14 p.m., licensed practical nurse (LPN-C) stated the facility kept a book of resident's who had code alert alarms at (SC)-D's desk by the main entrance. As an LPN, they were not assigned any assessments or checks for the code alert devices, the hydration NAs were the ones who went around and checked to make sure the devices were working. R3 had a code device on their ankle, and they were the only resident with ordered daily placement checks.During an interview on [DATE] at 11:41 a.m., RN-A stated residents got code alert devices placed if/when they were identified as having wandering/elopement behaviors and they could not be safe alone outside. The social worker was responsible for doing the wander/elopement assessments. There is always a concern a resident could elope because no system was fail proof. If a visitor went out the main door a resident could get out behind them. The alarm should go off if a resident makes it past the first door. NAs should know who has a code alert device and those residents should be watched closely. Wander and elopement risks should be added to the care plan with care interventions. Elopement attempts and behaviors should be documented in progress notes especially if the resident makes it out of the facility or past the first door. The NAs should also chart events in the behavior section of their charting. There should be progress notes about R12 and R19's attempts to leave.During an interview on [DATE] at 8:57 a.m., DPS-A said they had been called to check the main door. SC-D stated they had called DPS-A because they didn't see the yellow light sensor that meant the main door code alert system was working. DPS-A held a resident code alert devise and walked to the main entry door and was able to walk into the vestibule between the outermost door and the inner door on the facility side of the vestibule. Once inside the vestibule, the inner door back into the facility locked. DPS-A could not get back into the facility until the alarm was reset. DPS-A explained the facility side door locked when the alarm was triggered. The Door to the outside of the building did not lock, so if a resident made it past the inside door into the vestibule, they would be able to proceed out of the building through the outer door. The system had adjustable sensors [canoes] on both sides of the doors that required adjustment so when a resident with an alert device got close to the door it would lock and if a resident made it through the first door or it was open, then the system alarmed. Humidity could affect the sensors as well as how they were set. DPS-A did a second system test. DPS-A walked up to the door and was able to make it through the first door. DPS-A stated the system hadn't locked the door because they had approached the door too quickly. DPS-A did a slower approach with the same result and then adjusted the canoes (sensors on either side of the door that sense the wearable dvice). DPS-A approached the door two more times, and the door locked appropriately both times.During a follow-up interview on [DATE] at 9:04 a.m., DPS-A stated the system had last been tested on [DATE]. They had not been notified after R12 and R19 made it through the first door. If they had been notified the door would have been tested immediately. The facility did not have a formal notification or downtime plan for the code alert system. Maintenance numbers were posted, and they expected staff to call anytime there was a door malfunction. They came in on off hours to fix the door when needed. DPS-A binder showed their binder of manufacture manuals and testing logs. Logs indicated five doors were tested monthly. Upon review, DPS-A confirmed the Code Alert Monitoring System manual indicated that weekly door testing was optimal. DPS-A explained that when the main entrance door was working properly, the inside facility side door should lock when a resident got close. If the door was open and a resident was close to the door, then the alarm would go off. Once the door shut, the door would lock. The alarm would have to be reset for the door to unlock. Only the inside door locked, the door to outside was not part of the system, so that door opened regardless of the code alert system activation. During an interview on [DATE] at 4:00 p.m., the RS Technologies Tech confirmed they serviced the code alert system. Manufacturer instructions should be followed for system testing, in addition, the company recommended yearly on-site system inspections be scheduled with RS technologies.On [DATE] at 4:29 p.m., MA-B and DPS-A had tech support on the phone and continued to adjust and test the main entrance door. The door was still not locking or alarming. DPS-A said they planned to have a tech come and service the door. SC-D stated they had been instructed to watch the door.On [DATE] at 4:39 p.m., MA-B performed function tests on all the code alert doors. The internal corridor door between the long-term care and short-term rehab failed two function tests. Both times the door did not lock when approached, MA-B was able to go through the door into the short-term rehab. The door alarm did go off as intended. The short-term rehab unit had a small entry area with a single door that went directly outside to the parking lot. MA-B tested the exit door twice. Both times the door failed to lock to prevent exit from the building. On [DATE] at 5:04 p.m., MA-B reported the short-term rehab doors had been fixed and were functioning properly.During an interview on [DATE] at 2:43 p.m. DPS-A stated they had spoken with a tech who had recommended they leave the main entrance door locked until the door could be serviced. They planned to keep the door locked until a tech was able to get on site to fix the door. A staff member would be stationed at SC-D's desk to let people in and out of the building until Monday.During an interview on [DATE] at 12:54 p.m., the DON stated they had not been made aware R12 and R19 had made it out the first door of the main entrance into the vestibule, but they had been present when R12 made it all the way outside, so they were aware of that. The DON stated when an event occurred the nurse should be notified, and then a progress note should be made if a resident makes it past a code alert door. They would expect notes to have been made about the events that occurred with R12 and R19. They would also like residents to be closely monitored after an event. Elopement assessments were reviewed quarterly. Assessments should be re-done if a resident had an event between quarterly assessments or a change from the last quarterly assessment. Resident care plans should include the location of the code alert device and resident specific elopement and wandering interventions. They had a code alert book at the reception desk with a list of residents and their code alert device locations. Weekly code alert battery checks were recorded in the book. They did not do any other placement checks, or nursing assessments r/t code alert devices on a regular basis unless ordered. The DON stated they had never seen R12 ambulate without their walker but agreed residents who had the ability to ambulate without their assistive device potentially had a higher risk of elopement when the code alert was attached to their device instead of their person.During an interview on [DATE] at 1:14 p.m., LSW-A stated elopement risk assessments were done on admit determining if a resident should have a code alert device placed. New elopement assessments were not typically done after an attempt or elopement event if the resident already had a code alert device. However, a new quarterly elopement assessment would be done when due for any residents who had behavior changes or an event. Elopement behaviors and interventions do not get added to resident care plans, but that would be ideal. At present just the location of the code alert device like on walker etc. gets added to a problem area that is already on the care plan such as fall risk or cognition.During an interview on [DATE] at 2:08 p.m., the administrator stated they had not been notified of R19 and R12's attempts to exit the building. Leadership and maintenance should have been notified when R12 and R19 were able to get past the first door. They expected staff to notify maintenance anytime a door didn't seem to be functioning correctly so maintenance could service the door immediately. They had discussed the code alert system with DPS-A and decided they would start doing weekly door testing as recommended in the manual.The immediate jeopardy was removed on [DATE] at 4:36 p.m., when the facility scheduled maintenance for the call alert system, placed staff at the door to monitor the system at all times when the door was not locked, updated resident assessment and care plans for residents who used a code alert device, revised their Code Alert System policy, and educated staff on reporting failures in the call alert system.The facility policy Code Alert System dated 9/2017, identified the code alert transponder devices were to be tested weekly and the door function was to be tested by maintenance monthly. Malfunctions or repairs made were to be reported to the administrator and nursing along with the current status of the system and need for special monitoring due to delay in repairs. The policy did not address malfunctions and actions to be taken for malfunctions outside of monthly testing. Nor did it address down time procedures for malfunction of the system or doors.The facility policy Elopement dated 1/2023, identified residents known to wander and or who have cognitive deficits may wear the signaling device which activates an alarm should they leave the facility. Staff instruction for resident elopement was outlined in the policy. The policy did not include instruction to staff for reporting code alert system malfunctions or alternative actions to be implemented during code system malfunctions.

Based on interview and document review, the facility failed to ensure accurate MDS coding of the use of a code alert device occurred for 14 of 14 residents (R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, R46) who were identified as at risk for elopement and wandering. Findings include:The code alert system log titled Wander Guard Monitor dated 4/2026, identified the following 14 residents as having a code alert device: R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46.R3 was admitted on [DATE]. R3's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with a diagnosis of dementia neurocognitive Lewy body disease. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R4 had not exhibited wandering. R3's care plan last reviewed on 3/16/26 lacked interventions for elopement and wandering.R4 was admitted on [DATE]. R4's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with diagnoses of Alzheimer's disease and non-traumatic brain dysfunction. MDS. Section P. indicated a wander guard alarm was not in use. Section E900. indicated R4 had not exhibited wandering. R4's care plan last reviewed 4/6/26, lacked interventions for elopement and wandering.R13 was admitted on [DATE]. R13's quarterly MDS assessment dated [DATE], indicated R13 was moderately cognitive impaired with the diagnoses of dementia, anxiety, and cognitive impairment. Section E900. did not identify wandering behavior. Section P. indicated a wander device was not in use. R13's care plan last revised 4/16/26, did not include elopement or wandering intervention. On 5/1/26, R13's elopement assessment was completed and R12's code alert device was removed.R17 was admitted on [DATE]. R17's quarterly MDS dated [DATE], indicated R17 was moderately cognitively impaired with the diagnoses of dementia, and anxiety. Section E900. Indicated R17 had not exhibited wandering behavior. Section P. indicated a wander device was not in use. R17's care plan last updated 4/6/26, did not include elopement or wandering interventions. An Elopement assessment was completed on 5/1/26 and R17's code alert device was removed.R18 was admitted on [DATE]. R18's quarterly MDS assessment dated [DATE], indicated R18 was moderately cognitively impaired with a diagnosis of Alzheimer's disease. MDS Section P. indicated a wander guard alarm was not in use. Section E900. indicated R18 had not exhibited wandering. R18's care plan was last reviewed 4/21/26, did not include interventions for elopement and wandering. R22 was admitted on [DATE]. R22's quarterly MDS assessment dated [DATE], indicated R22 was severely cognitively impaired with diagnosis of vascular dementia with other behavioral disturbances. MDS. Section P. indicated a wander guard alarm was not in use. Section E900. identified R22 had not exhibited wandering. R22's care plan last reviewed 3/5/26, lacked interventions for elopement and wandering and did not identify the placement location or R22's code alert device.R23 was admitted on [DATE]. R23's admission MDS dated [DATE], indicated R23 was severely cognitively impaired with the diagnoses of anxiety disorder, unspecified head injury and type 2 diabetes. MDS Section E0900. indicated R23 had not exhibited wandering behavior. Section P. did not indicate R23 had a wander guard. R23's care plan last reviewed on 4/28/26, lacked interventions for elopement and wandering.R28 was admitted on [DATE]. R28's MDS assessment dated [DATE], indicated R28 was severely cognitively impaired with the diagnosis of dementia. MDS Section E0900. indicated R23 had not exhibited wandering behavior. Section P. did not indicate R23 had a wander guard. R28's care plan last reviewed on 4/6/26, lacked interventions for elopement and wandering.R32 was admitted on [DATE]. R32's annual MDS assessment dated [DATE], indicated R32 was significantly cognitively impaired with the diagnoses of Alzheimer's disease and dementia with behavior disturbances. MDS Section E0900. indicated R32 had not exhibited wandering behavior. Section P. did not indicate R32 had a wander guard. R32's care plan last reviewed 2/16/26, lacked interventions for elopement or wandering.R34 was admitted [DATE]. R34's quarterly MDS dated [DATE], indicated R34 was significantly cognitively impaired with the diagnoses of Alzheimer's disease and diabetes type 2. MDS Section E0900. indicated R34 had not exhibited wandering behavior. Section P. did not indicate R34 had a wander guard. R34's care plan last reviewed 4/5/26, lacked interventions for elopement and wandering.R37 was admitted [DATE]. R37's quarterly MDS dated [DATE], indicated R37 was significantly cognitively impaired with the diagnosis of Alzheimer's disease. MDS Section E0900. indicated R37 had not exhibited wandering behavior. Section P. did not indicate R37 had a wander guard. The problem area elopement was not initiated on R37's care plan until 5/1/26.R46 was admitted on [DATE], and was discharged on 4/20/26. R46's significant change MDS assessment dated [DATE], indicated R46 was significantly cognitively impaired with the diagnosis of Alzheimer's disease. MDS Section E0900. indicated R46 had not exhibited wandering behavior. Section P. did not indicate R46 had a wander guard. R46's care plan was requested but not received.R19 was admitted to the facility on [DATE]. R19' significant change MDS assessment dated [DATE], indicated R19 was severely cognitively impaired with the diagnosis of Alzheimer's disease. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R19 had not exhibited wandering. R19's care plan reviewed 2/10/26, lacked interventions for elopement and wandering.R19's most recent elopement assessment was completed on 2/9/26. The assessment identified R19 as low risk for elopement and interventions included clothing labeled with identification, identification band on resident. The Door Alarm band applied (code alert device) was not selected. R19's EMR lacked evidence to show elopement assessments had been performed quarterly.R12 was admitted to the facility on [DATE]. R12's quarterly MDS assessment dated [DATE], indicated R12 was severely cognitively impaired with diagnoses of non-Alzheimer's dementia and anxiety. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R12 had not exhibited wandering. R12's care plan last reviewed 4/16/26, lacked interventions for elopement and wandering.R12 had documented elopement assessments completed by the licensed social worker (LSW-A) on 10/27/23, 9/15/24, 8/18/25.R12's most recent assessment completed on 8/18/25, indicated R12 was a low risk for elopement and interventions in place included: clothing labeled, and an identification band placed on the wrist. The door alarm bad applied (code alert device) was not selected as an intervention. R12's EMR lacked evidence quarterly elopement assessments had been completed.Progress notes entered by LSW-A on 10,30/25, 1/22/26, and 4/16/26, indicated R12's elopement assessments had been reviewed with no change. R12's EMR lacked documentation regarding R12's successful exit of the building on 4/30/26, or their attempts to exit the building made on 4/28/26, and 5/1/26. During an interview on 4/29/26 at 1:39 p.m., NA-G stated if a resident had wandering or elopement risks that would be identified on the care plan.During an interview on 4/29/26 at 2:14 p.m., LPN-C stated the facility kept a book of resident's who had code alert alarms at SC-D's desk by the main entrance. As an LPN, they were not assigned any assessments or checks for the code alert devices.During an interview on 4/30/26 at 9:26 a.m., registered nurse (RN)-B verified section P of the quarterly MDS dated [DATE], did not identify R3 had a wanderguard in use. RN-B stated they never code them. RN-B stated she saw there was a wanderguard in use from reviewing the nursing assistant group sheets but again said they have never coded the wanderguards. RN-B stated the purpose of the MDS was to identify payment, create a picture of all aspects of the resident's life and stated it would help in creating a care plan for the resident(s).During an interview on 4/30/26 at 11:41 a.m., RN-A stated residents got code alert devices placed if/when they were identified as having wandering/elopement behaviors and they could not be safe alone outside. Wander and elopement risks should be added to the care plan with care interventions. Elopement attempts and behaviors should be documented in progress notes especially if the resident made it out of the facility or past the first door. The NAs should also chart events in the behavior section of their charting. The MDS nurse could access behavior charting and the care plan to know who had code alert.During an interview on 4/30/26 at 12:54 p.m., the DON stated elopement assessments were reviewed quarterly. Assessments should be re-done if a resident had an event between quarterly assessments or a change from the last quarterly assessment. Resident care plans should include the location of the code alert device and resident specific elopement and wandering interventions. The MDS should be coded to reflect code alert placement because MDS drives the care/care plan.The undated, facility policy Care Planning-IDT identified the care plan was based on the resident's comprehensive MDS assessment.MDS policies were requested but not received.

Based on interview and document review the facility failed to develop a comprehensive care plan with individualized elopement and wandering interventions with review and revision after subsequent MDS assessments or elopement status changes for 14 of 14 residents (R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, R46) who were identified as at risk for elopement and wandering. In addition, the facility failed to care plan necessary interventions for 3 of 3 residents (R7, R14, and R26) who were addressed for care planning.Findings include: The code alert system log titled Wander Guard Monitor dated 4/2026, identified 14 residents who had code alert devices: R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46. R3 was admitted on [DATE]. R3's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with a diagnosis of dementia neurocognitive Lewy body disease. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R4 had not exhibited wandering. R3's care plan last reviewed on 3/16/26 lacked interventions for elopement and wandering. R4 was admitted on [DATE]. R4's quarterly MDS assessment dated [DATE], indicated R4 was severely cognitively impaired with diagnoses of Alzheimer's disease and non-traumatic brain dysfunction. MDS. Section P. indicated a wander guard alarm was not in use. Section E900. indicated R4 had not exhibited wandering. R4's care plan last reviewed 4/6/26, lacked interventions for elopement and wandering. R13 was admitted on [DATE]. R13's quarterly MDS assessment dated [DATE], indicated R13 was moderately cognitive impaired with the diagnoses of dementia, anxiety, and cognitive impairment. Section E900. did not identify wandering behavior. Section P. indicated a wander device was not in use. R13's care plan last revised 4/16/26, did not include elopement or wandering intervention. On 5/1/26, R13's elopement assessment was completed and R13's code alert device was removed. R17 was admitted on [DATE]. R17's quarterly MDS dated [DATE], indicated R17 was moderately cognitively impaired with the diagnoses of dementia, and anxiety. Section E900. Indicated R17 had not exhibited wandering behavior. Section P. indicated a wander device was not in use. R17's care plan last updated 4/6/26, did not include elopement or wandering interventions. An Elopement assessment was completed on 5/1/26 and R17's code alert device was removed. R18 was admitted on [DATE]. R18's quarterly MDS assessment dated [DATE], indicated R18 was moderately cognitively impaired with a diagnosis of Alzheimer's disease. MDS Section P. indicated a wander guard alarm was not in use. Section E900. indicated R18 had not exhibited wandering. R18's care plan was last reviewed 4/21/26, did not include interventions for elopement and wandering. R22 was admitted on [DATE]. R22's quarterly MDS assessment dated [DATE], indicated R22 was severely cognitively impaired with diagnosis of vascular dementia with other behavioral disturbances. MDS. Section P. indicated a wander guard alarm was not in use. Section E900. identified R22 had not exhibited wandering. R22's care plan last reviewed 3/5/26, lacked interventions for elopement and wandering and did not identify the placement location or R22's code alert device. R23 was admitted on [DATE]. R23's admit MDS dated [DATE], indicated R23 was severely cognitively impaired with the diagnoses of anxiety disorder, unspecified head injury and type 2 diabetes. MDS Section E0900. indicated R23 had not exhibited wandering behavior. Section P. did not indicate R23 had a wander guard. R23's care plan last reviewed on 4/28/26, lacked interventions for elopement and wandering. R28 was admitted on [DATE]. R28's MDS assessment dated [DATE], indicated R28 was severely cognitively impaired with the diagnosis of dementia. MDS Section E0900. indicated R23 had not exhibited wandering behavior. Section P. did not indicate R23 had a wander guard. R28's care plan last reviewed on 4/6/26, lacked interventions for elopement and wandering. R32 was admitted on [DATE]. R32's annual MDS assessment dated [DATE], indicated R32 was significantly cognitively impaired with the diagnoses of Alzheimer's disease and dementia with behavior disturbances. MDS Section E0900. indicated R32 had not exhibited wandering behavior. Section P. did not indicate R32 had a wander guard. R32's care plan last reviewed 2/16/26, lacked interventions for elopement or wandering. R34 was admitted [DATE]. R34's quarterly MDS dated [DATE], indicated R34 was significantly cognitively impaired with the diagnoses of Alzheimer's disease and diabetes type 2. MDS Section E0900. indicated R34 had not exhibited wandering behavior. Section P. did not indicate R34 had a wander guard. R34's care plan last reviewed 4/5/26, lacked interventions for elopement and wandering. R37 was admitted [DATE]. R37's quarterly MDS dated [DATE], indicated R37 was significantly cognitively impaired with the diagnosis of Alzheimer's disease. MDS Section E0900. indicated R37 had not exhibited wandering behavior. Section P. did not indicate R37 had a wander guard. The problem area elopement was not initiated on R37's care plan until 5/1/26. R46 was admitted on [DATE], and discharged from the facility on 4/20/26. R46's significant change MDS assessment dated [DATE], indicated R46 was significantly cognitively impaired with the diagnosis of Alzheimer's disease. MDS Section E0900. indicated R46 had not exhibited wandering behavior. Section P. did not indicate R46 had a wander guard. R46's care plan was requested but not received. R19 was admitted to the facility on [DATE]. R19' significant change MDS assessment dated [DATE], indicated R19 was severely cognitively impaired with the diagnosis of Alzheimer's disease. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R19 had not exhibited wandering. R19's care plan reviewed 2/10/26, lacked interventions for elopement and wandering. R19's most recent elopement assessment was completed on 2/9/26. The assessment identified R19 as low risk for elopement and interventions included clothing labeled with identification, identification band on resident. The Door Alarm band applied (code alert device) was not selected. R12's quarterly MDS assessment dated [DATE], indicated R12 was severely cognitively impaired with diagnoses of non-Alzheimer's dementia and anxiety. MDS. Section P. indicated a wander guard alarm was not in use. Section E900 indicated R12 had not exhibited wandering. R12's care plan last reviewed 4/16/26, lacked interventions for elopement and wandering. R12 had documented elopement assessments completed by the licensed social worker (LSW-A) on 10/27/23, 9/15/24, 8/18/25. R12's most recent assessment completed on 8/18/25, indicated R12 was a low risk for elopement and interventions in place included: clothing labeled, and an identification band placed on the wrist. The door alarm bad applied (code alert device) was not selected as an intervention. During an interview on 4/29/26 at 1:39 p.m., NA-G stated if a resident had wandering or elopement risks that would be identified on the care plan. All staff watched for and redirected those behaviors. During an interview on 4/30/26 at 11:41 a.m., registered nurse (RN-A) stated residents got code alert devices placed if/when they were identified as having wandering/elopement behaviors and they could not be safe alone outside. NAs should know who has a code alert device and those residents should be watched closely. It was the licensed social worker's (LSW-A) responsibility to complete Elopement risk assessments. If nurses initiated a code alert device they would then notify the SW to complete the assessment. Devices were typically placed on resident assistive devices like wheelchairs, walkers, or canes. Once a week the hydration NA went around and checked each device battery to make sure it was still working. There were no other routine nursing assessments or placement checks done associated with the code alerts by nursing. R3 was the only resident with an ankle placement and ordered daily placement checks. Wander and elopement risks should be added to the care plan with care interventions. Elopement attempts and behaviors should be documented in progress notes especially if the resident made it out of the facility or past the first door. The NAs should also chart events in the behavior section of their charting. There should be progress notes about R12 and R22's attempts to leave. The MDS nurse and the social worker have access to the behavior charting. During an interview on 4/30/26 at 12:54 p.m., the DON stated elopement assessments were reviewed quarterly. Assessments should be re-done if a resident had an event between quarterly assessments or a change from the last quarterly assessment. Resident care plans should include the location of the code alert device and resident specific elopement and wandering interventions. Residents who eloped or exhibited wandering or elopement behaviors, and or had had lower cognition or other risk factors that put that at risk if they were to leave the building were assigned code alert devices. It was LSW's responsibility to complete the elopement assessments. Nurses had the ability to place a code alert device and then notify the LSW an assessment needed to be completed. The DON stated they were not sure if a new assessment was completed if a resident eloped or attempted to leave like R12 and R19 had. The MDS should be coded to reflect code alert placement because it drives the care plan and care. During an interview on 4/30/26 at 1:14 p.m., LSW-A stated they were responsible for completing elopement risk assessments. Assessments were done on admit to determine if a resident should have a code alert device placed. Assigning low, medium or high risk for elopement was a judgment call, there was not criteria or a tool for assigning a risk level. New elopement assessments were not typically done after an attempt or elopement event if the resident already had a code alert device. However, a new quarterly elopement assessment would be done when due for any residents who had behavior changes or an event. Elopement behaviors and interventions did not get added to resident care plans, but that would be ideal. At present just the location of the code alert device like on walker etc. gets added to a problem area that is already on the care plan such as fall risk or cognition. The facility policy Elopement dated 1/2023, identified residents known to wander and or who have cognitive deficits may wear the signaling device which activates an alarm should they leave the facility. Staff instruction for resident elopement was outlined in the policy. The policy did not address elopement assessment completion or frequency. The undated, facility policy Care Planning -IDT instructed a comprehensive care plan was to be developed within seven days of completion of the MDS. The facility policy Code Alert System dated 9/2017 procedure section instructed nurses to perform resident assessment of ambulation, cognitive reasoning, and mental capacity. Residents identified as at risk will have potential risk for elopement addressed in the care plan and a code alert transponder applied to person or device. R7: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified he was moderately cognitively intact and had diagnoses which included heart failure (a chronic condition where the heart muscle cannot pump blood effectively to meet the body's needs for oxygen), diabetes mellitus, anemia, insomnia, and chronic atrial fibrillation (a heart arrhythmia where the upper chambers of the heart beat rapidly and irregularly). In addition, R7's MDS identified he was taking an antidepressant. R7's current physician order report dated 4/1/26- 4/30/26, identified R7 was on the following medication: Trazadone 50 milligrams (mg), instructions identified to take at bedtime for sleep disturbance started on 1/21/26. R7's care plan dated 1/8/26, did not address sleep disturbance or antidepressant use. R7's electronic medication record dated 4/1/26-4/30/26, identified R7 received trazadone every night except 4/30/26. During an interview on 4/30/26 at 9:23 a.m., registered nurse (RN)-A reviewed the electronic medical record and verified there was nothing documented in R7's care plan for sleep or antidepressant use. RN-A stated it was important to have this information in the care plan to guide staff in caring for the resident. R14: R14's quarterly MDS dated [DATE], identified R14 was moderately cognitively intact and had diagnoses which included chronic obstructive pulmonary disease (COPD [a lung condition that causes long-term breathing problems by limiting air flow]), heart failure, tobacco use, Alzheimer's, chronic cough, and panlobular emphysema (a severe chronic, and irreversible type of COPD). In addition, R14's MDS identified verbal behaviors and rejection of care. R14's nursing assistant group sheet, dated 4/28/26, did not identify she smoked. R14's care plan dated 2/11/26, did not address smoking. During an observation on 4/27/26 at 3:30 p.m., R14 was wheeled out the front door by staff, she sat in her wheelchair just outside the front door and smoked a cigarette. During an observation on 4/27/26 at 4:45 p.m., R14 was brought out the front door by staff where she smoked a cigarette. During an interview on 4/30/26 at 8:59 a.m., registered nurse (RN)-A stated the resident care plans should be updated as part of the care conference. RN-A stated the facility did allow residents to smoke and said they did accept residents who smoked. RN-A reviewed R14's care plan and verified there was nothing in the care plan that addressed smoking for R14. During an interview on 4/30/26 at 9:39 a.m., the director of nursing (DON) verified they did allow residents to smoke and stated it should have been addressed in the care plan. The DON stated it was important for staff to know if a resident smoked for safety considerations. During an interview on 4/30/26 at 10:15 a.m., nursing assistant (NA)-B reviewed the group sheet for R14 and verified there was nothing to identify she smoked. Smoking Policy-Residents dated 3/2025, identified the facility would establish and maintain safe resident and smoking practices. The policy identified the resident's ability to smoke safely would be re-evaluated quarterly and upon a significant change. R26: R26's annual MDS dated [DATE], identified he was cognitively intact and had diagnoses which included hypertension, chronic kidney disease stage 5 with dependence on renal dialysis (a life-sustaining medical treatment that filters waste products, toxins, and excess fluids from the blood when the kidneys have failed), diabetes mellitus, chronic pain, morbid obesity, anxiety, COPD, cardiac pacemaker, and depressive disorder. In addition, R26's MDS identified he was receiving dialysis services. R26's nursing assistant group sheet, dated 4/28/26, did not identify in the safety column that he was on enhanced barrier precautions. During an interview on 4/30/26 at 9:37 a.m., the DON stated she would need to check with the infection preventionist to see if R26 needed to be in enhanced barrier precautions (EBP) based on his dialysis access site. The DON stated EBP would be used to protect any resident who had a wound, catheter, tube feeding, or a peripheral inserted central catheter. During an interview on 4/30/26 at 10:12 a.m., the infection preventionist (IP) reviewed R26's care plan and verified EBP were not part of the care plan. The IP stated she would expect a resident with a Quinton catheter (a large-bore, double-lumen central venous catheter designed for rapid blood flow in hemodialysis) to be in EBP and part of the care plan. The IP stated EBP are meant to protect the resident from infection. During an interview on 4/30/26 at 10:15 a.m., NA-B stated R26 should be in EBP and staff should be gowning up to perform any hands-on care. Enhanced Barrier Precautions dated 4/2024, identified the purpose of EBP was to reduce the spread of multidrug resistant organisms (MDRO). The policy identified EBP should be used if a resident had an indwelling medical device regardless of MDRO colonization. The policy identified EBP would be used during high contact resident care activities. Care Plans, Comprehensive Person-Centered Care no date, identified the plan would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. In addition, the plan would be developed from a thorough analysis of the information gathered as part of the comprehensive assessment. During an interview on 4/30/26 at 12:37 p.m., the DON stated the care plans should be addressed quarterly with the care conference and they should include information about smoking, wanderguard use, enhanced barrier precautions, and medication use (including use of an antidepressant). The DON stated this was important for direct care staff to have the information for safety, quality of life, and to address their needs and preferences for care.

Based on observation, interview and document review the facility failed to ensure proper hand hygiene and use of an ice scoop was followed during the snack pass. This deficient practice affected 3 of 3 residents (R29, R30, R7) and any other residents who received snacks during the snack pass. Finding include:R29's comprehensive Minimum Data Set (MDS) dated [DATE], identified she was moderately cognitively intact and had diagnoses which included heart disease, hypertension, hyperlipidemia, and gastroesophageal reflux disease.R30's quarterly MDS dated [DATE], identified she was moderately cognitively intact and had diagnoses which included heart failure (a chronic serious condition in which the heart muscle cannot pump enough blood to meet the body's needs for oxygen), diabetes mellitus and depression.R7's quarterly MDS dated [DATE], identified he was moderately cognitively intact and had diagnoses which included heart failure and diabetes mellitus.During an observation on 4/29/26 at 1:56 p.m., nursing assistant (NA)-A had a snack cart with two over-sized plastic pitchers filled with ice. NA-A stopped the cart outside of R29's room, NA-A was not wearing gloves entered the room, brought out the water cup, filled the water cup with ice using a plastic water glass, NA-A put the plastic glass back into the over-sized pitcher with ice, exited the room and did not perform hand hygiene. NA-A proceeded to R7's room and did not perform hand hygiene, entered the room brought out the water cup filled it with ice using the plastic water glass that was resting on top of the ice, poured juice into a cup, brought the water cup, the juice, a bag of chips and brought the items into R7's room. NA-A exited the room; no hand hygiene was performed. NA-A went into R30's room after knocking asked if they wanted any snacks, exited the room with a plate with food on it and put the plate and food into the garbage bag attached to the snack cart. NA-A did not perform hand hygiene, picked up a banana and brought it into R30's room, exited the room. No hand hygiene was performed.During an interview on 4/29/26 at 2:01 p.m., NA-A stated they took the snack cart around to rooms twice daily. NA-A verified she would put the plastic water glass back into the over-sized pitcher with ice and stated, it doesn't touch anything. NA-A verified they did not perform hand hygiene before or after exiting resident rooms or after disposing of uneaten food removed from R30's room.During an interview on 4/30/26 at 9:42 a.m., the director of nursing (DON) stated she would expect staff to perform hand hygiene before entering and after exiting a resident room. The DON stated using a plastic water glass to fill water cups coming from resident rooms and then putting the plastic water cup back into the over-sized ice pitcher was an infection control concern. Hand Hygiene dated 6/2019, identified all employees would be trained on hand hygiene practices. The policy identified hand hygiene would be performed before and after handling food and after handling soiled utensils or equipment.

Based on observation, interview, and document review the facility failed to ensure resident preferences for nail care were honored for 1 of 1 resident (R8).Findings include:R8's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R8 was moderately cognitively impaired with the diagnoses of non-Alzheimer's dementia, renal insufficiency, hypertension, and depression.R8's care plan last reviewed 3/26/26 indicated R8 had limited range of motion in their upper extremities and required an assist of 1 for daily bathing, weekly showers, daily grooming, oral care, and dressing.R8's progress notes indicated R8 had last had a shower on 4/3/26. Nail care was not addressed in progress notes.During an observation on 4/28/26 at 12:48 p.m., R8 was seated in wheelchair in room with their tv remote partially on their bedside table between their hands. Noted tremor in both hands, fingernails were long beyond tips of fingers. R8 stated they were trying to get their remote onto the bedside table, but their hands were so bad they couldn't do it. There was a nail clipper on the left side of R8's bedside table. R8 stated they had the nail clipper there because they wanted to have their nails trimmed, they were too long. R8 stated they couldn't trim their nails, so they had asked staff, but nobody had done it so far.During an interview on 4/29/2026 at 8:57 a.m., R8 stated staff had trimmed their nails before, but nobody had trimmed them yet. It bothered them to have their nails so long.On 4/30/26 at 11:22 a.m., R8 was seated in wheelchair in room the nail clipper was still on the bedside table. R8 stated they know I want my nails trimmed but nobody has done it yet.During an interview on 4/29/26 at 2:14 p.m., licensed practical nurse (LPN-C) stated all residents should have nail care offered on shower day. Nursing assistants (NA) do nail care unless the resident is a diabetic or has some other considerations, then the nurse would do the nail care on bath day.During an interview on 4/29/26 at 1:29 p.m., NA-J stated typically we do nail care on bath days but if a resident wanted their nails trimmed either the NA or the nurse should do it.04/29/2026 1:39 p.m., NA-G 3 stated NAs could do nail care for R8. Activities did a spa day group so R8 could get their nails done in group, otherwise fingernails got done on bath days.04/29/2026 1:46 p.m., NA-B stated NAs could cut fingernails on most residents including R8. Every room also had an activities calendar. Residents can see when they can go to group and get their nails done by activities.During an interview on 4/30/26 at 11:41 a.m., registered nurse (RN-B) stated both nursing assistant and wellness staff (they are NAs) can trim nails. R8 can have either trim their nails. Regardless of what day it is, if a resident requests to have their nails trimmed, their nails should be trimmed. If the NAs can't do it, then they should get the nurse to do it.During an interview on 4/30/26 at 12:52 p.m., the director of nursing (DON) stated nail trimming was typically done on shower days, but if a resident was requesting to have their nails trimmed on a different day, she would expect staff to trim those nails. A resident should not have to wait until their next bath day to get their nails trimmed.The facility policy Resident Choice Policy & Procedure dated 5/2/26, identified autonomy and self-determination were fundamental to quality of life and dignity. The facility would provide a supportive environment that encouraged and facilitated resident choice, respected individual preferences and needs to the greatest extent possible consistent with safety and regulations.The undated facility policy Fingernails-Cleaning and Trimming provided instruction on how to complete nail care and instructed nursing staff will provide nail care as necessary to residents.

Based on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 4 of 5 residents (R1, R19, R7, and R13); failed to obtain signed consent with use of an antidepressant medication for 1 of 5 residents (R38); failed to implement other interventions before initiating antipsychotic medication for 1 of 5 (R38); failed to implement appropriate target behaviors for 1 of 1 resident (R1); and failed to have an appropriate diagnosis for 1 of 1 resident (R19) reviewed for unnecessary medications. Findings include: R1 R1's quarterly minimum data set (MDS) dated [DATE], identified R1 had severe cognitive impairment, required extensive assististance with all activities of daily living (ADL's), and received antipsychotic and antidepressant medications. R1's dianoses included Alzheimers disease, age-related osteoporosis, anxiety, femur fracture, and repeated falls R1's physician orders included order for citalopram (antidepressant) 20 milligram (mg) by mouth daily for major depression; mirtazapine (antidepressant) 7.5mg by mouth daily for major depression and Alzheimers disease; and quetiapine (antipsychotic) 25mg by mouth twice daily for dementia. R1's medical record was reviewed and lacked any evidence orthostatic blood pressures had been obtained for R1. R1's record lacked evidence of blood test monitoring since 2022. R1's target behaviors (behaviors medication is intended to manage) include verbally abusive towards staff and number of times resident resisted cares. On 2/10/25 at 2:52 p.m., R1 was observed in her room looking out the window. During observation on 2/11/25 at 11:51 a.m., R1 was self-propelling wheelhcair in the hallway, R1 was calm with no negative verbalizations. When observed on 2/12/25 at 01:36 p.m. R1 was in the room reading a magazine outloud, no concerns regarding behavior were observed. When interviewed on 2/14/25 at 10:24 am. nursing assistant (NA)-E stated R1 banged on tables, would resist assistance from staff if attempted to remove pants or assisted with bathroom needs. During interview on 2/14/25 at 12:51 p.m. clinical manger (CM)-A stated clinical manager or director of nursing (DON) determined what target behaviors were monitored for psychotropic (drugs that affect a persons mental state) medications. CM-A stated was not aware of residents having orthostatic blood pressures monitored. When interviewed on 2/14/25 at 2:02 p.m., DON stated orthostatic blood pressures should be monitored due to psychotorpic medications can cause orthostatic hypotension (condition when blood pressure significantly drops when a person stands up fro ma sitting or lying position) increasing risk of resident falling. DON stated herslef or clinical managers determined the target behaviors. Name calling, verbal abuse towards staff and resitance of cares were not appropriate target behaviors, residents had the right to refuse cares. DON stated she expected the resident's provider to ensure required blood tests were ordered or recommened by consulting pharmacist if they hadn't been completed. R19 R19s quarterly MDS dated , 1/10/25, identified R19 had severe cognitive impairment, required extensive assistance with all ADLs. R19's diagnoses included Alzheimers disease, psychosis, dementia, osteoarthritis, major depression, falls, coronary artery disease and hypertension. R19's phsyician orders included order for citalopram 20mg by mouth daily for major depression; mirtazapine 7.5mg by mouth daily for alzhemiers disease; quetiapine 25mg by mouth twice daily; amd quetiapine 50mg by mouth once daily for alzheimers disease. R19's target behavior for mirtazapine was sleeps for six to eight hours at night. Progress note dated 1/18/2025, at 2:51p.m. identified new order: Resident has been having increased agitation behaviors. Increase seroquel (quetiapine) to 50 mg for mid day dose. Continue 25 mg for A.M and P.M doses. However, review of R19's progress notes failed to indicate R19 displayed increased agitaion or behaviors. During observation on 2/11/25 at 8:59 a.m., R19 was sitting at a table in common area sleeping. On 2/11/25 at 1:12 p.m., R19 was observed sleeping in recliner in her room. When observed on 2/12/25 at 10:36 a.m., R19 was in the dining room waiting for brunch, with no bserved negative behaviors displayed. During observation on 2/12/25 at 5:55 p.m., R19 was in the dining room observing an activity. R19 was calm and quite. When observed on 2/13/25 at 8:24 a.m., R19 was in the dining room talking with nursing assistant voice was in calm even tones. When interviewed on 2/14/25 at 10:24 a.m., NA-E stated R19 did not have much for behaviors, R19 believed her spouse was in the room with her. NA-E stated she thought R19 was better than she had previously been. When interviewed on 2/14/25 at 1:24 p.m., NA-F stated R19 thought her husband was in the room with her but could not talk, R19 had no behaviors like yelling out or hitting. When interviewed on 2/14/25 at 2:25 p.m., DON stated, sleeps six to eight hours was a goal not a behavior, there would be a sleep log that indicated a concern regarding sleep, R19 liked to be up at night with television on. DON stated she honestly did not feel that R19 required an increase in seroquel, behaviors had improved for the past six to eight months. DON reviewed progress notes, stated she did not see antyhing there that warrented an increase in the seroquel. 48013 R7 R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R7's diagnoses included unspecified dementia with other behavioral disturbance, malnutrition, depression, varicose veins or right lower extremity with inflammation, peripheral vascular diseases, hypothyroidism, essential hypertension, osteoarthritis and systemic sclerosis. R7's medication and treatment record, print date of 2/11/25, indicated R7 had an order to monitor for orthostatic blood pressures (blood pressure drops when you go from lying down to sitting up, or sitting to standing) once monthly. R7's physician orders included orders for Zyprexa (antipsychotic) 2.5 milligram (mg) by mouth once daily for agitation. R7's medical record was reviewed and lacked any evidence orthostatic blood pressures had been obtained for R7 in the past five months. During observation on 2/11/25 at 8:47 a.m., R7 was ambulating independently with walker down hallway with staff walking next to her. R7's gait was steady but needed staff to walk next to her for supervision. R13 R13's quarterly MDS dated [DATE], identified R13 had intact cognition. R13 was independent with bed mobility, sitting to standing and wheeling 50 feet with two turns. R13's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, non-Alzheimer's dementia, chronic obstructive pulmonary disease (COPD), dysphagia, unspecified mood disorder and peripheral vascular disease. R13's medication and treatment record, print date of 2/11/25, indicated R13 had an order to monitor for orthostatic blood pressures once monthly. R13's physician orders included orders for Seroquel (antipsychotic) 12.5 mg by mouth once daily for aggression and agitation. R13's medical record was reviewed and lacked any evidence orthostatic blood pressures had been obtained for since 12/12/24. Record indicated last orthostatic blood pressure obtained was on 12/12/24. During interview on 2/14/25 at 10:00 a.m., licensed practical nurse (LPN)-A stated orthostatic blood pressures are obtained monthly. If orthostatic blood pressures are not able to be completed, she would reattempt later in shift, if possible, otherwise document resident refused in medication administration record (MAR). During interview on 2/14/25 at 11:53 a.m., nurse practitioner stated she prescribed Seroquel in 10/2024 as R13 was agitated and having angry outbursts with staff. NP stated nicotine withdrawal could be contributing to her behaviors. During interview on 2/14/25 at 12:51 p.m., clinical manager (CM)-A stated R7 had an order for orthostatic blood pressures to be obtained once monthly. During interview on 2/14/25 at 2:02 p.m., director of nursing (DON) stated she expected staff to obtain orthostatic blood pressures as ordered and if staff are unable to obtain blood pressures, they should reattempt again the next shift. DON stated orthostatic blood pressures are important to ensure resident was not having a significant difference in blood pressures that could lead to falls or fainting episodes due to the side effects of prescribed medication. DON stated if R13 was able to go out and smoke, she may not have exhibited behaviors of aggression and agitation and may not have needed to be prescribed Seroquel. During interview on 2/14/24 at 3:22 p.m., consultant pharmacist (CP) stated any resident on an antipsychotic medication should have orthostatic blood pressures obtained monthly. CP stated orthostatic blood pressures consist of obtaining a blood pressure when resident was lying, sitting, and then standing within the same timeframe. Pharmacist stated orthostatic blood pressures were important to monitor due to postural hypotension being one of the major side effects, especially in an older person, and would put the resident at a higher risk for falls when taking these medications. A facility Antipsychotic Medication Use policy, dated 12/24, indicated antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: Cardiovascular: orthostatic hypotension. R38 R38's quarterly MDS dated [DATE], identified R38 had intact cognition and independent with all activities of daily living (ADL)'s. R38's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, heart failure, hypertension, anxiety disorder, depression, chronic obstructive pulmonary disease and polyneuropathy. R38's physician orders included orders for Lexapro (antidepressant) 10 mg by mouth once daily for major depressive disorder. R38's medical record was reviewed and lacked any evidence signed consent had been obtained for Lexapro. During interview on 2/14/25 at 2:02 p.m., DON stated consents should be obtained for all mood-altering medications as the resident has the right to know what medication was prescribed and decided if they want to take medication after reviewing potential side effects. During interview on 2/14/15 at 3:31 p.m., CM-A stated she was unable to find signed consent for R38's Lexapro. The facility Psychotropic Medication policy was requested but was not received.

Based on observation and interview, the facility failed to ensure correct use of personal protective equipment (PPE) to prevent the spread of COVID. This had the potential to affect all 4 residents, visitors and staff in short term stay unit. In addition, the facility failed to develop and implement a comprehensive infection control program that incorporated virasurveillance ofl infections and illnesses not treated with antibiotics to reduce the risk of spreading infections to other residents in the facility. This has the potential to affect all 44 residents who resided in the facility. Findings include: Mask and eye protection use During observation and interview on 2/10/25, at 1:58 p.m. registered nurse (RN)-A donned (put on) personal protective equipment (PPE) prior to entering COVID positive room. RN-A removed N95 mask from paper bag, placed on face then removed goggles from same paper bag, placed on face. RN-A stated that the facility had always reused the masks and goggles, placed inside paper bags when not in use. During observation on 2/11/25, at 10:10 a.m. overbed table was outside of COVID positive room containing 3 paper bags with staff names on outside of bags. On 2/12/25, at 10:47 a.m. observed overbed table with 7 paper bags labeled with staff names, one bag opened with edge of N95 mask out of paper bag. On 2/12/25, at 10:57 a.m. observed two unidentified staff members as they prepared to enter COVID positive room, both staff removed surgical mask from face, removed N95 mask and goggles from paper bag labeled with initials before surgical mask was placed into the same paper bag. When staff exited room, surgical mask reapplied from paper bag prior to N95 and goggles being placed back into the paper bags. When interviewed on 2/13/25, at 11:40 a.m. infection preventionist (IP) stated facility had adequate supply of PPE, staff labeled paper bag with their name or initials. N95 masks were reused for a full week as they have done since COVID first started. When IP was asked about surgical masks placed into paper bag and reused, IP stated new surgical masks should have been used to reduce the chance of spreading COVID. When interviewed on 2/14/25, at 2:58 p.m. director of nursing (DON) stated staff had reused N95 masks for the full shift. DON was reminded by IP there was no longer a mask shortage, new ones should be used when entering COVID positive rooms to help prevent the spread of COVID to other residents or staff. Facility policy titled Airborne Precautions dated 6/2019 indicated diseases transmitted through airborne transmission included but not limited to SARS (COVID). Heading of considerations identified resident placement and PPE as isolate resident in a private room, close the doors and alert staff. However, policy did not address the use of PPE. Infection Control Program The facilities infection control logs were reviewed form October 2024 through December 2024. January 2025 infection control log was requested; however, this was not provided. The facility provided documents with the month and year written along the top of the first page. The headings on the document included; unit, name, room number, admitted , existing infection from previous month (yes or no), infection type, body system of infection, surveillance definition (yes or no), symptoms, onset date, diagnostic test performed, test date, type of test, specimen source, test results, antibiotic resistant organism, antibiotic name, class, dose, route, frequency, provider, antimicrobial prescription origin, antibiotic end date, total days of therapy, meets criteria, antibiotic reassessment performed, transition based precautions required if yes specify and date symptoms resolved. There was no indication the facility included other infections not treated with antibiotics such as viral, fungal or yeast infections. Review of the facility infection control logs identified the following: October 2024 Infection Surveillance Log identified 14 residents listed. There were seven-line entries which identified the infection type of prophylaxis (preventative) with two entries contributed to one resident. Three-line entries addressed lower respiratory tract infections which were treated with antibiotic therapy. Three-line entries addressed urinary tract infections (UTI) which were treated with antibiotic therapy. Additionally, one line entry addressed cellulitis/soft tissue/wound infection which was treated with antibiotic therapy. There were no viral, fungal, yeast or viral illnesses identified, only illnesses that were treated with antibiotics. November 2024 Infection Surveillance Log identified 14 residents listed. There were seven-line entries which identified the infection type of prophylaxis (preventative) with two entries contributed to one resident. Six-line entries addressed urinary tract infections (UTI) which were treated with antibiotic therapy with two entries contributed to one resident. Additionally, two-line entries addressed cellulitis/soft tissue/wound infection which were treated with antibiotic therapy. There were no viral, fungal, yeast or viral illnesses identified, only illnesses that were treated with antibiotics. December 2024 Infection Surveillance Log identified 14 residents listed. There were seven-line entries which identified the infection type of prophylaxis (preventative) with two entries contributed to one resident. Three-line entries addressed cellulitis/soft tissue/wound infections which were treated with antibiotic therapy. Four-line entries addressed urinary tract infections (UTI) which were treated with antibiotic therapy. Additionally one line addressed upper respiratory tract infection which was treated with antibiotic therapy. There were no viral, fungal, yeast or viral illnesses identified, only illnesses that were treated with antibiotics. On 2/13/25, at 11:40 a.m. infection preventionist (IP) stated when residents have symptoms of infection it was written on daily report sheets and verbally passed on to the next shift, there was no tracking of infection symptoms or COVID infections on spreadsheets since they were not prescribed antibiotic therapy. IP stated facility had a COVID outbreak in December 2024, IP was nto able to confirm whether or not there were other infections that did not require antibiotics. When interviewed on 2/14/25, at 2:58 p.m. director of nursing (DON) stated tracking on resident infections should include any resident that had symptoms of illness, not just those that were prescribed antibiotics. Tracking should include people on antibiotics to assist with determining what occurred with illness when no antibiotics had been prescribed which included tracking of any incidence of COVID to track location in the building and extent of any outbreak. Facility policy titled Surveillance stated 6/2019 indicated surveillance was used to identify conditions, practices, and processes that increase the risk of infections.

Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 2 of 2 residents (R3, R10) reviewed and observed for self-administration of medications. Findings include: R3 R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R3's diagnoses included heart failure, chronic kidney disease, generalized anxiety disorder, chronic obstuctive pulmonary disease, encephalopathy, hypertension and type II diabetes mellitus and unspecified dementia with psychotic disturbance. R3's physician orders included order for Ipratropium bromide inhalation solution 0.02% - 0.5 mg(milligram) - Inhale 0.5 mg via neb twice daily related to chronic obstructive pulmonary disease. During observation on 2/11/25 at 8:29 a.m., R3 was sitting in her recliner holding the nebulizer mask to her face. Nebulizer cup contained a clear solution and nebulizer machine was running with no staff present in room. During observation on 2/12/25 at 8:07 a.m., R3 was sitting in her recliner holding the nebulizer mask to her face. Nebulizer cup contained a clear solution and nebulizer machine was running with no staff present in room. At 8:15 a.m., R3 turned the nebulizer machine off and placed nebulizer mask on nebulizer machine with a very small amount of clear solution remaining in cup. During record review on 2/11/25, the self-administration of medication assessment, completed on 11/30/24, identified R3 did not wish to self-administer any medications, did not indicate any medications R3 would like to self-administer, and indicated there was no MD order to self-administer medications. Assessment indicated R3 was not appropriate to self-administer any medications. During interview on 2/13/25 at 12:05 p.m., registered nurse (RN)-A confirmed the last self-administration assessment, completed on 11/30/24, indicated R3 was not able to self-administer medications. R10 R10's quarterly MDS dated [DATE], identified R10 had moderate cognitive impairment and required assistance with most ADL's. R10's diagnoses included hypertensive chronic kidney disease, chronic pain, cervicalgia (pain in the neck), anxiety disorder, metabolic encephalopathy, chronic combined systolic and diastolic heart failure, chronic obstructive pulmonary disease and dependence on renal dialysis. R10's physician orders included orders for: 1. Ipratropium-Albuterol inhalation solution 0.5 - 3 mg(milligram)/ml(milliliter) - 3 mL inhale orally three times a day related to chronic obstructive pulmonary disease. 2. Muscle rub (menthyl salicylate-menthol) cream - 15-10% - Muscle rub three times daily to right shoulder related to cervicalgia (pain in the neck). R10's physician orders lacked evidence for an order for eye drops. During observation and interview on 2/10/25 at 4:18p.m., R10 had two bottles of muscle rub cream in room and a bottle of artificial tears eye drops. R10 stated he applied the muscle rub up to three to fours times a day and staff also comes in and applies some. R10 stated he applied it just before surveyor entered room. Muscle rub menthol scent was present in room. R10 stated he applied the eye drops when his eyes were dry and itchy. During observation on 2/11/25 at 7:48 a.m., R10 was sitting in his wheelchair in his room. Two tubes of muscle rub and a bottle of eye drops remained in R10's room. Nebulizer cannister contained a clear solution, approximately 1/4 full, and was standing in an upright position on nebulizer machine. During observation on 2/12/25 at 10:32 a.m., R10 was not in room. Two tubes of muscle rub and a bottle of eye drops remained in R10's room. Nebulizer cannister contained a clear solution, approximately 3/4 full, and was standing in an upright position on nebulizer machine. During observation on 2/12/25 at 6:20 p.m., same amount of clear solution remained in nebulizer cannister from earlier this morning and was standing in an upright position on nebulizer machine. During observation on 2/13/25 at 8:03 a.m., R10 was sitting in his wheelchair in his room. Two tubes of muscle rub and a bottle of eye drops remained in R10's room. Nebulizer cannister contained a clear solution, approximately 3/4 full, and was standing in an upright position on nebulizer machine. During interview on 2/13/25 at 11:45 a.m., R10 stated he just returned to the facility from an appointment and stated he had not completed his nebulizer treatment this morning. During record review on 2/13/25, the self-administration of medication assessment, completed on 2/2/25, identified R10 wanted to self-administer medications, however assessment did not indicate any medications R10 would like to self-administer. Assessment indicated R10 was not appropriate to self-administer any medications and agreed to having nursing store and administer all medications. During interview on 2/13/25 at 11:46 a.m., trained medication aide (TMA)-A stated there was one resident on this unit, which was not R3 or R10, that were able to self-administer medications. TMA-A stated if a resident was able to self-administer medications, it would be displayed in the resident's electronic health record (EHR). TMA-A confirmed that R3 and R10 did not have an order to self-administer medications which included nebulizer treatments. TMA-A went to R10's room, confirmed two tubes of muscle rub and one bottle of eye drops were in room and took them out of room. TMA-A confirmed that R10's nebulizer cannister was still full of clear solution and stated she set it up this morning and had reminded him to complete his nebulizer treatment, however confirmed that R10 had not done nebulizer treatment. During interview on 2/13/25 at 11:57 a.m., RN-A confirmed there was no order for self-administration of medication in R10's EHR. RN-A stated the last self-administration assessment, completed on 2/2/25, indicated R10 wanted to self-administer medications but the assessment did not include what medication could be self-administered. RN-A asked TMA-A if R10 was able to administer the eyes drops independently with TMA-A stating that apparently R10 is able to self-administer the eye drops because she had never administered eye drops to R10. RN-A confirmed there was no order for eye drops. During interview on 2/14/25 at 2:02 p.m., director of nursing (DON) stated self-administration of medications assessments are completed by a licensed nurse. DON stated assessments should be completed at time of admission, quarterly, or with a significant change in status. DON confirmed nebulizer treatments set up for a resident to self-administer, when nurse leaves the room, needed to be assessed and a self-administer order would need to be obtained from the provider. It was important for the resident to be assessed for self-administration of medications to ensure the resident understands what the medication is for and is capable to complete the whole process. The facility Self-Administration of Medications policy, dated 3/24, identified residents have the right to self-administer medication if the nursing team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the nursing team assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident. 2. The nursing team considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self-administration. b. The resident is able to read and understand medication labels. c. The resident can follow directions and tell time to know when to take the medication. d. The resident comprehends the medication's purpose, proper dosing, timing, signs of side effects and when to report these to the staff. e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed quarterly and is based on changes in the resident's medical and/or decision-making status.

Based on interview and document review, the facility failed to provide smoking opportunities to promote quality of life and resident choice for 1 of 1 resident (R13) reviewed for choices. Findings Include: R13's Continuity of Care document (CCD) printed 2/11/25, included diagnosis of tobacco use, weakness and dementia without behavioral disturbance. R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had intact cognition. R13's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, non-Alzheimer's dementia, chronic obstructive pulmonary disease, dysphagia, unspecified mood disorder and peripheral vascular disease. R13's electronic health record (EHR) lacked evidence R13 was asked about or assessed for smoking. Progress note dated 6/17/24, indicated R13 expressed concerns and anger towards someone confiscating her cigarettes. Progress note dated 6/29/24, indicated R13 yelled at multiple staff to take her outside and smoke. When staff refused, R13 went outside by herself and attempted to light a match on the building and was unsuccessful. R13 came back into building and yelled at staff to assist her with lighting her cigarette. When staff refused, R13 began yelling and this went on four different times between the times of 6:30 to 9:30 p.m. Note indicated R13 was feeling up staff for cigarettes and lighters. Progress note dated 7/18/24, indicated R13 wheeled herself outside and was asking visitors who were entering building if they had a cigarette she could have. Progress note dated 8/2/24, indicated R13 was outside smoking and that she had a pack of cigarettes in her sweater. Staff approached R13 and asked for her cigarettes with R13 stating it was her last one. During the time R13 was outside, another staff member went into R13's room and found a pack of cigarettes, took them and placed them in the medication room. R13 approached staff later demanding her cigarettes back and stated staff had no right to invade her privacy and taking her pack of cigarettes. R13 was yelling and cursing at staff. Progress note dated 8/3/24, indicated R13 was very upset about not being able to smoke and that resident is in a decent mood other than being very upset about not being able to smoke. Progress note dated 8/7/24, indicated R13 was yelling and calling staff names. R13 stated that someone stole her cigarettes. Progress note dated 9/1/24, indicated staff assisted R13 with going outside. Staff walked back into the building and looked out window to see R13 attempting to light a cigarette with a lighter. Progress note dated 10/6/24, indicated R13 became angry with staff when they told R13 she was not allowed to have a cigarette. R13 began demanding staff to give her a cigarette and stating, someone stole hers. Progress note dated 10/22/24, indicated R13 continually asked staff for cigarettes and when staff refused, R13 yelled and swore at staff. Progress note dated 10/26/24, indicated R13 was seen outside the front entrance smoking. Progress note dated 11/6/24, indicated R13 was outside smoking and when R13 stood us there was a lighter under her leg. Progress note dated 12/19/24, indicated R13 continually asked staff for cigarettes, every 30 minutes, and to take her outside. Progress note dated 12/21/24, indicated R13 continually asked staff for cigarettes and would get angry with staff when they would not give her a cigarette. Progress note dated 12/28/24, indicated R13 had behaviors this evening. R13 was continually asking many staff members for cigarettes and would yell at staff when they would not give her a cigarette. Progress note dated 12/29/24, indicated R13 continually asked staff for cigarettes and to take her outside and sit with her. Note indicated R13 is capable of propelling her wheelchair outside independently and had been asking every 30 minutes. Progress note dated 1/3/25, indicated R13 was alert and oriented and was able to make her own decisions. Note indicated R13 continually will ask staff for cigarettes and for staff to take her outside and can get verbal with staff if she doesn't get the answers she is looking for. Progress note dated 1/28/25, indicated R13 was angry at staff for not allowing her to smoke. Progress note dated 1/28/25, indicated R13 was seen outside smoking a cigarette that she had hidden after continually asking staff for one of her cigarettes. R13 cursed and swore at staff. R13's care plan failed to address wishes to smoke. During interview on 2/11/25 at 12;02 p.m., R13 stated she was a smoker and would smoke if she had the opportunity. R13 stated she had smoked since she was [AGE] years old and was smoking up to the day she was admitted to facility. R13 stated it made her very angry and anxious when she is not able to smoke. During interview on 2/11/25 at 1:47 p.m., nursing assistant (NA)-A stated R13 usually went outside to smoke, however it depends on how often as management has stated she was not allowed to smoke. NA-A stated R13 has asked staff to take her outside and gets upset when staff refuses. NA-A stated a lot of R13's behaviors were from nicotine withdrawal. During interview on 2/12/25 at 1:36 p.m., NA-B stated R13 is a smoker but she was not allowed to smoke on grounds. NA-B stated R13 becomes angry and would yell in the hallway and common areas when staff told her she cannot smoke. NA-B stated she [R13] would not have behaviors if she was allowed to smoke. NA-B stated cigarettes and lighters have been found in R13's room by other staff who removed them and stored them at nursing station. During interview on 2/13/25 at 11:34 a.m., NA-C stated R13 was rude and would yell at staff. R13 has left facility to buy cigarettes and lighters. NA-C stated R13's behaviors stemmed from her not being able to smoke. During interview on 2/13/25 at 12:13 p.m., registered nurse (RN)-A stated R13 liked to go outside frequently but was not able to as we are a non-smoking facility. RN-A stated R13 had a gruff personality and became angry at staff when they would not allow her to go outside to smoke. RN-A stated R13's behaviors were from her not being able to smoke. During interview on 2/14/25 at 1:43 p.m., social worker (SW) stated R13 had aggressive behaviors, all verbal, that started in the past several months. SW stated R13's behaviors were from R13 not being able to smoke. R13 would be able to go outside to the street to smoke if facility completed an assessment to ensure resident was able and safe to. SW stated R13 was able to make daily choices and decisions. During interview on 2/14/25 at 2:02 p.m., director of nursing (DON) stated the facility was a non-smoking facility. R13 had verbal aggression where she would swear and yell at staff. DON stated R13 would state if I could just have a cigarette, I would be happier. DON stated they had another resident in the past that was allowed to smoke outside and stated if R13 was able to go outside and smoke it might de-escalate the behavior she is exhibiting. The Combined Federal and State [NAME] of Rights document, dated 2/1/17, that was in admission packet, indicated the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The facility Resident Preferences for Customary Routine & Activities policy dated 4/24, indicated the facility recognizes and respects the right of each resident to maintain their customary routines and engage in preferred activities to the greatest extent possible, consistent with their individual care plan, safety, and the rights of other residents. We believe that honoring these preferences contributes to residents' well-being, dignity, and quality of life. This policy aims to ensure that residents' choices regarding their daily schedules, personal habits, and social engagements are acknowledges and supported. The facility Tobacco/Smoke Free policy dated February 2025, indicated resident who do wish to continue to use tobacco, electronic cigarettes, or vape pens will be required to sign out in the Release of Responsibility for Leave of Absence book and go off facility property to use tobacco, electronic cigarettes, or vape pens.

Based on interview and document review the facility failed to complete neurological assessments following falls for 2 of 2 residents (R7 and R25) who had unwitnessed falls. Facility also failed to ensure medications were administered per physician's orders for 1 of 2 residents (R30) reviewed for bowel management and failed to ensure vitals were obtained per physician's order for 1 of 1 resident (R30) reviewed for following physician orders. Findings include: R7 R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R7's diagnoses included unspecified dementia with other behavioral disturbance, malnutrition, depression, varicose veins on right lower extremity with inflammation, peripheral vascular diseases, hypothyroidism, essential hypertension, osteoarthritis and systemic sclerosis. R7's progress note dated 6/5/24 at 1:51 p.m., identified an unwitnessed fall. R7 was heard screaming and staff found her on her knees next to recliner. R7 had a bump on her upper-mid forehead that was purplish in color. Record indicated neurological assessment was initiated but was not thoroughly completed. R7's progress note dated 12/13/24 at 2:51 a.m., identified an unwitnessed fall. R7 was found sitting on floor with back resting against recliner with sheet and blankets wrapped around her. R7's progress note dated 12/13/24 at 8:30 a.m., identified an unwitnessed fall. R7 was found on floor lying on left side. R7 had small bruise on left side of forehead. R7's record lacked evidence neurological assessment were completed after R7's unwitnessed falls on 12/13/24 and indicated the neurological assessment, dated 6/5/24, had four times blank where no neurological assessment was completed making the assessment incomplete: - On 6/5/24 at 2:15 a.m. line was drawn through assessment and had sleeping written through time slot. - On 6/5/24 at 2:45 a.m. line was drawn through assessment and had sleeping written through time slot. - On 6/5/24 at 2:45 p.m. assessment time was blank - On 6/5/24 at 6:45 p.m. assessment time was blank - On 6/5/24 at 11:45 p.m. line was drawn through assessment time and had sleeping written through time slot. R25 R25's quarterly MDS dated [DATE], identified R25 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R25's diagnoses included progressive neurological conditions, Parkinson's disease with dyskinesia (uncontrolled, involuntary movements of the face, arms or legs), non-Alzheimer's dementia, anxiety disorder, adult failure to thrive, severe protein-calorie malnutrition, hypothyroidism and unilateral primary osteoarthritis of left knee. R25's progress note dated 1/7/25 at 6:30 p.m., identified an unwitnessed fall. R25 was found on floor next to her bed with her face down and her hands under her abdomen and her legs straight. R25 had a large bump above her right outer eye that was purple in color. R25's Record indicated neurological assessment was initiated but was not thoroughly completed. Neurological assessment, dated 1/7/25, had two times blank where no neurological assessment was completed making the assessment incomplete. At 4:45 p.m. and 5:15 p.m. there was a line drawn through each assessment time and had eating written through time slots. During interview on 2/14/25 at 10:00 a.m., licensed practical nurse (LPN)-A stated when a resident falls, licensed nursing staff assess the resident and ensure there are no injuries. LPN-A stated if the fall was unwitnessed or if resident hit their head, neurological assessments would be initiated. LPN-A stated she would not wake a resident or interrupt resident when in dining room to complete neurological assessment unless she knew they had hit their head. During interview on 2/14/25 at 12:51 p.m., clinical manager (CM)-A stated when a resident fell , licensed staff would assess resident by obtaining vital signs, checking range of motion and assessing for injuries. CM-A stated if fall was unwitnessed or if resident hit their head, neurological assessment would be initiated. CM-A stated she would expect staff to wake up resident to complete the neurological assessments as it was important to obtain and monitor for any changes in vital signs of level of consciousness. During interview on 2/14/25 at 2:02 p.m., director of nursing (DON) stated when a resident fell staff alerted the nurse who would obtain vitals and assess for injury. DON stated when a fall was unwitnessed neurological checks are done every 15 minutes for two times, every 30 minutes for two times, every hour for four times and every four hours for seven times. DON stated she would expect staff to wake the resident up to complete neurological assessment at the scheduled time and to complete assessments even when resident was in the dining room. DON confirmed the neurological assessment for R7's and R25's falls were not completed and neurological assessment for R7's falls on 12/13/24 were not initiated. DON stated neurological assessments were important to complete due to residents being fragile and need to be monitored closely to ensure they are not experiencing a change in condition after a potential head strike. The facility Fall Protocol policy dated 3/24, indicated if a resident hit head or if hitting of head is unknown, start neuro checks using Neurological Check Observation. Neurological checks are every 30 min x 2, then every 1-hour x 4 hours, then every 4-hours x 24 hours. Bowel management medication R30 R30's quarterly MDS dated [DATE], identified R30 had intact cognition and required assistance with activities of daily living (ADL)'s such as transferring, toileting. R30's diagnoses included end stage renal disease, anemia, heart failure, hypertension, peripheral vascular disease, diabetes mellitus, malnutrition, anxiety disorder, depression, chronic obstructive pulmonary disease (COPD), polyneuropathy and paroxysmal atrial fibrillation. During review of R30's electronic medication record (EMR), R30 had the following orders: 1. Senna-docusate sodium oral tablet 8.6-50 mg (milligram) two tablets daily to prevent constipation, 2. Dilaudid (hydromorphone) 2 mg one tablet by mouth every Monday, Wednesday and Friday before dialysis, 3. Dilaudid 1 mg one tablet by mouth every four hours as needed for moderate to severe pain, 4. Senna-docusate sodium oral tablet 8.6-50 mg two tablets by mouth as needed at bedtime once daily for constipation, 5. Docusate sodium 100 mg one capsule by mouth as needed once daily for constipation 6. Bisacodyl suppository 10 mg rectally as needed once daily for constipation. R30's bowel record indicated R30's last bowel movement was on 2/8/25, indicating R30 had not had a bowel movement in six days. During review of R30's electronic health record (EHR), EHR lacked evidence of as needed medications ordered for constipation had not been provided for R30. During interview on 2/10/25 at 2:45 p.m., R30 stated she was constipated due to dialysis, fluid restriction and pain medication she had been receiving. R30 stated she received scheduled Senna, but it helps off and on. R30 stated she had not had a bowel movement in several days. During interview on 2/14/25 at 8:58 a.m., R30 stated she still had not had a bowel movement in several days and she was kind of uncomfortable due to this. During interview on 2/14/25 at 10:00 a.m., LPN-A stated the bowel program they followed included if a resident was on day three with no bowel movement prune juice would be given to resident. On day four of no bowel movement as needed Senna would be administered and on day five of no bowel movement an as needed suppository would be administered. During interview on 2/14/25 at 12:51 p.m., CM-A stated a bowel report was printed every day and expected staff to follow standing orders for constipation. During interview on 2/14/25 at 2:02 p.m., DON stated aides chart resident's bowel movement which relays the information to the nurses. DON stated small bowel movements were not counted. DON confirmed R30's last BM was on 2/8/25. DON stated she expected nursing to follow the protocol and offer PRN medications from the standing house orders which consisted of senna, Colace, suppositories and/or enema. DON stated PRN medications should have been offered especially since R30 was on narcotic medications. DON stated it was important so a resident did not get constipated and/or worst-case scenario could lead to hospitalization , and it also affected her quality of life. The facility Bowel Protocol policy dated 4/24, indicated: Do not apply routine bowel protocol if: -There is blood in resident's stool. -There is significant change in resident's mental status. -Bowel sounds are not heard on assessment. -An abdominal mass of unknown origin is palpated. -Dialysis residents cannot have Milk of Magnesia. Check residents MAR for scheduled or PRN stool softeners/laxatives before starting routine bowel program. Night shift nurse to print/review bowel report after 0500 daily. -Day 3 with no BM give 6-8 ounces of prune juice and document amount accepted in MAR. -Day 4 with no BM results give cc of Milk of Magnesia. -Day 5 with no BM results give Bisacodyl suppository -Day 6 with no BM results give Fleets Enema. -If no results on day 6 the day shift nurse will update MD/NP for further orders and request routine (or change in) med if indicated. Vital Signs During review of R30's electronic health record (EHR), provider notes, dated 2/4/25 indicated R30's heart rate was controlled on Coreg (carvedilol) and blood pressures run soft requiring midodrine on dialysis days. Due to hypotension and dizziness complaints will stop Coreg and monitor heart rate closely. R30's vital sign record indicated R30's last pulse was obtained on 2/1/25, indicating R30 had not had her pulse checked since discontinuation of carvedilol on 2/4/25. During interview on 2/14/25 at 2:02 p.m., DON stated any licensed nurse reviews the provider visit notes for orders and confirmed an order for regular pulse checks was completed after discontinuation of medication per provider's order. DON stated R30's last pulse was on 2/1/25. DON stated it was important due to it being a physician's order so it should be followed for resident's health. The facility's Processing of Physician's Orders policy and procedure was requested but was not received.

Based on interview and document review, the facility failed to ensure proper treatment was provided to maintain hearing for 1 of 1 resident (R10) reviewed for hearing. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had moderate cognitive impairment and required assistance with most ADL's. R10's care plan, indicated R10 was hard of hearing and has difficulty with normal conversations. Care plan indicated qualified nursing staff would monitor for changes with my [R10's] abilities with communication and would offer to arrange hearing evaluation as needed. R10's electronic health record (EHR) lacked evidence R10 was offered an audiology appointment. During observation and interview on 2/10/25 at 4:04 p.m., R10 stated he had difficulty with hearing and asked surveyor to speak louder as it was really hard to hear people talking. R10 did not have hearing aides in his ears. R10 stated he had three pairs of hearing aids; one pair won't stay in ears and his daughter took the other two pairs home to see if she could get them fixed. R10 stated the facility had not discussed audiology services with him. During observation on 2/11/25 at 7:48 a.m., R10 did not have hearing aids present in ears. During observation on 2/12/25 at 5:54 p.m., R10 did not have hearing aids present in ears. During interview on 2/13/25 at 11:34 a.m., nursing assistant (NA)-C stated R10 was very hard of hearing and staff needed to speak louder for him to hear. During interview on 2/14/25 at 9:53 a.m., NA-D stated R10 was very hard of hearing, did not wear hearing aids and needed staff to talk loudly for him to hear. NA-D stated it may take R10 a couple of times for him to understand what is being said. During interview on 2/14/25 at 9:57 a.m., NA-E stated R10 was very hard of hearing, did not wear hearing aides and needed staff to speak loud to him to hear. During interview on 2/14/25 at 12:51 p.m., clinical manager (CM)-A stated a consent form was completed on admission for services such as podiatry, audiology and ophthalmology from outside provider who came to facility. CM-A stated if a resident was having general concerns, the services were discussed again. During interview on 2/14/25 at 3:31 p.m., CM-A stated she could not find documentation to indicate audiology services were discussed with resident. During interview on 2/14/25 at 2:02 p.m., director of nursing (DON) stated if staff noticed a progression in hearing loss, facility should offer audiology services. DON stated staff could also check for wax buildup to see if could help with the resident being able to hear. She expected the resident was asked on admission if they would like audiology services and then it should be readdressed at every care conference. DON stated it was important to provide/assist with audiology services for his quality of life especially when R10 goes to dialysis as there was a community of individuals who go on the same schedule as R10 and being able to hear them was important so he can converse with them and be part of that community. The facility Hearing Impaired Resident policy, dated 1/25, indicated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. Staff will assist the resident (or representative) with locating available resources, scheduling appointments, and arranging transportation to obtain needed services. Staff will assist residents with the care and maintenance of hearing devices.

Based on observation, interview and document review, the facility failed to implement care plan interventions to prevent pressure ulcers for 1 of 1 residents (R6), who were at risk to develop pressure ulcers. In addition, the facility failed to provide timely assistance with repositioning to promote healing of pressure ulcer for 1 of 1 resident (R25) in accordance with the individualized care plan. Findings include: R6's annual minimum data set (MDS) indicated R6 was severely cognitively impaired and was dependant on staff for cares. R6's pressure ulcer care assessment area (CAA) dated 11/21/24, indicated R6 was at risk for pressure ulcers due to needing physical assistance with bed mobility, was completely incontinent of bowel and bladder. R6's skin risk assessment with braden scale dated 1/30/25, identified R6 was at high risk to develop pressure ulcers and had interventions which included pressure reducing device on bed and wheelchair and heel protectors. R6's care plan revised 2/4/25, indicated R6 was at risk for impaired skin with interventions which included pressure relieving boots on feet while in bed. During observation on 2/10/25, at 12:23 p.m. R6 was in bed, pressure relieving boots were in chair. On 2/11/25, at 1:13 p.m. R6 was observed in bed sleeping on her right side, pressure relieving boots were in chair across the room On 2/12/25, at 1:39 p.m. R6 was observed in bed sleeping, laying on her right side, pressure relieving boots were nn chair across the room. When interviewed on 2/14/25, at 10:24 a.m. nursing assistant (NA)-E stated pressure relieving boots were on R6's feet during hours of sleep which included anytime R6 was in bed, including naps. When interviewed on 2/14/25, at 12:51 p.m. clinical manager (CM)-A stated pressure relieving boots were to be put on when in bed, come off when out of bed, this included during the day when naps were taken. When interviewed on 2/14/25, at 2:25 p.m. director of nursing (DON) stated the expectation was pressure relieving boots were placed on resident's [R6] feet anytime they were in bed to protect the heels to prevent pressure ulcers. 48013 R25 R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R25 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R25's diagnoses included progressive neurological conditions, Parkinson's disease with dyskinesia (involuntary, erratic movements of the face, arms, legs or trunk), non-Alzheimer's dementia, anxiety disorder, adult failure to thrive and severe protein-calorie malnutrition. MDS indicated R25 was at risk for the development of pressure ulcers and currently had one stage four pressure ulcer (stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone). R25's care plan dated 1/8/25, identified R25 had a stage four pressure ulcer to right ischial tuberosity (large posterior bony protuberance on the superior ramus of the ischimum) and was at a high risk for altered skin integrity and pressure injuries and directed staff to reposition R25 every two hours while in bed and/or wheelchair. During continuous observation on 2/13/25 from 9:01 a.m. to 1:03 p.m. R25 was observed to be seated in a Broda (reclining wheelchair with bilateral supportive cushions) chair. At 9:01 a.m., hospice aide brought R25 to the common area to sit with other residents. At 10:03 a.m., R25 remained in common area watching television. At 11:11 a.m., R25 remained in common area watching television. At 12:38 p.m., R25 remained in common area watching television. At 12:49 p.m., R25 remained in common area watching television. At 1:03 p.m., staff assisted R25 to her room to assist R25 with laying down in bed to rest. During interview on 2/14/25 at 9:53 a.m., nursing assistant (NA)-D stated R25 was unable to reposition herself in her wheelchair and needs staff to assist with repositioning. NA-D stated R25 was to receive assistance with repositioning every two hours. During interview on 2/14/25 at 9:57 a.m., NA-E stated R25 needed to be turned and repositioned every two hours. During interview on 2/14/25 at 10:00 a.m., licensed practical nurse (LPN)-A stated R25 should be turned and repositioned every two hours. During interview on 2/14/25 at 12:51 p.m., clinical manager (CM)-A stated R25 had a pressure ulcer and needed to be turned and repositioned every two hours whether she was in bed or Broda chair. During interview on 2/14/25 at 2:02 p.m., director of nursing (DON) stated she expected staff to turn and reposition R25 every two hours. DON stated it was important for R25 to be turned and repositioned every two hours as R25 had current stage four pressure ulcer, had end stage Parkinson's, had no adipose tissue, was contracted and had very fragile skin. DON stated it was not appropriate R25 was not turned and repositioned every two hours per her care plan. The Individualized Care Plan Policy dated 10/26/22, indicated the facility would develop a comprehensive care plan using the comprehensive assessments, will individualize the plan of care to accurately reflect resident's functional capacity and medical, nursing, psychosocial, activity and other identified needs. The facility Position a Resident in Chair/Wheelchair / Position - Side lying / Position - Supine policy, undated, indicated staff to provide proper positioning and good body alignment in order to prevent skin breakdown, relieve pressure and provide for better circulation. Nursing staff will provide resident with good body alignment and will reposition residents every 2 hours or more often as needed.

Based on observation, interview and document review, the facility failed to comprehensively assess to assure safety with smoking for 1 of 1 resident (R13) who was smoking outside the facility. Findings include: R13's Continuity of Care document (CCD) printed 2/11/25, included diagnosis of tobacco use, weakness and dementia without behavioral disturbance. R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had intact cognition. R13's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, non-Alzheimer's dementia, chronic obstructive pulmonary disease, dysphagia, unspecified mood disorder and peripheral vascular disease. R13's electronic health record (EHR) lacked evidence R13 was asked about or assessed for smoking. During the facility entrance conference on 2/10/25, the administrator and the clinical manager (CM)-A stated the facility did not have any residents who smoke as the facility was a non-smoking facility. R13's care plan printed 2/11/25, did not indicate R13 smoked. Progress note dated 6/29/24, indicated R13 yelled at multiple staff to take her outside and smoke. When staff refused, R13 went outside by herself and attempted to light a match on the building and was unsuccessful. R13 came back into building and yelled at staff to assist her with lighting her cigarette. When staff refused, R13 began yelling and this went on four different times between the times of 6:30 to 9:30 p.m. Note indicated R13 was feeling up staff for cigarettes and lighters. Progress note dated 8/2/24, indicated R13 was outside smoking and that she had a pack of cigarettes in her sweater. Staff approached R13 and asked for her cigarettes with R13 stating it was her last one. During the time R13 was outside, another staff member went into R13's room and found a pack of cigarettes, took them and placed them in the medication room. R13 approached staff later demanding her cigarettes back and stated staff had no right to invade her privacy and taking her pack of cigarettes. R13 was yelling and cursing at staff. Progress note dated 9/1/24, indicated staff assisted R13 with going outside. Staff walked back into the building and looked out window to see R13 attempting to light a cigarette with a lighter. Progress note dated 10/26/24, indicated R13 was seen outside the front entrance smoking. Progress note dated 11/6/24, indicated R13 was outside smoking and when R13 stood up there was a lighter under her leg. Progress note dated 1/28/25, indicated R13 was seen outside smoking a cigarette that she had hidden after continually asking staff for one of her cigarettes. During interview on 2/11/25 at 12:02 p.m., R13 stated she was a smoker and would smoke if she had the opportunity. During interview on 2/11/25 at 1:47 p.m., nursing assistant (NA)-A stated R13 usually went outside to smoke, however it depended on how often as management stated she was not allowed to smoke. During interview on 2/12/25 at 1:36 p.m., NA-B stated R13 is a smoker, has gone outside to smoke several times, but was recently told that she is not allowed to smoke on grounds. During interview on 2/13/25 at 11:34 a.m., NA-C stated R13 will go out of facility and buy cigarettes and lighters. During interview on 2/13/25 at 12:13 p.m., registered nurse (RN)-A stated R13 liked to go outside frequently but is not able to as we are a non-smoking facility. During interview on 2/14/25 at 11:53 a.m., nurse practitioner (NP) stated the facility staff saw R13 smoking outside a lot. During interview on 2/14/25 at 12:51 p.m., clinical manager (CM)-A stated R13's family brought in cigarettes in for R13. CM-A stated she did not think a smoking assessment would be done for R13 as the facility is non-smoking. During interview on 2/14/25 at 2:02 p.m., director of nursing (DON) stated the facility was a non-smoking facility. DON stated a smoking assessment should have been completed when R13 was first seen out smoking. DON confirmed no smoking assessment had been completed for R13. The facility Tobacco/Smoke Free policy dated February 2025, indicated residents and/or their families or designated responsible party are informed during the admission screening process that we are a tobacco/smoke free facility. Resident who has history of smoking will be offered smoking cessation. Residents who do wish to continue to use tobacco, electronic cigarettes, or vape pens will be required to sign out in the Release of Responsibility for Leave of Absence book and go off facility property to use tobacco, electronic cigarettes, or vape pens.

Based on interview and document review, the facility failed to ensure the development of parameters for administration of heart rate control medication was assessed and implemented with pulse monitoring to ensure the parameters were met, if needed, to decrease the risk for complications for 2 of 5 residents (R13 and R40) reviewed for unnecessary medication use. Findings include: R13 R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had intact cognition. R13 was independent with bed mobility, sitting to standing and wheeling 50 feet with two turns. R13's diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, non-Alzheimer's dementia, chronic obstructive pulmonary disease (COPD), dysphagia, unspecified mood disorder and peripheral vascular disease. R13's care plan, print date of 2/11/25, indicated R13 was at risk for impaired cardiac function related to congestive heart failure, hypertension, hyperkalemia, atrial flutter, COPD, obesity, and type two diabetes mellitus. The care plan did not include digoxin (heart rate control medication) medication use and required monitoring. Care plan indicated staff would administer medications as ordered and monitor for signs and symptoms of cardiac distress such as altered vital signs, etc. R13's Order Summary Report dated 1/14/25, indicated R13 received 0.125 milligrams (mg) of digoxin once daily for atrial flutter. The order did not include parameters indicating when the medication should be held related to heart rate. R13's Medication Administration Record (MAR) dated 1/1/25 through 2/13/25, indicated R13 had received metoprolol (approximately) once daily during this period but did not include pulse measurements taken before digoxin administration. R13's Pulse Summary, print date of 2/13/25, identified three pulse measurements were obtained since 1/1/25, ranging from 54 to 63 beats per minute and indicated R13's last pulse measurement was dated 2/5/25. R13's history and physical summary dated 7/12/24, indicated R13 had atrial fibrillation and for staff to monitor heart rate. R40 R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R40's diagnoses included non-traumatic brain dysfunction, Alzheimer's disease with late onset, cancer, coronary artery disease, hypertension, peripheral vascular disease, pneumonia, hyperlipidemia, malnutrition, generalized anxiety disorder, major depressive disorder, COPD, paroxysmal atrial fibrillation, pan lobular emphysema, other obstructive and reflux uropathy, hallucinations, transient cerebral ischemic attack and benign prostatic hyperplasia with lower urinary tract symptoms. R40's care plan, print date 2/12/25, indicated R40 was at risk for impaired cardiac function related to atrial fibrillation, hyperlipidemia, history of NSTEMI and history of angina pectoris. The care plan did not include digoxin (heart rate control medication) medication use and required monitoring. Care plan indicated staff would administer medications as ordered and monitor for signs and symptoms of cardiac distress such as altered vital signs, etc. R40's Order Summary Report dated 1/14/25, indicated R40 received 0.25 milligrams (mg) of digoxin once daily for atrial fibrillation. The order did not include parameters indicating when the medication should be held related to heart rate. R40's Medication Administration Record (MAR) dated 1/1/25 through 2/13/25, indicated R40 had received metoprolol (approximately) once daily during this period but did not include pulse measurements taken before digoxin administration. R40's Pulse Summary, print date of 2/13/25, identified 12 pulse measurements were obtained since 1/1/25, ranging from 61 to 94 beats per minute and indicated R40's last pulse measurement was dated 2/9/25. During observation on 2/11/25 at 9:13 a.m., trained medication aide (TMA)-A went into R40's room and administered medications to R40 on a spoon mixed with pudding. TMA-A did not check pulse prior to administering medications. During interview on 2/11/25 at 9:15 a.m., TMA-A stated the nurses complete all the monitoring of medications and confirmed there were no vitals that she obtains prior to medication administration. TMA-A stated she had administered R40's pulse medication this morning. TMA-A stated she was unsure what his pulse was this morning or if it was safe to administer the medication as she had not measured R40's pulse. TMA-A stated the electronic medical record (EMR) notified her when she needed to take a resident's pulse and it did not for R40, so she had not taken it. During interview on 2/13/25 at 12:10 p.m., registered nurse (RN)-A stated there are no residents that need any vitals taken prior to administration of medications. RN-A stated pulse should be checked prior to administration of digoxin and if the heart rate is less than 60 beats per minute medication should be held. RN-A confirmed there was no order for pulse to be checked prior to administration of digoxin for R13 and R40. During interview on 2/13/25 at 1:12 p.m., TMA-A stated pulse should be taken before administering digoxin. TMA-A confirmed there was no order to check pulse prior to administering digoxin for R13 or R40 and confirmed she had not been obtaining pulse prior to administration. During interview on 2/14/25 at 2:02 p.m., director of nursing (DON) stated she expected nursing staff to measure R13's and R40's pulse before giving the digoxin to ensure R13's and R40's safety as digoxin slows the heart down. DON stated she expected the provider to include parameters with the digoxin order so nursing staff would know when it was unsafe to give the medication and when they needed to notify the provider of pulse readings. DON stated she expected nursing staff to document pulse measurements taken prior to administering digoxin in the MAR. DON confirmed there were no orders in place for R13 or R40 and pulses were not being obtained prior to administration from digoxin. During interview on 2/14/25 at 3:22 p.m., consultant pharmacist (CP) stated it was standard practice to obtain pulse prior to administration of digoxin as medication should be held if pulse is less than 60 bpm. The facility Medication and Treatment policy and procedure, dated 1/24, indicated Digoxin should be administered on the noon medication pass with apical pulse obtained prior to administration.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R30) 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 10/24, 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. R30's face sheet, dated 2/13/25, indicated she was [AGE] years old. The immunization record dated 2/13/25, indicated R30 received the following pneumococcal vaccinations: PPSV23 on 1/1/04 and 12/5/18, she also received a PCV13 on 6/30/15. 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 that R30 was offered or received PCV20. During an interview with infection preventionist (IP) on 2/13/25, at 11:40 a.m. IP stated has a worksheet for tracking of pneumococcal vaccines, upon checking spreadsheet IP stated R30 was not listed for PCV20 but should have been as R30's last pneumococcal vaccine was over six years prior. IP stated all infection control related policies were reviewed 1/2025, but has not yet updated policy content or review dates. A facility policy titled Pneumococcal Vaccines for Residents with a review date of 10/22, the policy did not address administer or offer PCV20 with shared decision making with provider.

Based on interview and document review, the facility failed to manage bowel and constipation needs for 1 of 3 residents (R2) who were reviewed. Findings include: R2's significant change Minimal Data Set (MDS) dated [DATE], revealed R2 had diagnoses which included Alzheimer's Disease, constipation and had severely impaired cognition. Further, MDS assessment indicated R2 was incontinent of bowel. R2's care plan revised 12/16/23, indicated R2 was at risk for incontinence due to diagnoses of Alzheimer's disease, dementia, constipation and previous right and left femur fractures with repair. R2's goal was identified as have a large bowel movement (BM) at least every three days and interventions included: qualified nursing staff will monitor BM status daily, administer medications as ordered, and indicated R2 required staff assistance for toileting needs. R2's Bowel assessment dated [DATE], revealed R2 was occasionally incontinent of bowel and did not feel urge sensation for BM. Review of R2's output for BM revealed the following: -From 12/29/23 through 1/4/24, no BM was documented. -From 2/4/24 through 2/9/24, no BM was documented. -From 2/14/24 through 2/17/24, no BM was documented. -From 2/23/24 through 2/28/24, no BM was documented. R2's medical record lacked evidence of facility's Bowel Protocol being implemented during above time frames documented with out a BM. On 4/11/24 at 1:35 p.m., licensed practical nurse (LPN)-A stated R2 was incontinent of bowel and bladder most of the time and had issues with constipation at times and staff administer Milk of Magnesia (MOM) or MiraLAX which was effective. Further, LPN-A stated the facility had a Bowel Movement Protocol staff are expected to follow and then document in the resident's medical record. On 4/11/24 at 2:00 p.m., registered nurse (RN)-A stated she was not aware of any constipation issues for R2. Further, RN-A stated staff were expected to follow the facility's Bowel Movement Protocol and document a progress note in the resident's medical record. On 4/11/24 at 3:51 p.m., RN-B stated R2 had impaired cognition and required staff assistance for toileting due to incontinence, however RN-B stated she was not aware of any constipation concerns for R2. On 4/12/24 at 11:20 a.m., director of nursing (DON) indicated R2 had severe cognitive impairment and required staff assistance with toileting due to incontinent of bowel and bladder. DON stated R2 did have concerns with constipation and required PRN (as needed) medications for relief. Further, DON confirmed R2's medical record lacked evidence of a recorded BM for the following dates: 12/29/23 through 1/4/24; 2/4/24 through 2/10/24; 2/14/24 through 2/17/24; and 2/23/24 through 2/28/24. DON stated R2's medical record also lacked evidence of the facility's Bowel Movement Protocol being implemented for those dates as well. In addition, DON stated staff were expected to follow the facility's BM protocol. Review of facility document titled Bowel Protocol dated 5/17, directed staff to print and review bowel report daily after 4:00 a.m. and the day nurse would review for any urgent bowel concerns and offer prune juice. Further, protocol directed staff on day two with no bowel movement evening shift would administer Milk of Magnesia, day three with no bowel movement results staff would administer a Bisacodyl suppository, day four with no bowel movement results administer a fleet enema. In addition, the protocol directed staff if no bowel movement results on day three the day shift nurse would be expected to call the provider for further orders and request routine or change in medication.

Based on interview and document review, the facility failed assess and implement new intervention(s) to prevent future falls for 1 of 3 residents (R2) reviewed for accidents. Findings include: R2's significant change Minimal Data Set (MDS) dated [DATE], revealed R2 had diagnoses which included Alzheimer's Disease, constipation and had severely impaired cognition. Further, MDS assessment indicated R2 had two or more falls with no injuries since last assessment. R2's care plan revised 2/28/24, identified R2 was at risk for falls related to diagnoses and medications which may increase the risk for falls. R2's care plan revealed the following interventions to reduce the occurrence and injuries with falls: therapy assessment, encourage resident to wear gripper slippers at night, toileting between 3:30 a.m. and 4:00 a.m., encourage and participate in activities, ambulate with staff daily, bolstered mattress on bed, padded call light within reach and position to help alert staff when attempting to get up from bed. R2's Fall Risk assessment dated [DATE], identified R2 had intermittent confusion, poor recall, judgment, and safety awareness and was determined to be at risk for falls. R2's Safety Events-Fall report dated 2/12/24, revealed R2 had an unwitnessed fall in her room at 8:15 p.m. R2 was noted to be attempting to self-transfer from bed to her wheelchair and did not sustain an injury. Further, report indicated R2 was impulsive with poor safety awareness. Interdisciplinary team (IDT) reviewed and ruled out abuse and neglect, and refer to fall CP [care plan] for interventions. However, R2 medical record lacked evidence a new intervention was implemented to prevent re-occurrence. R2's Safety Events-Fall report dated 2/25/24, revealed R2 had an unwitnessed fall in her room at 8:16 p.m. R2 was self-transferring, without shoes or gripper socks, and fell . R2 did not sustain an injury. Further, report indicated R2 was impulsive with poor safety awareness and does not remember to use call light or that she requires assistance with mobility. IDT was noted to review the fall. However, R2 medical record lacked evidence a new intervention was implemented to prevent re-occurrence. On 4/11/24 at 12:24 p.m., R2 was observed in her room sitting in her wheelchair. R2 appeared to be positioned well in wheelchair, shoes on, bed was appropriate height and had a concave mattress, room was free of clutter, and gray padded call light was within reach. R2 denied having any falls while living in the facility and stated if she needed staff, she would use the call light. On 4/11/24 at 2:00 p.m., registered nurse (RN)-A stated R2 was at risk for falls and staff were directed to visually check on her frequently, bed in lowest position when in bed, walking program, and R2 was enrolled with hospice. Further, RN-A stated R2 had not had a fall for two months. On 4/11/24 at 2:44 p.m., nursing assistant (NA)-A stated R2 was identified as a fall risk due to R2 self-transferring without staff assistance. Further, NA-A stated staff were directed to keep bed in low position when R2 was in bed, padded call light placed next to her to alert staff when R2 was moving, gripper socks when in bed or shoes on when in wheelchair, wheelchair next to bed in case R2 attempts to self transfer out of bed, and visually checking R2 frequently. On 4/11/24 at 3:51 p.m., RN-B stated the IDT will meet and review each fall that occurs and determine a root cause for the fall and any further interventions needed. Further, RN-B stated the root cause analysis and new interventions are documented in the incident report (Safety Event-Fall) and the new interventions would be verbally communicated to staff as well as updating the resident's care plan. RN-B stated R2 was identified to be at risk for falls and interventions include frequent visual checks, toileting plan, gripper socks at bedtime, concave mattress, and a gray padded call light. In addition, RN-B confirmed R2 had fallen on 2/12/24 and 2/25/24, and there were no new interventions implemented following either fall to prevent reoccurrence. RN-B stated these two falls both occurred closer to the time when R2 likes to go to bed, and the IDT will try to identify a trend or pattern with falls and implement an intervention to hopefully decrease the fall but we did not do that here it appears. On 4/12/24 at 11:20 a.m., director of nursing (DON) indicated each morning the IDT would review any incidents that occurred. DON stated the nurse manager would be expected to gather more information related to the fall and the IDT would discuss the fall and determine a root cause for each fall and develop an intervention. Review of facility policy titled Falls and Fall Risk Managing revised 9/23, revealed if falling reoccurs despite initial interventions, staff would implement additional or different interventions, or if underlying causes cannot be identified still would try various interventions based on the assessment of the nature or category of falling was reduced or stopped. Further, policy indicated if the resident continues to fall, staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions.

Based on observation, interview and document review the facility failed to ensure 2 of 3 medication carts and 1 of 2 treatment carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. This deficient practice had the potential to affect 46 of 46 residents who resided in the facility. Findings include: On 12/26/23 at 12:40 p.m., a grayish tan cart identified by licensed practical nurse (LPN)-A as a treatment cart, and a blueish gray cart with a light tan top and small computer screen sitting on top identified by LPN-A as a medication cart, were observed by the nursing station in the central area of the day room. The carts were unlocked and unattended by staff. Several unidentified staff, visitors, and residents observed walking past the carts. On 12/27/23, at 11:21 a.m., grayish tan treatment cart was observed unlocked and unattended in east wing hallway. Observed both unidentified residents and staff in hallway where cart was located. On 12/27/23, from 4:11p.m. to 4:40 p.m., bluish gray medication cart was observed sitting in front of nursing desk near wellness room, unlocked and unattended. The following observations were made: - 4:21 p.m. unidentified staff and residents were observed walking in front of medication cart. - 4:23 p.m. unidentified staff member walked in front of unlocked and unattended medication cart. - 4:23 p.m., medication cart remained; in front of nursing desk near wellness room, unlocked and unattended. Unidentified staff member walked by backside of cart, where drawers are located, and got hand sanitizer from top of Left cart without locking it. - 4:25 p.m., bluish gray medication cart remained in front of nursing desk near wellness room unlocked and unattended. - 4:28 p.m., trained medication aide (TMA)-B approached medication cart, got water from top of cart for personal consumption. Left cart without locking it. - 4:29 p.m., TMA-B opened unlocked medication cart drawer and began setting up medications. - 4:31 p.m., TMA-B walked away from cart that was located by nursing desk in central day room without locking the cart. TMA-B then walked through central day room to dining room by main entrance and lobby to administer medications. Unlocked medication cart was out of sight of TMA-B. - 4:31 p.m., TMA-B returned to cart, completed hand hygiene, immediately opened unlocked drawer and set up next resident's medication. - 4:33 p.m., TMA-B walked away from the medication (can't abbreviate without explaining what abbreviation means) cart without locking it, returned to dining room by main entrance and lobby. Unlocked medication cart was out of sight of TMA-B. - 4:34 p.m., TMA-B returned to unlocked medication, hand hygiene completed, began setting up meds. - 4:35 p.m., TMA-B left medication cart unlocked and unattended. - 4:36 p.m., TMA-B returned to cart. Hand hygiene completed. - 4:37 p.m., TMA-B left medication cart unlocked and unattended. - 4:40 p.m., TMA-B began setting up medications while surveyor observed. TMA-B set up medications and then walked away from medication cart leaving it unlocked and unattended. During interview on 12/27/23, at 4:41 p.m., TMA-B stated they always locked the medication cart when they walked away. TMA-B stated it was important to lock the medication cart because other staff, residents or visitors could remove medication. TMA-B acknowledged they left the medication cart unlocked while they administered medications in the dining room near the main entrance. On 12/28/23, at 7:30 a.m., grayish tan treatment cart was in the common area, left of the nursing station in front of the bulletin board unlocked and unattended. On 12/28/23, from 12:51 p.m. to 1:00 p.m., grayish tan treatment cart was in the common area, right of the nursing station unlocked and unattended. On 12/28/23, at 2:12 p.m., LPN-A stated medication and treatment carts should be locked when not in use so that residents did not get into them, and nothing was stolen. LPN-A also stated insulin and medicated creams are kept in treatment carts. A resident could have an allergic reaction from something they removed from the cart. On 12/28/23, at 2:19 p.m., Case manager (CM)-A stated they expected medication and treatment carts to be locked when not in use. This is important to prevent residents, visitors and unauthorized staff from removing items from the cart. A resident could get hurt or sick if they removed medication and consumed it. On 12/28/23, at 4:46 p.m., grayish tan treatment cart observed unlocked and unattended in the hallway near room [ROOM NUMBER]. LPN-C came out of a resident's room and was met by surveyor 49035. LPN-C stated medication cart was within their site while they administered medications in room [ROOM NUMBER]. LPN-C then confirmed they could not see the medication cart when they administered insulin. On 12/28/23, at 4:57 p.m., bluish gray medication cart in front of the fireplace in the central day room observed unlocked and unattended. On 12/28/23, at 4:57 p.m., grayish tan treatment cart in front of bulletin board located left of the nurse's station in the central day room area observed unlocked and unattended. Another bluish tan medication cart in front of the door to the wellness room and to the right of the nurse's station in the central day room area observed unlocked and unattended. Director of nursing (DON) immediately notified. During interview with DON on 12/28/23, at 5:01 p.m., DON stated she did not have knowledge of residents going through the medication carts, and no medications have been reported missing. DON stated she expected staff to lock medication and treatment carts when left unattended. This was important because there were medications, medicated creams and insulin in the medication and treatment carts. DON also stated she was unaware of medications missing from the treatment carts. DON indicated insulin would be a high-risk medication and possible drug seeking behavior could be a reason why someone would try to gain access to a medication or treatment cart. Facility policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles with last revision date of 10/31/16: The facility should ensure that all medications, and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observation, interview, and document review, the facility failed to ensure confidential information was not readily available for all residents, staff, and visitors to view for 20 of 20 residents whose confidential information was observed to be visible on an open computer screen in a common area. Findings include: On 12/27/23, at 4:39 p.m., trained medication aide (TMA)-B was observed to walk away from the bluish gray medication cart with electronic medical record (eMAR) documentation system open on computer screen. Resident information including names, room numbers and diagnosis from residents in north and east wings was observable on the computer screen. Medication cart was in front of the wellness room door. Several unidentified staff, residents and visitors were observed passing front of the medication cart. At 4:41 p.m. TMA-B returned to medication cart and stated the computer screen should be locked and closed when unattended. TMA-B acknowledged that they did not close out or lock the eMAR when they left the cart to administer medications. TMA-B went on to state this was important so others could not see residents' personal information. On 12/28/23, at 2:19 p.m. clinical manager (CM)-A stated they expected all computer screens and medical records should be shut and locked when not in use. CM-A went on to say this was to protect resident's privacy and HIPAA. On 12/28/23, at 2:40 p.m., director of nursing (DON) stated she expected staff closed out eMARs when away from the treatment or medication carts, so no protected information was visible. DON stated this was because of HIPAA and privacy rights. Facility Nondisclosure Confidentiality Privacy Security Agreement with a last review date of 4/2019: Staff will be knowledgeable regarding all new and/or revised policies and procedures concerning confidentiality, privacy and HIPAA regulations. Staff will log off any computer or terminal prior to leaving it unattended. Staff will agree to abide by the HIPAA policies and procedures set for the by the facility as well as current regulations governing privacy issues.

Based on interview and document review, the facility failed to provide written notice of a bed hold after transportation to the hospital for 1 of 1 residents (R43) reviewed for hospitalization . Findings include: R43's minimum data set (MDS) dated [DATE], indicated R43 has moderate cognitive impairment. Medical record failed to note bed hold discussion. During interview on 12/26/23 at 5:29 p.m., R43 stated she did not remember being requested to fill out a bed hold prior to hospitalization . During interview with nurse manager (NM)-A on 12/28/23 at 10:07 a.m., NM-A stated the facility typically did not have residents sign a bed hold when transferred to the hospital. During interview on 12/28/23 at 10:17 a.m., business manager (BM-A) stated the bed hold policy was in the admission packet. The bed hold was not typically filled out when residents were transferred to the hospital because they have not billed for the bed hold due to facility census. Undated facility document titled Bed Hold Policy, indicated that staff will provide the current resident/responsible party with a copy of the bed hold policy notification at time of transfer or therapeutic leave. In the case of emergency transfer, staff will attempt to provide resident with a copy of the bed hold policy notification and notify the responsible party of the transfer and policy within 24 hours. Staff will follow up with a phone call to clarify any questions concerning the policy on the next working business day.

Based on observation, interview and document review, the facility failed to appropriately assess and implement appropriate interventions to prevent repeated falls for 2 of 2 residents (R1 and R3), who were at high risk for falls. This failure resulted in actual harm for R1 who sustained a mildly displaced right femoral neck fracture, right hip fracture, which required surgical repair and sustained a right periprosthetic femur fracture. Findings include: R1's face sheet undated, identified R1 had the following diagnoses: Alzheimer's disease, dementia, adult failure to thrive, ataxic gait, muscle weakness, syncope with collapse, repeated falls and unsteadiness on feet. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had significantly impaired cognition, required one person assist with transfers, toileting, dressing and locomotion on the unit. R1 was not steady and only able to stabilize with human assistance for balance during transitions and walking. MDS identified R1 used a wheelchair for mobility. R1 was occasionally incontinent of bowel and bladder with no bowel or bladder toileting program. R1's bladder assessment, dated 7/12/23, identified R1 was frequently incontinent with risk factors of impaired mobility and dependent transfer. R1 has urine leakage on the way to bathroom and has wet close or wet incontinent pads. Environment limitations included impaired mobility and decreased manual dexterity with contributing diagnosis of Alzheimer's, diabetes, falls and pain with movements. Medications may be contributing to bladder dysfunction includes antidepressants, diuretics, and narcotics. Stress incontinence includes incontinence without sensation of loss of urine as well as urge urinary incontinence with strong uncontrolled urgency prior to incontinence and urine loss on the way to toilet. Scheduled toileting/habit training schedule includes every two hours with no further information. Fall care plan dated 3/28/23 identified R1 to be at risk for falls and interventions in place included soft touch call light, assist of one using EZ-Stand (mechanical lift) for transfers, wheelchair for mobility, nonskid footwear, nursing staff to encourage out of room activities, room close to nursing station and nursing staff to toilet ever two hours and as need to reduce risk of falls. Mobility care plan dated 5/25/23 identified R1 to have impaired mobility and history of repeated falls and unsteadiness on feet, R1 required assist of one person using front wheeled walker for transfers, ambulation, and toileting. R1 used wheelchair for mobility and can propel independently or with assist of one person as needed. R1 requires gripper socks at all times. The following Fall Risk Assessments were completed with a score of over ten indicating a high risk of falls. 12/21/23 with a score of 17, 3/22/23 with a score of 17, 3/28/23 with a score of 20, 5/1/23 with a score of 21, 7/12/23 with a score of 23, and 7/25/23 with a score of 19. Fall Risk Observations Reviewed: Dated 3/28/23 - Fall risk assessment summary: recent falls in the past three months and a score of 20 indicating high risk. Dated 5/1/23 - Fall risk assessment summery: Resident had unwitnessed fall on 3/23 resulting in a femur fracture. Requires the EZ-stand lift to assist with transfers with a diagnosis of Alzheimer's disease, dementia, ataxic gait, generalized muscle weakness and a history of falls. Dated 7/12/23- Fall risk assessment summary: At risk of falls with a score of 23 (high fall risk), Resident was alert but had confusion. Pivot transfers- do not walk with history of falls. Had multiple medications and diagnoses with potential to contribute to a fall. The following Fall Events and internal investigations were reviewed: Fall event 2/5/23 at 8:05 p.m., unwitnessed fall in room with walker and R1 sustained scratch and bump on head and small abrasion on left knee. Fall event 2/9/23 at 7:15 p.m., unwitnessed fall in bathroom attempting to self-transfer onto toilet without injuries. Fall event 3/23/23 at 4:45 a.m., unwitnessed fall in resident room self-transferring, wheelchair found outside the bathroom. Resident reported to the charge nurse he was attempting to get to the bathroom. Fall required hospitalization and found to sustain a right femur fracture requiring surgical repair. Internal investigation requested, however not received. Fall event 3/30/23 at 11:15 a.m., , unwitnessed fall in bathroom attempting to self-transfer from wheelchair onto toilet without injuries. Fall event 4/15/23 at 7:45 p.m., unwitnessed fall in bathroom attempting to self-transfer from wheelchair onto toilet. Fall event 5/6/23 at 7:50 p.m., unwitnessed fall in bathroom attempting to self-transfer from wheelchair onto toilet without injuries. Fall event 5/25/23 at 12:30 p.m, unwitnessed fall in bathroom attempting to self-transfer with skin tear an inch long on wrist. Internal investigation identified gripper socks on but was not able to safely transfer without the use of an EZ stand lift and nursing staff to assist. R1 was last toileted at 10:30 and fall happened at 12:30. Fall event 7/6/23 6:27 p.m., unwitnessed fall in R1's room, resident on floor, w/c tipped over and walker next to wheelchair. Fall required hospitalization and identification of periprosthetic femur fracture. Review of facility's internal investigation notes indicated a patterned statement of root cause was due to resident's impaired level of mobility, cognitive status and generalized weakness. The internal investigation lacked evidence of a general assessment for pattern of falls, reason for falling (time, toileting needs, supervision) and lacked fall interventions to prevent future falls. R1's group assignment sheet information noted to be on two separate group sheets as indicated below. -R1's float group assignment sheet undated, identified R1 to require assist of one person with the use of EZ-Stand and toilet every two hours. Safety considerations include history of self-transfers, poor safety awareness/impulsive. Comments include bed in low position, lotion to feet/legs at night. -R1's west group assignment sheet dated 7/25/23 consistently notes assist of one person with use of EZ-Stand and toilet every two hours. Safety consideration includes history of self-transfers with bathroom, and comments include bed in low position, lotion to feet/legs every two hours, hip precautions, no bending past 90 degrees, no crossing legs. Incontinent of bowel and bladder, alert to self, forgetful needs cues. After visit hospital summery printed 3/27/23, indicated that R1 was hospitalized on [DATE] and admitted for evaluation and management of mildly displaced right femoral neck fracture due to R1 falling under unclear circumstances at skilled nursing home facility. Note further identifies that resident required surgical repair on 3/24/23 for a right hip fracture due to an unwitnessed fall. After visit hospital summery signed on 7/11/23, indicates R1 was hospitalized on [DATE] and discharged on [DATE] for a right periprosthetic femur fracture. It was determined to be treated non operatively. Group assignment sheets directing nursing aids provided inconsistent information, lacked information from the care plan and safety consideration for R1, including resident FALL RISK and care following femur fracture. During interview on 7/25/23 at 3:29 p.m., R1 indicated the staff are too busy so he uses the bathroom independently. R1 indicated to know how to use the call light, but he likes to take himself to the bathroom. During interview on 7/25/23 at 3:40 p.m., nurse aid (NA)-E indicated they used the the group sheets to know what care the residents need and if residents were a high fall risk, by the group sheet indicating *High Fall Risk.* During interview on 7/25/23 at 4:16 p.m., license practical nurse (LPN)-A indicated care group sheets should never have discrepancies from either the care plan or if a resident were to be on different groups. During interview on 7/25/23 at 4:59 p.m., LPN-B indicated R1 was a high fall risk only when in bed and interventions include floor mat, bed to the lowest position, and call light within reach to prevent falls. LPN-B declined R1 to be a fall risk from wheelchair and had never been notified R1 tries to self-transfer onto the toilet, just from the bed. During interview on 7/27/23 at 2:11 p.m., NA-C indicated R1 had a walker in his room however shouldn't be in his room because he doesn't use it and either should the nursing staff. NA-C indicated R1 did not use call light and would attempt to transfer from the wheelchair to the toilet on his own. NA-C indicated to be aware of R1's behaviors as R1 tends to wheel his wheelchair close to the bathroom door when he needs to go to the bathroom and R1 was not always incontinent and will request to use the toilet when needed. During interview on 7/27/23 at 9:00 a.m., physical therapist (PT)-A indicated R1 was a high fall risk and it was therapy's recommendation for nursing staff to use EZ-Stand for transfers for safety. PT-A indicated R1 was unsafe to transfer independently and unable to correctly position wheelchair or lock brakes to transfer to the toilet and does not follow the steps required to complete a safe and independent transfer, further R1 was impulsive with cognitive deficits. PT-A confirmed fall mat, high low bed and soft touch bedroom call light would not prevent or address a safety concern from R1 attempting to transfer to toilet. During interview on 7/27/23 at 9:04 a.m., RN-B indicated R1 had a room closer to the nurses station, high low bed, soft touch call light and slipper socks as interventions implemented prior to February of 2023 frequent monitoring is encouraged, however no formal protocol or time frame of the expectation. RN-B indicated there should never be discrepancies on care cards or group guides and it was identified the care guides directed nursing assistance to use EZ-Stand, however the care plan reflected assist of one person with walker and it was identified on 7/25/23 as a discrepancy. Upon reviewing interventions for falls for R1, RN-B indicated the current interventions do not prevent or address R1 from self-transferring in the bathroom and an intervention should have been in place. RN-B furthermore reflected there was not enough causal analysis of stopping and preventing falls in the bathroom and if frequent checks are encouraged it should be care planned and on the group guides. Fall risk assessment scores reviewed and noted an upward trend from 12/21/23 to 7/25/23 with no preventative action. During interview on 7/27/23 at 2:27 p.m., (PT)-B indicated it was not therapies recommendation for nursing staff to use the walker with R1, however sees no issue with it being accessible in his room. PT-B indicated the first functional bathroom transfer assessment was completed on 7/25/23 and not addressed prior. PT-B declined occupational therapy to be involved or evaluate or provide recommendations for functional transfer training in bathroom or cognitive based interventions. During interview on 7/27/23 at 10:10 a.m., fall review completed with director of nursing (DON) and noted 3/23/23 root cause of fall to be R1's cognition and fall happened due to self-transferring and R1 not consistently use call light. Following the fall on 3/23/23, the wheelchair was implemented for mobility, mat and high low bed were also implemented (changes were not reflected on care plan dated 3/28/23). DON indicated for the 3/30/23, 4/15/23, 5/6/23 falls without interventions in place she would expect something more have been in place and frequent checks should have been put in both the care plans and group sheets. R1 was screened by physical therapy after 5/6/23 fall, however it was not indicated for therapy to see him on caseload and R1 was transferring with the EZ-Stand per therapy recommendation at that time with nursing. After the 5/25/23 fall also did not have interventions placed and the DON indicated the facility should have done something more including identified, trend tracking of self-transferring, placed interventions to protect R1 and recognition current toileting schedule was not preventing falls. DON added, the 7/6/23 fall was reviewed and the intervention that was placed was anti-lock brakes on to the wheelchair to prevent it from sliding as well as initiating therapy (changes were not reflected on care plan dated 3/28/23). Reviewed group sheets with DON which identified the Float and [NAME] group sheet were not consistent, DON indicated care plans and care guides should not have conflicting transfer status as it could pose a safety risk to the resident. DON indicated R1 should not have a walker in his room and could lead to additional falls and could encourage him to self-initiate ambulation or self-transfer. R3's face sheet undated, identified R3 had the following diagnoses: Osteoarthritis of right knee, pain in right knee, right patella fracture, diabetes, chronic congestive heart failure, history of diseases of the digestive system, GI bleed, chronic kidney disease, and constipation. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitive and required one person assist with toileting and transfers, also identified R3 to be occasionally incontinent, however did not require a toileting program. Fall care plan dated 5/11/21, identified R3 to be at risk for falls and interventions in place included having call light within reach, non-skid footwear with all transfers/ambulation and assist of 1 with transfers and ambulation using four-wheel walker. Additionally, intervention dated 3/16/23 directed staff to follow wheelchair behind when ambulating and remove the footrests for safety. Mobility care plan dated 5/11/21 identified R3 to require assist of one person and four wheeled walker to assist for both transfers and ambulation and assist of one person to propel wheelchair on and off unit. R3's group sheet indicated R3 required assist of one person with walker for transfers, ambulation and toileting/peri care. R3's group sheet lacks information regarding high fall risk, requiring wheelchair follow when ambulating nor need for slipper socks. R3's bladder assessments dated 6/17/23 indicate R3 was occasionally incontinent, impaired mobility and ambulation with contributing diagnosis and medications related to bladder dysfunction and both stress and urge incontinence. Based off assessment a scheduled toileting program was indicated, however lacks details on program type and frequency. The following Fall Events and internal investigation was reviewed: 5/15/23 witnessed fall in bathroom lowered to floor due to bucking knees and sustained a 4 cm scratch on back. Fall event identified R3's knees are buckling. 5/28/23 unwitnessed fall in bathroom- attempting to self-transfer and legs gave out and was wearing non-skid footwear. 6/21/23 unwitnessed fall in bathroom- attempting to self-transfer and legs gave out. Was wearing non-skid footwear. Root cause of falls were due to residents increased weakness and impaired level of mobility, balance with transfers and ambulation. During interview on 7/27/23 at 2:20 p.m., NA-E indicated working with R3 and she had intervened and needed to stop R3 from self-transferring and it was common behavior. R3 tends to self-transfer after meals and mainly in the afternoon. During interview on 7/25/23 at 1:44 p.m., trained medication aid (TMA)-A identified to have worked with R3 and observes her as cognitively intact, pleasant and not impulsive. TMA-A indicated to be aware of R3's falls as R3 attempts to self transfer onto the toilet. TMA-A was unaware of any interventions in place to prevent falls as R3 uses the call light appropriately, R3 was just impatient. During interview on 7/27/23 at 1:53 p.m., NA-C was aware of R3's falls and indicated its due to R3 self-transferring. NA-C reported R3's knees are bouncy and give out during transferring, R3 will use the call light in the mornings, but doesn't typically use to call for help in the afternoons and would self-transfer from the wheelchair to the toilet. NA-C had not observed her self-transfer elsewhere. NA-C indicated R3 was at high risk of falls after lunch or following mealtimes as it was when she was in the wheelchair and her wheelchair was a surface she could physically self-transfer from. During interview on 7/27/23 at 2:28 p.m., PT-B indicated therapy had been involved to assessed R3 on both 5/25/23 and 6/26/23 and was aware of R3's bouncy knees, however when therapy assessed R3 did not exhibit bouncy knees and there was no clinical diagnosis. Additionally, no recommendations were made to the floor staff from therapy as they did not identify any concerns. PT-B indicated R3 did well with therapy involvement and makes progress and R3 knee concerns started when she was taken off caseload from therapy. PT-B declined therapy involvement with causal analysis when it comes to falls and typically done within the management meetings with nurse managers and DON. During interview on 7/27/23 at 3:30 p.m., DON indicated she was unaware R3 was known to be self-transferring from wheelchair to toilet. DON indicated the bowel and bladder assessments should identify individual needs and identifies risk factors related to self-transferring in relation to toileting. Reviewed bowel and bladder assessments completed on 3/30/23 and 6/17/23, however there was not a bladder assessment on or near 5/28/23 despite R3 falling next to the toilet. R3's bladder assessment on 6/17/23 lacked any individualized recommendation. Facility policy titled Accident Prevention- Fall Risk Observation dated 2/2023 indicates the purpose of the policy was for residents to be assessed for his/her risk for falls and or accidents. Residents identified to be at risk for falls have interventions implemented through the care plan and the licensed nurse was responsible. -It was to be used as a consistent method to determine residents at risk for falls in addition to the MDS, Corresponding Care Area assessment (CAA) for falls, cognitive loss/dementia, physical restraints, and psychotropic drug use are completed to identify additional risk factors and interventions. -Residents at risk for falls/accidents have an individualized care plan developed. Care plan interventions are based on the findings of fall risk observation. -Additional professionals may be contracted to provide assessment regarding fall risk and prevention including but not limited to attending physician, pharmacist, physical therapist and occupational therapist. Facility policy titled transfer/lifting policy and Procedure dated 3/2023 indicates the purpose of the policy was to provide safe transfer techniques to reduce incidents or injuries to all residents and staff, as well as to establish and communicate transfer and lifting policies for facility. The expected transfer plan for each resident was to be found on the care plan and the nursing assistant group sheet and it's the responsibility of all employees to follow the care plan and designated lifting policy for each resident for their personal safety as well as responsibility to report problems that would make compliance difficult.

Based on observation, interview and document review, the facility failed to provide emergency services according to POLST (provider orders for life sustaining treatment) for 1 of 1 resident (R73) who showed stoke symptoms, and was not immediately sent to the emergency department (ED) as directed by her POLST. This resulted in actual harm for R73 who had a decline in her condition, as a result of the facility not following her POLST. Findings include: R73's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she was severely cognitively impaired, needed staff supervision with assistance of one for activities of daily living (ADLs), she needed set up assistance with eating and physical assistance of one for bathing. There were no other limitations of R73's ADL's during this assessment period. R73's significant change MDS dated [DATE], identified the following changes in her activity of daily living (ADL) status: She now needed limited assistance of one with bed mobility, transfers, dressing and toileting. In addition the MDS indicated she was totally dependent upon staff for toileting, ambulated only once or twice and needed staff supervision and assistance of one with eating. R73 remained severely cognitively impaired which was the same on 6/1/17. R73's most recent Cognitive CAA dated 6/21/17, identified R73 had dementia with severely impaired decision making, which was the same as the 9/22/16, Cognitive CAA. However, now R73 required, increased help since return from hospital with (stroke). The following new care areas triggered on the 6/21/17 MDS for a CAA assessment, which was not completed on the 9/22/16 CAA. R73 Visual Function CAA dated 6/26/17, indicated R73 had a change in vision function and now had right field cut vision related to [MEDICAL CONDITION] or (stroke) and used a wheelchair for mobility and she got caught on other's wheelchair wheels when in congested areas. Communication CAA triggered due to [MEDICAL CONDITION] a language deficit resident received speech for expressive and receptive [MEDICAL CONDITION] and staff need to assist the resident in finding the correct words for communication. The communication CAA further indicated R73 gets frustrated when unable to find the correct words. The urinary incontinence CAA identified now R73 was occasionally incontinent of urine and needed assistance with toileting and was on a toileting plan every two hours and as needed. The urinary incontinence CAA further indicated due to altered communication R73 was at greater risk for incontinence. The CAA also indicated pressure ulcers triggered due to [MEDICAL CONDITION] was now on a turning and repositioning schedule every two hours and as needed. She was currently receiving Physical Therapy (PT) and Occupation Therapy (OT) for strengthening and endurance related to the [MEDICAL CONDITION]. During observation 8/29/17, at 6:54 p.m. R73 was seated in standard wheelchair in the South wing hallway. R73 was leaning to the right side with her shoulder against the rear frame of the chair, and was propelling the wheelchair using both feet. R73 was mumbling non nonsensical words, and had a furrowed brow facial expression. During subsequent observation on 8/30/17, at 9:22 a.m. R73 was lying in bed in her room. Nursing assistant (NA)-J entered the room to help R73 with morning cares. NA-J put R73's socks on, and proceeded to assist R73 to sit up in bed. NA-J assisted and strapped R73 into a mechanical standing lift, and assisted to a standing position from her bed. NA-J wheeled R73 in the mechanical lift to the bathroom, removed her visibly soiled incontinence product and seated her on the toilet. R73 did not void when seated on the toilet. NA-J used a wet washcloth to wash R73's face, back, arms and perineal area. R73 did not participate in the bathing. NA-J stated R73 used to be ambulatory and transferred on her own, however, R73 sustained a stroke a few months ago and now required a mechanical lift for transfers, used a wheelchair for mobility and was unable to ambulate. R73's undated Resident Face Sheet indicated family member (FM)-A was R73's emergency contact, responsible party and the person to call if a change in condition. Further, the sheet indicated FM-B was the secondary contact. During interview on 8/29/17, at 1:41 p.m. family member FM-A stated she was the person who would be notified of a change in condition, or accident, with R73. FM-A stated a few months ago (R73) developed stroke symptoms and the facility attempted to call her, however, just left a message on her phone about her sudden change in condition and they thought she had a stroke and wanted me to call back they didn't say she wasn't sent to the hospital. FM-A stated she did not receive the message until several hours later. When she called the facility back, they had not sent (R73) to the hospital for these symptoms. FM-A stated she told staff to send R73 to the emergency room for treatment immediately and thought if someone had stroke symptoms should have gone in right away. FM-A stated she was unaware why the facility did not send her immediately to the hospital, adding she was upset the facility waited too long to send (R73) to the emergency room for treatment. During interview 8/30/17, at 8:02 a.m. registered nurse (RN)-B stated she was the clinical manager and MDS coordinator. RN-B stated that R73's FM-A wanted to make sure if anything happened to (R73) that was reversible she wanted her to be hospitalized FM-A has told us this multiple times. During interview 8/30/17, at 11:41 a.m. the director of nursing (DON) stated when R73 woke up on 6/10/17, and showed symptoms of a stroke she should have been sent her to emergency department right away. It was my understanding that FM-A would want her sent in right away and staff should not have waited for FM-A to call back. The DON stated (R73) she was walking before her stroke, and feeding herself. Now she needs a wheelchair and supervision with eating. The DON further stated she was not aware the licensed practical nurse (LPN)-C waited so long for FM-A to call the facility back, and was unaware of the ED discharge summary identifying it was too late to treat (R73) with tPA because she was not sent in right away by the nursing home. On 8/30/17, at 12:20 p.m. a message was left with MD-A (who was not her primary physician) at First Light Health System who completed the hospital discharge summary on 6/12/17. MD-A did not return the phone call. During interview 8/31/17, at 9:00 a.m. the DON stated LPN-C was the nurse working on 6/10/17 and was R73's nurse. The DON stated she spoke to LPN-C and he stated the reason why he waited for the family to return the call instead of sending her in was because the nurse practitioner (CNP)-A told him to wait and see what the family wanted to do first. LPN-C stated he could not remember is he contacted the secondary family contact. During interview 8/31/17, at 9:12 a.m. CNP-A stated on 6/10/17, LPN-C called her and told her the symptoms R73 was having. CNP-A stated based on past conversation with the FM-A they only wanted things treated that were reversible and wanted (R73) sent in for things like an infection and if it was a chronic condition she didn't want her sent in. CNP-A further stated (R73) had a [DIAGNOSES REDACTED] and chronic abdominal pain. FM-A wasn't treating that so she assumed they would not want her sent in when she was having stroke symptoms. The CNP-A stated FM-A was upset that she wasn't sent in right away, and stated I knew she was upset since the day it happened, I am well aware she is upset. During interview 8/31/17, at 10:46 a.m. with the facility medical director who was not R73's primary physician reviewed R73's POLST and hospitalization on [DATE]. The facility medical director stated if a resident has a POLST like hers and was having stroke symptoms she should have been sent to the emergency room right away and not wait for family to return the call. The medical director stated if she had pneumonia or something that was not so urgent they could have waited. The medical director reviewed the emergency department note and stated MD-B was the emergency room physician. Reading MD-B note and was sleeping at 1430 you have to assume this was the last time (R73) had [MEDICAL CONDITION]. When she got to the ED they decided not treat with tPA because too much time had passed. The medical director stated a stroke could be a reversible condition and it would make sense to send her to the ED right away. During interview 8/31/17, at 11:19 a.m. the DON stated during an emergency situation she would expect the facility to call the physician or nurse practitioner , and family. If they were unable to contact the primary contact, then they should call the secondary contact and then just send the resident in. The DON stated they should not have waited for the family to call back and should have just sent her in. The DON stated they don't have a specific policy stating that but it is their protocol. During interview 8/31/17, at 12:57 p.m. LPN-C stated he was R73's nurse on 6/10/17, and when she woke up he noted a facial droop and paralysis so he called the CNP-A, who told him she didn't think the family would want her to go to the ED because of her [DIAGNOSES REDACTED]. When FM-A called back she told me to send her in right away. LPN-C stated he was unable to recall the events after calling FM-A, but had not received a call back right away and was unsure if he attempted to call the secondary contact FM-B. LPN-C stated even though so much time had passed, he had not heard from FM-A nor did he recall calling CNP-A again about not being able to reach FM-A, because CNP-A did not seem too concerned. On 8/31/17, at 1:12 p.m. a call was placed to the ED and a message was left for MD-B. MD-B did not return the call. During interview 8/31/17 at 1:33 p.m. CNP-A stated she can not recall if LPN-C called her on 6/10/17 about not being able to reach (R73's) FM-A or FM-B right away. CNP-A stated even if LPN-C called me again, she would not have not changed her decision because she was under the impression FM-A did not want to treat (R73). During interview 8/31/17, at 3:16 p.m. FM-A stated the facility called her on 6/10/17 and left her a message. The facility did not call FM-B who was (R72's) secondary emergency contact. Review of R73's Provider Order for Life Sustaining Treatment (POLST) dated and signed by R73's certified nurse practitioner (CNP)-A on 10/14/15, identified R73 was do not resuscitated or intubated (DNR/DNI). A section labeled, Goals of Treatment, included directions to be implemented if R73, has pulse and/or is breathing, which indicated R73 being on, Comfort Care, with several options that could be selected in accordance with R73's wishes. There was a box to check or not check next to each of these areas, to clarify their wishes. The areas on the form were: - Avoid calling 911, call (blank line to fill in) instead, - If possible, do not transport to ER (emergency department) ., and, - If possible, do not admit to the hospital from the ER . However, all of these options were left unchecked, identifying R73 wanted these actions completed. Further, R73's POLST identified a checked option for, Limit Interventions and Treat Reversible Conditions, which described, Provide interventions aimed at treatment of [REDACTED]. The POLST was signed by R73, however was undated. R73's progress note dated 6/10/17, at 18:23 indicated, Noted (R73) was difficult to rouse before dinner at 1615. Noted resident with unsteady gait, RT (right) facial droop, RT pupil non-reactive, slurred/slow speech, and bilateral hand/foot strength WNL (with in normal limits). BP (blood pressure) 149/52, P (pulse) 73, RR (respiration rate) 18, Sp02 (oxygen saturation in blood) 97% on RA (room air) and T (temperature) 96.7. Family notified writer at 1815 that they want resident sent into the hospital to get checked out. A First Light Health System Ambulance Report dated 6/10/17, indicated dispatch was called at 18:21 and the primary impression was neuro-stroke/[MEDICAL CONDITION]. R73 arrived at the hospital on [DATE], at 18:50 via ambulance, 2 hours and 35 minutes after R73's significant change in condition was identified at the nursing home. R73's ED (emergency department) to Hosp-Admision report dated 6/10/17, at 6:49 p.m. identified R73 had a primary [DIAGNOSES REDACTED]. The report indicated she was a [AGE] year old female with a history of dementia, [DIAGNOSES REDACTED] (non-cancer [DIAGNOSES REDACTED] that arises from the membranes to the spinal cord), history of [MEDICAL CONDITION]'s, DM (diabetes mellitus), [MEDICAL CONDITION] (high cholesterol),[MEDICAL CONDITION](hypertension) and was admitted with probable [MEDICAL CONDITION]. The report indicated her primary deficit was confusion with speech difficulty and will continue [MEDICATION NAME] (blood thinner) for secondary prevention. PT/OT and speech therapy were ordered at the hospital. In addition the report indicated a CT (cat scan) of the head was done and compared to a previous CT completed on 10/09/15, the findings indicated CSF (cerebral spinal fluid) spaces with no [DIAGNOSES REDACTED] (fluid in the brain), atrophy (waste away). The CT scan impression indicated no acute intracranial abnormality, stable atrophy and chronic small vessel ischemic (restriction of blood) change, stable anterior lateral left cerebellar (area of the brain that controls coordination and balance) [DIAGNOSES REDACTED] and chronic right frontal lobe infarct (stroke). A Progress Note on the ED to Hosp-Admission report indicated on 6/11/17, that R73 was admitted on [DATE], with a [MEDICAL CONDITION]. A First Light Health System Hospital Discharge Summary dated 6/12/17, completed by medical doctor (MD)-A indicted she had a acute [MEDICAL CONDITION]. A Brief HPI/PE (history of present illness/physical exam) indicated she was a [AGE] year old female with history of dementia, [DIAGNOSES REDACTED], prior [MEDICAL CONDITION], MD, [MEDICAL CONDITION] and hypertension (which blood pressure) presented to the ER with increased confusion and difficulty with speech. Lives in SNF (skilled nursing facility) due to dementia. IS DNR/DNI but family wants treatment for [REDACTED]. Pt (patient) took nap at 1430 today. Was difficult to arouse at 1630 and once she was awake staff noted a change. It took time to contact family and once family was contacted pt was brought to ER (POLST listed comfort care but family wanted treatment for [REDACTED]. By that time, too much time had passed from the last known normal time so tPA (tissue plasminogen activator that is ischemic stroke treatment that dissolves the clot and improves blood flow to the part of the brain deprived of blood flow) was not an option. Pt has significant dementia making history and exam difficult. Denies any f/c (fevers/chills), chest pain, sob (shortness of breath), cough or trouble going to the bathroom (unclear how reliable pt is.) no other concerns. A First Light Health System Mora, Minnesota Physician Criteria for tPA Use In Stroke guidelines last revised 2/11/10, indicated the following Inclusion Criteria: -Clearly defined time of onset of symptoms -tPA can be given within 3 hours of symptom onset -Patients over 18 -The patient's symptoms are clearly consistent with acute ischemic stroke with measurable deficit A Senior Care Transitions Long Term Care Visit dated 6/15/17, completed by CNP-A indicated she was seen for a long term care visit and her primary [DIAGNOSES REDACTED]. She felt ill on 6/10/17 and laid down for nap. When she awoke, she had increased confusion, unstable gait, and difficulty speaking. She was brought to ED for evaluation and felt to have had an acute [MEDICAL CONDITION]. She stabilized and returned to St. Clare on 6/12/17. She continues to have deficits in speech, difficulty swallowing and increased confusion. She is on mechanical soft diet with honey thickened liquids. She is wheelchair bound, gait and balance unstable. The report indicated R73 returned to the nursing home following an acute [MEDICAL CONDITION], primary deficits in cognition, speech and swallow and referrals were made to PT/OT/SLP. R73 had her diet changed to honey-thick liquids, mechanical soft. Although R73 had a change in condition on 6/10/17, with stroke symptoms. The facility failed to provide prompt emergency treatment by not sending R73 immediately to the ED following R73's POLST, which outlined R73 wanted treatment for [REDACTED]. As a result of not receiving this medication, R73 had a significant change in her ADL's and was dependent upon staff, resulting in actual harm to R73 by not following R73 POLST. A facility policy St. Clare Living Community dated 3/8/11, indicated under Policy: Each resident will have a completed POLST form included in their medical record. This form will be completed based on wishes of the resident and/or appointed representative agent. The form will be reviewed regularly and kept current. Purpose: To provide the nursing staff, physicians, family and all others involved with the care of the resident, a written plan that states the resident's wishes about how they want to manage their treatment and care. This form will address their wishes not only related to the end of life, but also the quality of life they desire while living with a chronic illness.

Based on observation, interview and document review, the facility failed to provide timely emergency medical services for 1 of 1 residents (R73) who had stroke symptoms and subsequent stroke which caused physical impairment that limited R73's ability to complete activities of daily living (ADL's), that resulted in actual harm. Findings include: R73's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she was severely cognitively impaired, needed staff supervision with assistance of one for activities of daily living (ADLs), she needed set up assistance with eating and physical assistance of one for bathing. There were no other limitations of R73's ADL's during this assessment period. R73's significant change MDS dated [DATE], identified the following changes in her activity of daily living (ADL) status: She now needed limited assistance of one with bed mobility, transfers, dressing and toileting. In addition, the MDS indicated she was totally dependent upon staff for toileting, ambulated only once or twice and needed staff supervision and assistance of one with eating. R73 remained severely cognitively impaired which was the same on [DATE]. R73's most recent Cognitive Care Area Assessment (CAA) dated [DATE], identified R73 had dementia with severely impaired decision making, which was the same as the [DATE], Cognitive CAA. However, now R73 required, increased help since return from hospital with (stroke). The following new care areas triggered as a result of changes on her [DATE] MDS. R73's Visual Function CAA dated [DATE], indicated R73 had a change in vision function and now had right field cut vision related to [MEDICAL CONDITION] or (stroke) and used a wheelchair for mobility and she got caught on other's wheelchair wheels when in congested areas. R73's Communication CAA triggered due to [MEDICAL CONDITION] a language deficit resident received speech for expressive and receptive [MEDICAL CONDITION] and staff need to assist the resident in finding the correct words for communication. The communication CAA further indicated R73 gets frustrated when unable to find the correct words. The urinary incontinence CAA identified now R73 was occasionally incontinent of urine and needed assistance with toileting and was on a toileting plan every two hours and as needed. The urinary incontinence CAA further indicated due to altered communication R73 was at greater risk for incontinence. The CAA also indicated pressure ulcers triggered due to [MEDICAL CONDITION] was now on a turning and repositioning schedule every two hours and as needed. She was currently receiving Physical Therapy (PT) and Occupation Therapy (OT) for strengthening and endurance related to the [MEDICAL CONDITION]. R73's care plan dated [DATE], identified she had impaired cognition related to [MEDICAL CONDITION], but was alert to self, some family and knowledge she was not at home. The care plan further indicated she had severely impaired decision making, wandered the facility with a lost look on her face, used a wheelchair for mobility and propelled herself independently but needed constant curing to time, place and room location. In addition, the care plan identified R73 was incontinent of urine, had impaired ADL's related to [DIAGNOSES REDACTED]. Further, the care plan indicated R73 was at risk for impaired mobility related to [DIAGNOSES REDACTED]. During observation [DATE], at 6:54 p.m. R73 was seated in a standard wheelchair in the South wing hallway. R73 was leaning to the right side with her shoulder against the rear frame of the chair, propelling the wheelchair using both feet. R73 was mumbling non sensical words, and had a furrowed brow facial expression. During subsequent observation on [DATE], at 9:22 a.m. R73 was lying in bed in her room. Nursing assistant (NA)-J entered the room to help R73 with morning cares. NA-J put R73's socks on, and proceeded to assist R73 to sit up in bed. NA-J assisted and strapped R73 into a mechanical standing lift, and assisted her to a standing position from her bed. NA-J wheeled R73 in the mechanical lift to the bathroom, removed her visibly soiled incontinence product and seated her on the toilet. R73 did not void when seated on the toilet. NA-J used a wet washcloth to wash R73's face, back, arms and perineal area. R73 made no attempts to participate in her bathing. NA-J stated R73 used to be ambulatory and transferred on her own, however, R73 sustained a stroke a few months ago and now required a mechanical lift for transfers, used a wheelchair for mobility and was unable to ambulate anymore. During interview on [DATE], at 1:41 p.m. family member (FM)-A stated she was the person who would be notified of a change in condition, or accident, with R73. FM-A stated a few months ago (R73) developed stroke symptoms and the facility attempted to call her, however, just left a message on her phone about her sudden change in condition. The nursing home thought she had a stroke and wanted her to call them back. They did not tell her she had not been sent the hospital. FM-A stated she did not receive this message until several hours later. When she called the facility back, they had not sent (R73) to the hospital for these symptoms. FM-A stated she told staff to send R73 to the emergency room for treatment immediately and thought if someone had stroke symptoms they should have gone in right away. FM-A stated she was unaware why the facility did not send her immediately to the hospital, adding she was upset. The facility waited too long to send (R73) to the emergency room for treatment. R73's undated Resident Face Sheet indicated family member (FM)-A was R73's emergency contact, responsible party and the person to call if a change in condition. Further, the sheet indicated FM-B was the secondary contact. Review of R73's Provider Order for Life Sustaining Treatment (POLST) dated and signed by R73's certified nurse practitioner (CNP)-A on [DATE], identified R73 had do not resuscitated or intubated (DNR/DNI) on the POLST. A section labeled, Goals of Treatment, included directions to be implemented if R73, has pulse and/or is breathing, and identified R73 had Comfort Care, with several options that could be selected in accordance with R73's wishes. There was a box to check or not check next to each of these areas, to clarify their wishes of comfort care. The areas on the form were: - Avoid calling 911, call (blank line to fill in) instead, - If possible, do not transport to ER (emergency department) ., and, - If possible, do not admit to the hospital from the ER . However, all of these options were left unchecked, identifying R73 wanted these actions implemented. Further, R73's POLST identified an option that was checked which identified, Limit Interventions and Treat Reversible Conditions, which was described as, Provide interventions aimed at treatment of [REDACTED]. The POLST was signed by R73, however, was undated. R73's progress note dated [DATE], at 18:23 indicated, Noted (R73) was difficult to rouse before dinner at 1615. Noted resident with unsteady gait, RT (right) facial droop, RT pupil non-reactive, slurred/slow speech, and bilateral hand/foot strength WNL (with in normal limits). BP (blood pressure) ,[DATE], P (pulse) 73, RR (respiration rate) 18, Sp 02 (oxygen saturation in blood) 97% on RA (room air) and T (temperature) 96.7. Family notified writer at 1815 that they want resident sent into the hospital to get checked out. A First Light Health System Ambulance Report dated [DATE], indicated dispatch was called at 18:21 and the primary impression was neuro-stroke/[MEDICAL CONDITION]. R73 arrived at the hospital on [DATE], at 18:50 via ambulance, 2 hours and 35 minutes after R73's significant change in condition was identified at the nursing home. R73's ED (emergency department) to Hosp-Admision report dated [DATE], at 6:49 p.m. identified R73 had a primary [DIAGNOSES REDACTED]. The report indicated she was a [AGE] year old female with a history of dementia, [DIAGNOSES REDACTED] (non-cancer [DIAGNOSES REDACTED] that arises from the membranes to the spinal cord), history of [MEDICAL CONDITION]'s, DM (diabetes mellitus), [MEDICAL CONDITION] (high cholesterol),[MEDICAL CONDITION](hypertension) and was admitted with probable [MEDICAL CONDITION]. The report indicated her primary deficit was confusion with speech difficulty and will continue [MEDICATION NAME] (blood thinner) for secondary prevention. PT/OT and speech therapy were ordered at the hospital. In addition, the report indicated a CT (cat scan) of the head was done and compared to a previous CT completed on [DATE], and the findings indicated CSF (cerebral spinal fluid) spaces with no [DIAGNOSES REDACTED] (fluid in the brain), atrophy (waste away). The CT scan impression indicated no acute intracranial abnormality, stable atrophy and chronic small vessel ischemic (restriction of blood) change, stable anterior lateral left cerebellar [DIAGNOSES REDACTED] and chronic right frontal lobe infarct (stroke). A Progress Note on the ED to Hosp-Admission report dated [DATE], R73 was admitted to the hospital on [DATE], for a [MEDICAL CONDITION]. A First Light Health System Hospital Discharge Summary dated [DATE], completed by medical doctor (MD)-A indicated she had an acute [MEDICAL CONDITION]. A Brief HPI/PE (history of present illness/physical exam) indicated (R73) was a [AGE] year old female with history of dementia, [DIAGNOSES REDACTED], prior [MEDICAL CONDITION], MD, [MEDICAL CONDITION] and hypertension presented to the ER with increased confusion and difficulty with speech. Lives in SNF (skilled nursing facility) due to dementia. The DNR/DNI but family wants treatment for [REDACTED]. Pt (patient) took nap at 1430 today. Was difficult to arouse at 1630 and once she was awake staff noted a change. It took time to contact family and once family was contacted pt was brought to ER (POLST listed comfort care but family wanted treatment for [REDACTED]. By that time, too much time had passed from the last known normal time so tPA (tissue plasminogen activator that is ischemic stroke treatment that dissolves the clot and improves blood flow to the part of the brain deprived of blood flow) was not an option. Pt has significant dementia making history and exam difficult. Denies any f/c (fevers/chills), chest pain, sob (shortness of breath), cough or trouble going to the bathroom (unclear how reliable pt is.) no other concerns. A First Light Health System Mora, Minnesota Physician Criteria for tPA Use In Stroke guidelines last revised [DATE], indicated the following Inclusion Criteria: -Clearly defined time of onset of symptoms -tPA can be given within 3 hours of symptom onset -Patients over 18 -The patient's symptoms are clearly consistent with acute ischemic stroke with measurable deficit A Senior Care Transitions Long Term Care Visit dated [DATE], completed by certified nurse practitioner (CNP)-A indicated she was seen for a long term care visit and her primary [DIAGNOSES REDACTED]. She felt ill on [DATE] and laid down for nap. When she awoke, she had increased confusion, unstable gait, and difficulty speaking. She was brought to ED for evaluation and felt to have had an acute [MEDICAL CONDITION]. She stabilized and returned to St. Clare on [DATE]. She continues to have deficits in speech, difficulty swallowing and increased confusion. She is on mechanical soft diet with honey thickened liquids. She is wheelchair bound, gait and balance unstable. The report indicated R73 returned to the nursing home following an acute [MEDICAL CONDITION], with primary deficits in cognition, speech and swallow and referrals were made to PT/OT/SLP. R73 also had a diet changed to honey-thick liquids, mechanical soft. A Speech Therapy Plan Of Care Initial assessment dated [DATE], completed by ST-A indicated R73 was seen for expressive and receptive [MEDICAL CONDITION]. The assessment indicated her prior level of communication was minimal assist and able to understand communication in a structured conversations with both familiar and unfamiliar communication partners. Her current level of communication had changed and she needed maximum assistance with consistent, maximal cues, was able to follow simple directions and respond to simple yes and no questions. A Physical Therapy Initial assessment dated [DATE], completed by PT-A indicated that prior to [MEDICAL CONDITION] after the following deficits were identified: -gait 150 ft. (feet) prior with modified independence (assistive device or extra time needed), currently walks 100 ft. with contact guard assist (contact with patient due to unsteadiness). -transfers she went from modified independence to supervision and needing verbal cures -falls she went from moderate risk to high risk of falls The assessment further indicated R73's goal was to ambulate 100 ft with contact guard assist and front wheeled walker with right neglect. The end of goal status indicated her goal was not met and the patient ambulates 100 ft with minimal assistance and front wheeled walker in order to complete functional mobility. An Occupational Therapy Progress and Discharge Summary dated [DATE], completed by OT-A indicated prior to her stroke R73 needed set up assist with self care, supervision with hygiene, partial to minimal assist with toileting. The assessment indicated that her current level on [DATE], R73 now required supervision and verbal cues with eating and moderate assistance with toileting. During interview [DATE], at 8:02 a.m. registered nurse (RN)-B stated she was the clinical manager and MDS coordinator. RN-B stated that R73's FM-A wanted to make sure if anything happened to (R73) that was reversible she wanted her to be hospitalized FM-A has told us this multiple times. During interview [DATE], at 11:41 a.m. the director of nursing (DON) stated when R73 woke up on [DATE], and showed symptoms of a stroke she should have been sent her to emergency department right away. It was her understanding that FM-A would want her sent in right away and staff should not have waited for FM-A to call back. The DON stated (R73) she was walking before her stroke, and feeding herself. Now she needs a wheelchair and supervision with eating. The DON further stated she was not aware the licensed practical nurse (LPN)-C waited so long for FM-A to call the facility back, and was unaware of the ED discharge summary identifying it was too late to treat (R73) with tPA because she was not sent in right away by the nursing home. On [DATE], at 12:20 p.m. a message was left with MD-A (who was not her primary physician) at First Light Health System who completed the hospital discharge summary on [DATE]. MD-A did not return the phone call. During interview [DATE], at 9:00 a.m. the DON stated LPN-C was the nurse working on [DATE], and was R73's nurse. The DON stated she spoke to LPN-C and he stated the reason why he waited for the family to return the call instead of sending her in was because the nurse practitioner (CNP)-A told him to wait and see what the family wanted to do first. LPN-C stated he could not remember if he contacted the secondary family contact. During interview [DATE], at 9:12 a.m. CNP-A stated on [DATE], LPN-C called her and told her the symptoms R73 was having. CNP-A stated based on past conversation with the FM-A they only wanted things treated that were reversible and wanted (R73) sent in for things like an infection and if it was a chronic condition she didn't want her sent in. CNP-A further stated (R73) had a [DIAGNOSES REDACTED] and chronic abdominal pain. FM-A was not treating that so she assumed they would not want her sent in when she was having stroke symptoms. The CNP-A stated FM-A was upset that she was not sent in right away, and stated, I knew she was upset since the day it happened, I am well aware she is upset. During interview [DATE], at 10:46 a.m. with the facility medical director (who was not R73's primary physician) reviewed R73's POLST and hospitalization on [DATE]. The facility medical director stated if a resident has a POLST like hers and was having stroke symptoms she should have been sent to the emergency room right away and not wait for family to return the call. The medical director stated if she had pneumonia or something that was not so urgent they could have waited. The medical director reviewed the emergency department note and stated MD-B was the emergency room physician. Reading MD-B note and was sleeping at 1430 you have to assume this was the last time (R73) had [MEDICAL CONDITION]. When she got to the ED they decided not treat with tPA because too much time had passed. The medical director stated a stroke could be a reversible condition and it would make sense to send her to the ED right away. During interview [DATE], at 11:19 a.m. the DON stated during an emergency situation she would expect the facility to call the physician or nurse practitioner, and family. If they were unable to contact the primary contact, they should call the secondary contact and then just send the resident in. The DON stated they should not have waited for the family to call back and should have just sent her in. The DON stated they don't have a specific policy stating this but this was their protocol. During interview [DATE], at 12:57 p.m. LPN-C stated he was R73's nurse on [DATE], and when she woke up he noted a facial droop and paralysis so he called the CNP-A, who told him she did not think the family would want her to go to the ED because of her [DIAGNOSES REDACTED]. When FM-A called back she told LPN-C to send her in right away. LPN-C stated he was unable to recall the events after calling FM-A, but had not received a call back right away and was unsure if he attempted to call the secondary contact FM-B. LPN-C stated even though so much time had passed, he had not heard from FM-A nor did he recall calling CNP-A again about not being able to reach FM-A, because CNP-A did not seem too concerned. On [DATE], at 1:12 p.m. a call was placed to the ED and a message was left for MD-B. MD-B did not return the call. During interview [DATE], at 1:33 p.m. CNP-A stated she can not recall if LPN-C called her on [DATE], about not being able to reach (R73's) FM-A or FM-B right away. CNP-A stated even if LPN-C called me again, she would not have not changed her decision because she was under the impression FM-A did not want to treat (R73). During interview [DATE], at approximately 2:45 p.m. NA-B stated prior to R73's stroke she did not need much assistance from staff to brush her hair, brush teeth and dress and undress herself. NA-B further stated she fed herself and knew the schedule of activities, would voluntarily assist staff but pushing resident wheel chairs to and from activities and meals when residents requested, was happy and joked around. NA-B stated, Since her stroke she seems sad, down, brushes off conversations and it seems that she knows life is now different. NA-B further stated, She also seems embarrassed, while (R73) doesn't ask for help and when she is assisted with care, (R73's) expressions appears that she doesn't like it. During interview [DATE], at approximately 3:00 p.m. NA-C after R73's stroke she seems more sad. NA-C stated that prior to the stroke R73 dressed and groomed herself with occasional assist to tuck in a blouse. NA-C stated since the stroke, R73 needs total assistance with all her daily needs. During interview [DATE], at 3:16 p.m. FM-A stated the facility called her on [DATE], and left her a message. The facility did not call FM-B who was (R73's) secondary emergency contact. Although R73 had a change in condition on [DATE], with stroke symptoms, the facility failed to provide prompt emergency treatment by not sending R73 immediately to the ED following R73's POLST, which outlined R73's wanted treatment for [REDACTED]. As a result of not receiving this medication, R73 had a significant change in her ADL's and was dependent upon staff, resulting in actual harm to R73. A facility policy Change In Condition reviewed [DATE], indicated, Except in medical emergency or when a resident is incompetent, the facility must consult with the resident immediately and notify the residents's physician, and if known the resident's legal representative or interested family member when there is: a) A change in resident's physical, mental or psychosocial status. b) A need to alter treatment significantly. c) A decision to transfer or discharge the resident from the facility. The policy further indicated to notify the family significant other when there is a change in status of a resident, the RN or designee will: 1. Notify the first designated contact person 2. If unable to locate this individual, the next designated individual will be contacted. A facility policy Emergency Care undated indicated licensed nursing staff will provide care for residents in an emergency situation and the procedure would be to stay with the resident while 911 would be called, give address, nature of the problem and do not hang up until told to do so. And in a non-life threatening emergency to give emergency care, notify physician, if needed call for ambulance and notify family. A facility policy St. Clare Living Community Of Mora Policy and Procedure For Documentation Guidelines And Maintaining Legally Sound Health Record dated ,[DATE], indicated under notification or communication that notification to the resident's physician, nurse practitioner or family is required. When a discussion with the resident's family occurs regarding care of the resident, all such communication (including attempts at notification) have to be charted. Include the time and method of all communications. The entry has to include any orders received or responses, the implementation of such orders if any and the resident's response. Messages left on answering machines should be limited to a request to return call and does not meet the definition of notification. Make sure to report to the the next shift that a message was left with the family and that they need to follow up with another call. A facility policy St. Clare Living Community dated [DATE], indicated under Policy: Each resident will have a completed POLST form included in their medical record. This form will be completed based on wishes of the resident and/or appointed representative agent. The form will be revived regularly and kept current. Purpose: To provide the nursing staff, physicians, family and all others involved with the care of the resident, a written plan that states the resident's wishes about how they want to manage their treatment and care. This form will address their wishes not only related to the end of life, but also the quality of life they desire while living with a chronic illness.