Every finding on record at Sterling Park Health Care Center

Based on interview and record review, the facility failed to ensure a prescribed medication was available for administration and follow up when a medication remained unavailable from the pharmacy. This resulted in a resident not receiving the prescribed medication for six consecutive days for 1 of 1 resident (R33) reviewed for medication availability.Findings include:R33's admission Minimum Data Set (MDS) dated [DATE], identified R33 had intact cognition and required assistance with activities of daily living (ADL)'s. R33's diagnoses included. atrial fibrillation (common heart rhythm disorder where the upper chambers of the heart beat chaotically and out of sync), heart failure (heart muscle is too weak or stiff to pump blood well, so the body does not get enough oxygen and blood backs up into the lungs or body), end-stage renal disease (permanent kidney failure where the kidneys stop working well enough to keep you alive, requiring dialysis or a kidney transplant), and dependence on renal dialysis (when a person relies permanently or long-term on a dialysis machine to stay alive because their kidneys can no longer function on their own). R33's physician orders printed 8/6/26, indicated calcium acetate (medication to treat high blood phosphate levels in residents with end-stage kidney disease who are on dialysis) 667 milligrams (mg) by mouth three times daily, initiated on 7/15/26.R33's medication administration record (MAR) for July 2026, indicated calcium acetate was not administered as ordered on 7/15/26, 7/16/26, 7/17/26, 7/18/26, 7/19/26, or for two scheduled doses on 7/20/26. R33 did not receive the prescribed calcium acetate for six consecutive days.R33's progress notes indicated the medication was unavailable from the pharmacy during this period:On 7/15/26 at 7:41 a.m. and 12:27 p.m., staff documented the medication had not been delivered by the pharmacy. At 5:09 p.m., staff documented the medication was unavailable and on order.On 7/16/26 at 11:38 a.m. and 11:39 a.m., staff documented the medication had not been delivered and no supply was available.On 7/17/26 at 7:13 a.m. and 11:00 a.m., staff documented the medication remained on order.On 7/18/26 at 3:35 p.m., staff documented no calcium acetate was available from the pharmacy. The progress note indicated staff contacted the pharmacy, and pharmacy personnel confirmed the medication was in the pharmacy's system and would be sent the following night.On 7/19/26 at 12:33 p.m. and 3:23 p.m., staff documented calcium acetate remained unavailable.On 7/20/26 at 12:38 p.m., staff documented the medication had not been delivered and the pharmacy had been contacted regarding delivery.R33's EHR lacked evidence that staff checked the emergency medication supply or took additional action to obtain calcium acetate from an alternative source when the medication remained unavailable.During an interview on 8/6/26 at 8:53 a.m., licensed practical nurse (LPN)-A stated when a medication was unavailable, nursing staff should have checked the emergency medication supply, contacted the pharmacy by telephone, and documented the communication.During an interview on 8/6/26 at 10:10 a.m., registered nurse case manager (RN)-A stated the facility's pharmacy was located in Iowa, and medications were delivered late in the evening. RN-A stated the facility had recently entered into an agreement with a local pharmacy to obtain medications when ordered medications were unavailable. RN-A stated when a nurse did not have a medication available, the nurse should have contacted the pharmacy to determine the reason and notified the director of nursing (DON) or RN-A the medication was unavailable.During an interview on 8/6/26 at 10:39 a.m., DON stated the pharmacy was located in Iowa, and the facility was working with the pharmacy to obtain medications more timely. The DON stated admission orders were sent to the pharmacy and medications identified as most important were sent to a local pharmacy under a new agreement so they could be obtained sooner. DON stated nursing staff should have contacted the pharmacy when the medication was unavailable and notified DON so she could also contact the pharmacy and attempt to obtain the medication sooner. The DON stated she had been unaware R33 had not received calcium acetate and nursing staff had not notified her the medication had not been delivered. After reviewing R33's July MAR, DON stated calcium acetate arrived on 7/20/26 and it appeared the facility did not have the medication available until it was delivered that day.The facility's Unavailable Medications policy, revised 11/18, indicated medications used by residents could occasionally be unavailable for dispensing from the pharmacy due to circumstances including the pharmacy being temporarily out of stock, a drug recall, a manufacturer's shortage of an ingredient, or discontinuation of the medication by the manufacturer. The policy indicated the facility was required to make every effort to ensure medications were available to meet each resident's needs.

Based on interview and record review, the facility failed to ensure coordination and communication of dialysis-related care when staff did not notify the provider, nephrologist, or dialysis center, after a resident did not receive a prescribed dialysis-related medication for six consecutive days for 1 of 1 resident (R33) reviewed for dialysis services.Findings include:R33's admission Minimum Data Set (MDS) dated [DATE], identified R33 had intact cognition and required assistance with activities of daily living (ADL)'s. R33's diagnoses included. atrial fibrillation (common heart rhythm disorder where the upper chambers of the heart beat chaotically and out of sync), heart failure (heart muscle is too weak or stiff to pump blood well, so the body does not get enough oxygen and blood backs up into the lungs or body), end-stage renal disease (permanent kidney failure where the kidneys stop working well enough to keep you alive, requiring dialysis or a kidney transplant), and dependence on renal dialysis (when a person relies permanently or long-term on a dialysis machine to stay alive because their kidneys can no longer function on their own). R33's electronic health record (EHR) indicated R33 received hemodialysis three days per week at an outpatient dialysis center.R33's physician orders printed 8/6/26, indicated calcium acetate (medication to treat high blood phosphate levels in residents with end-stage kidney disease who are on dialysis) 667 milligrams (mg) by mouth three times daily, initiated on 7/15/26.R33's medication administration record (MAR) for July 2026, indicated calcium acetate was not administered as ordered on 7/15/26, 7/16/26, 7/17/26, 7/18/26, 7/19/26, or for two scheduled doses on 7/20/26. R33 did not receive the prescribed calcium acetate for six consecutive days.R33's dialysis communication documentation dated 7/16/26, 7/18/26, and 7/21/26, lacked evidence that the facility notified the dialysis center of R33's missed doses of calcium acetate.R33's EHR lacked evident the provider or nephrologist was notified R33 had not received the prescribed calcium acetate from 7/15/26 through 7/20/26.During an interview on 8/6/26 at 8:53 a.m., licensed practical nurse (LPN)-A stated the provider and dialysis center should have been notified R33 had not received the medication. LPN-A stated the notification should have been documented in the progress notes.During an interview on 8/6/26 at 10:10 a.m., registered nurse case manager (RN)-A stated if a resident did not receive a medication, the provider should have been notified. RN-A confirmed nursing staff should have notified the dialysis center R33 had not received the medication.During an interview on 8/6/26 at 10:39 a.m., the director of nursing (DON) stated she was unaware R33 had not received calcium acetate. Nursing staff had not notified her the medication had not been delivered. After reviewing R33's progress notes, the DON confirmed the EHR lacked documentation the provider or nephrologist had been notified of the missed doses of calcium acetate.The facility's Dialysis: Care and Monitoring of Resident policy, dated 12/3/25, indicated the facility would provide adequate long-term access for dialysis, administer medications as ordered, and immediately report abnormal findings to the dialysis department and physician.

Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) (CMS-10055) to 1 of 3 residents (R49) reviewed for beneficiary notices.Findings include:R49's electronic health record (EHR) indicated Medicare Part A coverage for skilled nursing facility services ended on 2/2/26. Following the end of Medicare Part A coverage, R49 remained in the facility and transitioned to private-pay status.R49's EHR and beneficiary notice documentation lacked evidence that a completed SNFABN (CMS-10055), had been provided to R49 and/or R49's representative when Medicare Part A covered ended and R49 became financially responsible for continued services.During an interview on 8/4/26 at 11:32 a.m., the Assistant Director of Nursing (ADON) confirmed SNFABN, CMS-10055, had not been completed for R49. The ADON stated she was new to the role and had not been aware that an SNFABN was required. The ADON stated R49 had been expected to transfer to another setting; however, the transfer had been delayed after R49 developed COVID-19. The ADON confirmed an SNFABN should have been completed to inform R49 of his financial responsibility when he transitioned to private-pay status.When requested to provide the facility policy related to beneficiary notices, the facility provided an undated Beneficiary Notice Guidelines document. The guidelines indicated when a Medicare Part A stay ended because the provider determined the beneficiary no longer required daily skilled services, the beneficiary had skilled benefit days remaining, and the beneficiary was discharged from Medicare Part A but continued to reside in the facility under a different payer source, beneficiary notices were issued. The guidelines identified the SNFABN, CMS-10055 and a Notice of Medicare Non-Coverage (NOMNC), CMS-10123, as types of beneficiary notices to be issued.

Based on interview and record review, the facility failed to ensure potential adverse consequences associated with antipsychotic medication use were adequately monitored when orthostatic blood pressures were not completed as ordered for 1 of 3 residents (R31) reviewed for unnecessary medications.Findings include:R31R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had intact cognition and required assistance with activities of daily living (ADL)'s. R31's diagnoses included non-Alzheimer's dementia (permanent decline in mental abilities), Parkinson's disease (long-term brain disorder that slows and impairs movement as specific nerve cells die), bipolar disorder (a mental health condition defined by at least one full manic episode, which is a period of abnormally high energy, extreme excitement, or intense irritability) and repeated falls. MDS indicated R31 received antipsychotic medications (used to treat symptoms of psychosis, such as hallucinations and delusions, by balancing brain chemicals).R31's physician orders identified quetiapine fumarate, an antipsychotic medication, 300 milligrams (mg) by mouth at bedtime for bipolar I disorder, initiated on 10/23/25; quetiapine fumarate 50 mg by mouth every morning for bipolar I disorder, initiated on 10/24/25; and quetiapine fumarate 50 mg by mouth every six hours as needed (PRN) for bipolar I disorder with manic episodes for 13 days, initiated on 8/4/26.R31's progress noted dated 3/17/26 at 9:20 a.m. indicated orthostatic blood pressure was not completed because R31 was unable to stand.R31's progress noted dated 4/17/26 at 9:33 a.m. indicated orthostatic blood pressure was not completed because R31 was unable to stand.R31's progress noted dated 5/17/26 at 9:17 a.m. indicated orthostatic blood pressure was not completed because R31 was unable to stand.R31's progress noted dated 6/18/26 at 9:03 a.m. indicated orthostatic blood pressure was not completed because R31 was unable to stand.R31's electronic health record (EHR) lacked evidence staff obtained blood pressures in the positions R31 was able to tolerate, including lying and sitting, when a standing measurement could not be obtained. As a result, the scheduled orthostatic blood pressure monitoring was not completed during March, April, May or June 2026.During an interview on 8/6/26 at 8:53 a.m., licensed practical nurse (LPN)-A stated orthostatic blood pressure monitoring consisted of obtaining blood pressure measurements while the resident was lying, sitting, and standing. LPN-A stated when a resident was not able to stand, staff would obtain the blood pressure measurements while the resident was lying and sitting. LPN-A further stated if a resident refused the monitoring, staff would reattempt the monitoring and document the refusal.During an interview on 8/6/26 at 10:10 a.m., the registered nurse case manager (RN)-A stated orthostatic blood pressures were completed by the floor nurse. RN-A stated that if a resident was unable to stand, staff should still obtain blood pressure measurements while the resident was lying and sitting and document the resident's inability to stand. RN-A stated orthostatic blood pressure monitoring was important for resident receiving psychotropic medications to monitor for potential adverse effects.During an interview on 6/4/26 at 12:14 p.m., RN Case Manager (CM)-C stated orthostatic blood pressures should be completed monthly and include blood pressure measurements in the lying, sitting, and standing positions. CM-C stated orthostatic blood pressures were important because antipsychotic medications could cause side effects that increased a resident's risk for falls. CM-C stated they would not expect blood pressure readings to be exactly the same in all three positions because some variation would typically occur. CM-C further stated that if a resident refused the monitoring, staff should document the refusal and attempt the monitoring again later. CM-C reviewed the orthostatic blood pressure documentation for the identified residents and confirmed several readings were identical in all positions. CM-C stated they would ensure nursing staff were educated on the correct procedure for obtaining orthostatic blood pressures.During an interview on 8/6/26 at 9:55 a.m., a call was placed to the consultant pharmacist, and a message was left requesting a return call regarding psychotropic medication monitoring and orthostatic blood pressure monitoring. As of survey exit, the consultant pharmacist had not returned the call.During an interview on 8/6/26 at 10:39 a.m., director of nursing (DON) stated residents receiving psychotropic medications were expected to have orthostatic blood pressure monitoring completed monthly, when they were able to participate. The DON stated orthostatic blood pressure monitoring consisted of obtaining blood pressure measurements while the resident was lying, sitting, and standing when the resident was able. The DON stated that when a resident was unable to stand, staff were still expected to obtain the lying and sitting blood pressure measurements. The DON stated orthostatic blood pressure monitoring was important to identify dizziness and adverse effects associated with medications that could increase a resident's risk for falls.The facility policy, Use of Psychotropic Medication(s), updated 4/21/25, indicated psychotropic medications were to be used when appropriate for the resident's diagnosed condition and their benefit demonstrated through monitoring and documentation of the resident's response to the medication. The policy indicated the effects of psychotropic medications on the resident's physical, mental, and psychosocial well-being were to be evaluated on an ongoing basis, including through nursing assessments and medication-monitoring parameters consistent with clinical standards of practice, manufacturer specifications, and the resident's comprehensive care plan. The policy further indicated the resident's response to the medication, including the presence or absence of adverse consequences, was to be documented in the medical record.

Based on observation, interview, and document review, the facility failed to ensure a comprehensive resident care plan was completed for 1 of 3 residents (R25) reviewed for smoking. Findings include: R25's electronic health record (EHR) diagnosis list printed 8/6/26, indicated R25's diagnoses included emphysema (a long-term lung disease where the tiny air sacs in lungs are harmed), dependence on oxygen, chronic obstructive pulmonary disease (COPD), and tobacco use. R25's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R25 was cognitively intact and dependent on facility staff for her activities of daily living (ADLs). On 8/3/26 at 11:56 a.m., R25 was observed outside the skilled nursing facility, in front of the attached assisted living facility, smoking at the public bus stop shelter. R25 stated, This is were we are to smoke. No skin or clothing burn marks were observed on R25, and resident held and disposed of her smoking materials safely. R25's Smoking and Safety assessment dated [DATE], indicated the facility had determined R25 was safe to smoke independently. The status of the assessment indicated activating. R25's comprehensive care plan revised 7/19/26, indicated R25 had potential/actual impairment to skin integrity related to (r/t) decreased mobility from recent surgery, fragile skin due to agingand smoking, surgical wound from surgery, and R25 had altered respiratory status/difficulty breathing, shortness of breath related to COPD/emphysema. However, R25's care plan lacked the addition of a smoking section with interventions after R25 had been assessed on 7/9/26. During an interview on 8/4/26 at 4:20 p.m., assistant director of nurse (ADON) stated R25's care plan lacked documentation of R25 smoking. ADON reviewed R25's smoking assessment and noted that the care planning option was stuck on activating. ADON stated the assessment, once the care plan option was activated, should send a message that a care planning problem needed to be addressed. The beginning of the month (July 2026) PCC was updated with new assessments {Nursing Advantage assessments) that provided the facility staff to be alerted to the need to address a resident concern. ADON stated she would contact the administrator of this issue. During an interview on 8/6/26 at 9:13 a.m., the director of nursing (DON) stated they had assessment updates the beginning of July 2026, and there appears to have been a computer glitch, noting that the smoking assessment was still in the activating mode. DON stated, the facility staff should have reviewed the care plan after the assessment was completed, to personalize it to R25's smoking needs and habits. DON stated, even with this new feature, facility staff could still enter care plan problems manually. DON further stated, when a care plan is reviewed and revised, the entire care plan should be reviewed, to note if further revisions are needed. In review of the facility's policy, entitled: Comprehensive Care Plan (Updated 12/3/25) documented only the following:e) The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The care plan will be updated in a timely manner to ensure that services to be furnished to attain or maintain the resident's highest practicable physical, mental and psycho social well-being.

Based on interview and document review, the facility failed to ensure a written agreement was established with an outside dialysis provider that furnished dialysis services to facility residents. This deficient practice had the potential to affect all residents who received dialysis services at an outside facility.Findings include:Review of facility documentation identified that residents received outpatient hemodialysis services from an outside dialysis provider.Review of facility contracts and agreements failed to identify a written agreement between the facility and the dialysis provider that defined the services provided and the responsibilities of the facility and the dialysis provider related to the residents' dialysis care.During an interview on 8/3/26 at 12:48 p.m., Administrator confirmed the facility did not have a written agreement or contract with the dialysis provider. Administrator stated an agreement or contract was not needed because the facility did not provide peritoneal dialysis on site.During an interview on 8/6/26 at 11:39 a.m., Administrator stated a contract or agreement with the dialysis provider was not needed. The Administrator stated that she did not know whom to contact regarding an agreement and that, if the facility was required to have one, the facility might stop admitting residents who received dialysis. The Administrator stated the facility did not arrange the dialysis services because the services had been arranged before the residents were admitted . The Administrator also stated the facility did not pay the dialysis provider and therefore, she saw no need for a contract/agreement unless dialysis services were provided in the facility.The facility policy titled Dialysis: Care and Monitoring of Resident, dated 12/3/25, indicated that the facility would provide adequate long-term access for dialysis and monitor for patency, infection, and bleeding. The policy also indicated that the facility would assess residents and evaluate changes in condition related to their physical condition upon return to the facility after receiving dialysis treatment. The policy did not identify a requirement for a written agreement with the outside dialysis provider or define the responsibilities of the facility and the dialysis provider for coordinating and providing dialysis-related care.

Based on observation, interview, and document review, the facility failed to ensure facility staff followed the infection control practices for 1 of 2 resident (R2) in the sample who were review for activities of daily living (ADLs). Findings include - R2's Point Click Care (PCC - electronic medical record system) printed 8/6/26, indicated diagnoses included; acute respiratory failure with hypoxia (the bodies tissues do not get enough oxygen to function), traumatic subdural hemorrhage with loss of consciousness, cardio-vascular accident resulting in aphasia (the complete inability to swallow due to physical damage or muscle failure in the mouth, throat, or esophagus) and dysphagia (difficulty or discomfort when swallowing. It can range from mild trouble passing certain foods to a complete inability to swallow) and received nutrition though a gastric feeding tube. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 was severely cognitively impaired and dependent on facility staff for all of resident's activities of daily living (ADLS).During general observations of R2's room, it was posted with Enhanced Barrier Precautions (EBP) signage (EBP = infection control guidelines used in nursing homes and long-term care facilities to stop the spread of dangerous germs called multidrug-resistant organisms (MDROs)). Within R2's room were gloves and disposable gowns to be used during direct care due to R2's gastric feeding tube.In an observation on 8/6/26 at 6:45 a.m., nursing assistant (NA)-B was already in R2's room providing morning cares. NA-B stated she was waiting on NA-C to return to assist with resident positioning to do back care. NA-B was wearing gloves, however no gown. NA-C entered the room shortly after, preformed hand hygiene and donned gloves. NA-C did not don a gown. NA-C then assisted NA-B, rolling R2 towards NA-C so NA-B could provide back side care. After R2's care was provided, R2 was dressed, and placed in her wheelchair using a Volaro brand lift. NA-B and NA-C removed their gloves and performed hand hygiene, with NA-B again donning gloves to perform R2's oral hygiene. In an interview on 8/6/26 at 7:42 a.m., NA-B and NA-C approached surveyor (while surveyor was called away to another observation) and stated they wanted to tell surveyor that they forgot to wear gowns while doing morning cares on R2. During this interview, both staff member stated it was important to have worn the gown, not only for R2's protection, but theirs and the other resident they would have been caring for after, due to her gastric feeding tube.During interview 8/6/26 at 9:11 a.m., the director of nursing (DON) was interviewed while the facility's infection preventionist was out. The DON stated the two nursing assistants should have worn gowns during the morning care of R2. DON stated the room had the postings and the PPE (personal protective equipment) and should have cued both nursing assistants to wear.In review of the facility's Infection Control Manual (last reviewed 1/29/26) on page 55 it documented the following: a) Staff must wear a gown, or an apron when performing task(s) that will likely soiled employee's clothing with infective matter (i.e.: blood, feces, body fluid, tissue, etc.) And on Page 58, Enhanced Barrier Precautions: c) section 2 PPE for enhanced barrier precautions is only necessary when performing high -contact care activities and may not be needed to be donned prior to entering the resident's room

Based on observation, interview, and document review, the facility failed to ensure residents' grooming needs were met for 1 of 2 residents (R12) in the sample who were observed for the provision of activities of daily living cares. Findings include: R12's electronic health record (EHR) printed 8/6/26, indicated R5's diagnoses included; acute respiratory failure with hypoxia (the bodies tissues do not get enough oxygen to function), pleural effusion (an abnormal buildup of fluid between the tissues that line the lungs and the inside of the chest cavity), repeated falls, and wedge compression fractures of T11-T12 vertebra. R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 was cognitively intact and required partial-moderate assistance from facility staff for her grooming needs. On 8/3/26 at 10:34 a.m., R12 had multiple 1/4-inch whiskers on both corners of her chin. R12 stated she was unaware the whiskers where there and felt her chin. R12 stated You're the first person to ask me about that. I have a razor. I don't like hair on my face. Can you help me with that? R12 stated she was assisted that morning, but no one offered to shave her or mentioned she had chin hair. A nursing assistant care sheet, undated, indicated R12 required one assist with dressing, hygiene, and oral care. R12's EHR task section indicated Shaving (electric/razor) was assigned to the nursing assistants and was to be done as needed. On 8/4/26 at 12:22 p.m., R12 pointed to her chin and stated, no one has offered yet.On 8/5/2026 at 8:54 a.m., R12 was in her room waiting for breakfast and watching TV. R12 pointed to both side of her chin and stated, Have you found out anything about these yet? No one has said or offered to help with it. Am I going to have to have them surgically removed?, and then she chuckled. During an interview on 8/5/26 at 9:29 a.m., nursing assistant (NA)-A stated she has offered to set up / lay out R12's shaver (electric - in the bedside stand) but she always refused. NA-A further stated, We have offered and she refused, even offered to assist her and she refused.During an observation on 8/6/26 at 8:37 a.m., R12 was in her room placing her hearing aids into the charger case. R12 looked up and stated, I still got these as she rubbed her chin. She stated her morning cares had been completed earlier and no one said anything. During this conversation, the director of nursing (DON) knocked and entered R12's room. DON asked if there was something she could assist with. R12 pointed to her chin and stated, I want these gone. DON stated she had a razor and found the razor in R12's bedside stand with the battery compartment door missing and no batteries. R12 stated, You just have to get some batteries and put some tape over them to hold them in. DON got batteries and shaved R12's chin.During an interview on 8/6/26 at 9:09 a.m., DON stated R12 had admitted to the facility a couple of times before, and resident had functioned at a high-level and did her own cares. DON stated the nursing assistants should have asked R12 and other residents if they needed help with shaving. DON was concerned that the staff had not noticed the shaver lacked batteries and the razor compartment door was missing. DON stated all the staff had to do was ask, and DON stated it caused her to wonder how long the razor had been that way. The facility's Activities of Daily Living (ADLs) policy, updated 5/27/26, indicated a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and document review, the facility failed to follow process to ensure advanced directives were accurately documented and updated on the resident's electronic health record (EHR) banner, physician orders and Physician's Orders for Life Saving Treatment (POLST) which affected 2 of 16 residents (R35 and R19) reviewed for advance directives. These findings constituted an immediate jeopardy (IJ) situation for R35 and R19 who would not have received cardiopulmonary resuscitation measures (CPR) according to their wishes. The IJ began on [DATE], when R35's POLST, indicating R35's wishes for resuscitation was signed by the medical provider and it was not changed within the facility's EHR to reflect R35's wishes. This error was not identified despite multiple opportunities; and a series of interviews with direct care staff outlined they would implement the incorrect directions and not perform CPR which was against R35's wishes due to this error. The director of nursing (DON) was notified of the IJ on [DATE] at 5:55 p.m. The IJ was removed on [DATE] at 10:56 a.m., but non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. The director of nursing (DON) was notified of the IJ on [DATE] at 5:55 p.m. The IJ was removed on [DATE] at 10:56 a.m., but non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm.Findings include: R35's quarterly Minimum Data Set (MDS) dated [DATE], identified R35 had intact cognition and required assistance with all activities of daily living (ADL)'s. R35's diagnoses included acute on chronic systolic (congestive) heart failure, hypertension, renal failure, diabetes mellitus, and chronic respiratory failure with hypoxia. R35's electronic health record (EHR) banner reviewed on [DATE] at 4:18 p.m., identified R35 was do not resuscitate/do not intubate (DNR/DNI). R35's Order Summary report dated [DATE], indicated DNR/DNI status. R35's most current Physician's Orders for Life Sustaining Treatment (POLST) located in the emergency binder in the nurse’s station, signed by R35 and medical doctor (MD)-A on [DATE] indicated full code status. During interview on [DATE] at 3:02 p.m., trained medication aide (TMA)-A stated she would refer to the banner in the EHR, in the event of an emergency, regarding resident’s code status. TMA-A confirmed R35’s code status stated DNR/DNI. TMA-A stated they would take no action, except to notify the nurse, in the event R35 was without breath or heartbeat. According to information noted in R35's EHR, TMA-A stated they would alert the nurse R35 was do not resuscitate/do not intubate. During interview on [DATE] at 3:04 p.m., nursing assistant (NA)-A stated she would refer to the banner on the computer or tablet regarding resident’s code status. During interview on [DATE] at 4:29 p.m., R35 stated if her heart stopped, she would want cardiopulmonary resuscitation (CPR) to resuscitate her. During interview on [DATE] at 4:31 p.m., director of nursing (DON) stated her expectations would be for staff to look at the emergency red binder located in the nurse’s station in the event of an emergency at the actual signed POLST for code status. If code status orders do not match, there would be a high risk of initiating the wrong life-saving treatments. DON looked at POLST that was in the emergency red binder and confirmed code status was changed to full code on [DATE] and was signed by both R35 and the provider. DON then confirmed the banner and order in the EHR stated code status as DNR/DNI and the order date on it was [DATE]. DON confirmed the providers order from [DATE] had gotten missed and that R35 would not have received CPR in the event of an emergency. R19’s R19's admission Minimum Data Set (MDS) dated [DATE], identified R19 had intact cognition and required assistance with all activities of daily living (ADL)'s. R19's diagnoses included type II diabetes mellitus (DM) with polyneuropathy, hypothyroidism, hypertension, and chronic kidney disease stage 3. R19's electronic health record (EHR) banner reviewed on [DATE] at 3:20 p.m., identified R19 was do not resuscitate (DNR). R19's Order Summary report dated [DATE], indicated DNR status. R19's most current Physician's Orders for Life Sustaining Treatment (POLST) located in the emergency binder in the nurse’s station, signed by R19 on [DATE] indicated full code status. R19’s Directives to Define Scope of Medical Care form, signed by R19 and dated [DATE], indicated TO RESUSCITATE. Both forms were signed by certified nurse practitioner (CNP)-A on [DATE] and were scanned into R19’s EHR. During interview on [DATE] at 3:00 p.m., R19 stated she wanted cardiopulmonary resuscitation (CPR) to be performed if necessary, but she did not “want all the tubes and stuff. During interview on [DATE] at 3:03 p.m., licensed practical nurse (LPN)-B stated she would refer to the banner in the EHR, in the event of an emergency. If she did not have access, she would look in the binder kept in the nurses charting room. LPN-B accessed PCC and confirmed R19’s banner indicated DNR. LPN-B stated if there was a discrepancy she would call the residents family member or power of attorney if they had one to determine the residents wishes. LPN-B stated, if R19's heart stopped or R19 stopped breathing, she would not initiated CPR as directions in PCC were DNR. During interview on [DATE] at 3:57 p.m., Director of Nursing (DON) stated during the admission process they completed an initial form named Directives to Define Scope of Medical Care, indicating the residents wishes and code status. That form was temporary, until the medical provider comes in and the completes the POLST form with the resident and/or Power of Attorney (POA). Once the POLST was completed it was scanned into the EHR and then placed in the red binders at the nurse’s station. The Case Manager was responsible for obtaining orders signed by the medical provider and entering the order into the residents EHR which pulled into the banner. DON stated if there were a discrepancy the care staff know to use the POLST/binder. DON stated she felt the orders should be double checked by another nurse. DON stated CNP-A was usually good about telling them if there was a change, and the residents code status was also supposed to be reviewed with the resident and/or family during care conferences quarterly and annually and this was handled by the social worker. DON stated her expectation in the event of a medical emergency, was for staff to go directly to the red POLST binder, rather than trying to log in to the EHR. If there were a discrepancy there would not have been time to call a POA for clarification. DON stated if they found a discrepancy while performing chart audits, they would have followed up with the resident/POA to determine their wishes and then make sure it is reflected in the banner and the POLST. During interview on [DATE] at 4:30 p.m., social services (SS)-A stated she pulled the code status off the EHR and checked the advanced directives documents such as POLST, to verify accuracy as well as any POA or legal guardianship paperwork when she prepared for resident’s care conferences. SS-A stated she verbalized the current code status, and asked the resident and/or POA if that is still their wishes. If resident or POA had not agreed, she would have corrected this with them. During interview on [DATE] at 10:51 a.m., trained medication aide (TMA)-C- stated she recently received education regarding resident POLST’s. TMA-C stated in the event of a medical emergency, she would look in the red binder, which is alphabetized by residents last name, to locate the necessary residents' POLST. TMA-C stated the training entailed reading the information provided, followed by a verbal quiz on the information. During interview on [DATE] at 10:55 a.m., nursing assistant (NA)-D stated he received training last night about CPR and code statuses. He stated they are to look in the red binders at the nurses’ station. NA-D stated he was told how he was to determine code status, and that the nurse was to make the call. In the event of an emergency someone checked the POLST kept at the nurses’ station in two red binders filed alphabetically. NA-D stated the DON spoke with him and signed off on his retraining. The facility policy Cardiopulmonary Resuscitation (CPR) dated [DATE], identified it was the policy of the facility to adhere to resident’s rights to formulate advance directives. Advance Directives to define the scope of medical care will be discussed with the potential resident and/or resident representatives at the time of admission. The facility will review decisions about a resident’s CPR status at each initial care conference, at quarterly care conferences, at resident and/or resident representative request as well as at the time of any permanent, significant change in the resident’s status that results in the development of a new care plan. The IJ was removed on [DATE] at 10:56 a.m., when the facility developed and implemented a systematic removal plan which was verified by interview and document review. On [DATE], the facility completed an audit of all residents' code status, reviewed the process to ensure the entered POLST information into the EMR was accurate and updated. On [DATE] licensed staff were educated regarding the updated POLST procedure and where to find a residents' code status. and continued for staff prior to their next shift. During interview on [DATE] at 11:45 a.m., director of operations (DOO) stated the facility did not have an advance directive policy. DOO stated the POLST should have been processed and entered in the EHR as any other provider order.

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on-site for at least 8 consecutive hours on a daily basis. Lack of consistent RN coverage may result in delayed assessment, clinical decision-making, or care interventions, potentially jeopardizing resident health and safety. This failure had the potential to negatively impact resident care and oversight.Findings include: Facility payroll based journal (PBJ) staffing data report for fiscal year 2025, quarter 2 (January 1- March 31) triggered excessively low weekend staffing. Facility assessment dated [DATE]- indicated facility need for 1 RN for 40 residents. Facility staffing schedules indicated RNs were scheduled for 12-hour shifts (6am-6:30pm, and 6pm-6:30am). Review of facility staffing data submitted for PBJ report, for weekends 1/1/25-3/31/25, revealed no RN coverage for Sunday 2/23/25.During interview on 7/30/25 at 2:39 p.m., director of operations (DOO) stated the facility had a contingency plan in place for RN coverage. If the need did not meet the level to activate that plan, they would mandate overtime and activate their call tree to the director of nursing (DON) and DOO for emergency staffing needs, which included calling in qualified leadership team members, as needed (PRN) and agency staff. During interview on 7/31/25 at 8:18 a.m., staffing coordinator (SC) stated on weekends the nurse in charge would contact SC and DON if nursing staff called in. DON and SC then would look for someone to cover the open shift. DON used OnShift app (an application used to post open shifts) to post the open shift. SC stated if facility did not have a RN in the building, they would have one come in. The DON and RN case managers had an on-call rotation and were expected to come in if needed. SC stated she was trained the facility was allowed a maximum of three days per quarter with no RN coverage, but the goal was to have zero days, and to avoid using days. The facility had four PRN nurses. SC stated the facility utilized a block schedule rotation which auto populated into the monthly calendar, she then reviewed the vacation time to determine open shifts needing to be filled. The monthly schedule was published by the second week of the previous month. During interview on 7/31/25 at 1:37 p.m., human resources (HR) stated they used OnShift for scheduling and time keeping which was reviewed by the corporate HR consultant and leadership team. HR facilitated newly hired personnel, which included full-time, part-time, and PRN. HR confirmed they used a rotating two-week block schedule and strived for zero days with no RN coverage. During interview on 7/31/25 at 1:51 p.m., DOO stated when staff called in, they required a minimum of two hours prior to their scheduled shift, the charge nurse filled out a call off slip for tracking. They had contracts with agencies, and an RN on-call rotation to ensure RN coverage. DOO expected the nurse on-call to address the need accordingly. DOO stated her expectation for the on-call nurse on the weekend, was to be within one hour of the facility and able to come in if needed, at any time. During follow-up interview on 7/31/25 at 2:30 p.m., DOO explained on 2/23/25 there had been an open RN shift posted to OnShift, which had been picked up by a licensed practical nurse (LPN). DOO believed SC had accepted, and this had not been recognized as an error.

Based on observation, interview and document review, the facility failed to comprehensively assess a resident for safe electric recliner usage for 1 of 1 resident (R21) reviewed for accidents.Findings include: R21's annual Minimum Data Set (MDS) dated [DATE], identified R21 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R21's diagnoses included unspecified dementia with anxiety, atrial fibrillation, anemia, hypertension, peripheral vascular disease, hyperlipidemia, arthritis, non-Alzheimer's dementia, anxiety disorder, depression, hypomagnesemia, hypokalemia, and chronic venous hypertension with ulcer of left lower extremity. R21's care plan, print date of 7/31/25, indicated staff were to encourage R21 to elevate legs in recliner. R21's care plan reviewed 7/31/25, identified R21 had limited physical mobility with fall risk related to weakness and limited mobility and had no recent history of falls. Care plan indicated R21 was non-ambulatory and needed assistance from two staff for bed mobility and transfers. During review of R21's electronic health record (EHR), Physical Device assessment completed on 6/9/25 indicated R21 utilized grab bars that were on bed and a wheelchair. Physical device assessment did not identify the electric recliner was assessed or utilized by R21. During observation and interview on 7/28/25 at 1:43 p.m., R21 was sitting in her electric recliner in her room with her legs elevated. R21 stated she was able to control the remote for the electric recliner and reached for the remote to demonstrate. R21 started to push buttons on the remote and then stopped and put the remote on the arm of the recliner. During observation on 7/28/25 at 1:55 p.m., staff rushed into R21's room as R21 had gotten her electric recliner elevated all the way up and was about to slide to the floor. Staff intervened and safely lowered the recliner without further incident. During interview on 7/28/25 at 1:58 p.m., nursing assistant (NA)-C confirmed R21 had gotten electric recliner raised up, so R21 almost slid out of the recliner onto the floor. During observation on 7/30/25 at 9:49 a.m., R21 was sitting in her electric recliner in her room with her legs elevated. Electric recliner remote was within R21's reach. During observation on 7/30/25 at 3:50 p.m., R21 was sitting in her electric recliner in her room with her feet placed on the floor. Electric recliner remote was within R21's reach. During interview on 8/1/25 at 10:39 a.m., NA-A stated R21 could not function the remote on the electric recliner and had confusion occasionally on what she is supposed to do or be doing. NA-A stated R21 sat in her recliner in the morning after breakfast with her legs elevated to help with swelling in her legs. During interview on 8/1/25 at 10:46 a.m., NA-B stated R21 does not usually attempt to get out of her recliner. NA-B stated R21 can function the remote of the electric recliner and uses the remote all the time. During interview on 8/1/25 at 11:15 a.m., trained medication aide (TMA)-A stated R21 will play/fidget with the remote of her electric recliner. During interview on 8/1/25 at 11:32 a.m., registered nurse clinical coordinator (RN)-A, registered nurse clinical coordinator (RN)-B and director of nursing (DON) stated R21 needed assistance to get out of chair, was a fall risk and confirmed R21 utilized the electric recliner in her room. Stated electric recliner should be assessed through the physical device assessment and should be assessed quarterly or with a change in condition. DON confirmed electric recliner was not assessed or mentioned on the physical device assessment and should have been. DON stated it was important for the electric recliner to be assessed to ensure the resident can use the recliner safely. An assistive device and assessment of physical devices policies were requested but was not received.

Based on interview and record review the facility failed to develop a person-centered care plan for 1 of 2 residents (R25) reviewed for care planning.Findings include: R25's annual Minimum Data Set (MDS) dated [DATE], identified R25 had intact cognition and required moderate assistance with activities of daily living (ADL)'s. R25's diagnoses included acute respiratory failure with hypoxia, atrial fibrillation, hypertension, benign prostatic hyperplasia, diabetes mellitus, hyperkalemia, depression, respiratory failure, obstructive sleep apnea, and mild cognitive impairment of uncertain or unknown etiology. R35's care plan included: (Preferred Name) has an ADL Self Care Performance Deficit r/t (related to). dated 5/16/25 and lacked goals and interventions. (Preferred Name) has (SPECIFY: Diabetes Mellitus, hyperglycemia, hypoglycemia) dated 5/16/25 and lacked goals and interventions. (Preferred Name) has altered cardiovascular status R/T (SPECIFYCARDIAC DX) (SPECIFY: With / without potential for bleeding/bruising R/T aspirin use, anticoagulant therapy, Lovenox, heparin, Plavix) dated 5/16/25 and lacked goals and interventions. (Preferred Name) has an alteration in hematological status R/T dated 5/16/25 and lacked goals and interventions. (Preferred Name) uses Antidepressant Medication due to (SPECIFY: feelings of sadness, low self-esteem, tearfulness, withdrawal from cares/activity, ineffective coping) R/T dated 5/16/25 and lacked goals and interventions. (Preferred Name) has actual/potential for (SPECIFY: Chronic, Acute, Neuropathic) Pain with need for medication management R/T (SPECIFY) dated 5/16/25 and lacked goals and interventions. (Preferred Name) is considered a vulnerable adult R/T dated 5/16/25 and lacked goals and interventions. (Preferred Name) has altered respiratory status/difficulty breathing (SPECIFY: shortness of breath) R/T (SPECIFY: Requires oxygen therapy) dated 5/16/25 and lacked goals and interventions. (Preferred Name) wishes to return to the community (SPECIFY: goals for admission and desired outcome) dated 5/16/25 and lacked goals and interventions. R25's physician orders included amlodipine and metoprolol for hypertension; Xarelto for atrial fibrillation; duloxetine for depression and anxiety; menthol-methyl salicylate cream, acetaminophen, pregabalin and tramadol for pain; and Baqsimi, Lantus and Mounjaro insulin injections for diabetes. During interview on 8/1/25 at 11:37 a.m. director of nursing (DON) and registered nurse clinical coordinators (RN)-A and RN-B stated the MDS coordinator was responsible for entering and revising resident care plans and that she left the facility in February 2025. DON confirmed R25's was not completed nor individualized. DON stated person-centered care plans are important, so staff are aware of how to care for the resident and that the care is individualized. The facility Comprehensive Care Plan policy, dated 4/25, indicated facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview and document review, the facility failed to ensure parameter mattress (a type of mattress cover, or encasement designed to create a gentle barrier around the edge of the bed, preventing falls) was not used in a manner to restrain resident while in bed for 1 of 1 resident (R21) reviewed for restraints.Findings include: R21's annual Minimum Data Set (MDS) dated [DATE], identified R21 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R21's diagnoses included unspecified dementia with anxiety, atrial fibrillation, anemia, hypertension, peripheral vascular disease, hyperlipidemia, arthritis, non-Alzheimer's dementia, anxiety disorder, depression, hypomagnesemia, hypokalemia, and chronic venous hypertension with ulcer of left lower extremity. MDS did not indicate R21 utilized restraints. R21's care plan reviewed 7/31/25, identified R21 had limited physical mobility with fall risk related to weakness and limited mobility and had no recent history of falls. Care plan indicated R21 had a lipped mattress initiated on 6/21/23, to decrease the risk of falls when sitting on edge of bed and low bed to limit injuries from falls. Care plan indicated R21 was non-ambulatory and needed assistance from two staff for bed mobility and transfers. During review of R21's electronic health record (EHR), Physical Device assessment completed on 6/9/25 indicated R21 utilized grab bars that were on bed and a wheelchair. Physical device assessment did not identify the parameter mattress was assessed or utilized by R21. During observation and interview on 7/28/25 at 1:48 p.m., R21's bed had a parameter mattress in place. R21 stated she was not sure why she had the parameter mattress on the bed and she does not attempt to get out of bed by herself as she knows she is not strong enough and she waits for staff for assistance. During interview on 7/31/25 at 3:22 p.m., licensed practical nurse (LPN)-A confirmed R21 had a parameter mattress present on bed. LPN-A stated R21 was not able to get out of bed by herself and has not tried to get out of bed by herself for some time. During interview on 8/1/25 at 10:39 a.m., nursing assistant (NA)-A stated R21 had a parameter mattress in place that has been there for several years to assist R21 with not falling out of bed. NA-A stated R21 was not able to reposition herself and was not able to get out of bed by herself for approximately the past year. During interview on 8/1/25 at 10:46 a.m., NA-B stated R21 had a parameter mattress present to assist R21 with not falling out of bed. NA-B stated R21 no longer attempts to get out of her bed independently and has not for quite a while. During interview on 8/1/25 at 11:32 a.m., registered nurse clinical coordinator (RN)-A, registered nurse clinical coordinator (RN)-B and director of nursing (DON) stated R21 needed assistance to get out of bed, was a fall risk and confirmed R21 had a parameter mattress in place. Parameter mattresses were assessed through the physical device assessment and should be assessed quarterly or with a change in condition. DON stated parameter mattresses helped resident identify the edge of the bed. The mattress could be considered a restraint when it was used to prevent the resident from getting out of bed or if resident was immobile. DON confirmed R21's parameter mattress was not assessed or mentioned on the physical device assessment and should have been. RN-A, RN-B and DON stated they are not sure why R21 still had the parameter mattress in place. The facility Restraint Free Environment policy, dated 2/23/25, indicated it was the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints. Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent tot eh resident's body that the individual cannot removed easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to placing a resident on a concave mattress so that the resident cannot independently get out of bed. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms. Physical restrains may e used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner, unless the resident has previously made a valid refusal of the treatment in question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint.

Based on interviews and document review, the facility failed to ensure that a safe and orderly discharge was arranged for 1 of 2 residents (R40) who was discharged against medical advice (AMA). The facility did not complete a comprehensive discharge plan, or adequate documentation of efforts to educate the resident about the risks of leaving AMA. Findings Include: R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 had intact cognition and required minimal or limited assistance with activities of daily living (ADL)'s. R40's diagnoses included type II diabetes mellitus (DM) with other specified complication, major depressive disorder, hypertension, bilateral primary osteoarthritis of knee, postprocedural; hypothyroidism, and hyperlipidemia. R40's quarterly care conference dated 6/10/25 noted resident plan to discharge to assisted living (AL) facility once medical assistance (MA) was open. R40 would need outpatient therapy, assistance with medication management, and a commode with bars that goes over the toilet. R40's order summary report dated 6/30/25 noted discharge plan as home, alone. R40's Notice of Medicare Non-Coverage (NOMNC) listed last covered date (LCD) as 2/6/25. Review of R40's progress notes dated 7/18/25, indicated R40 left the facility with her daughter for an appointment and expressed intent to leave the facility AMA on 7/18/25. R40's daughter informed the facility of intent to return to gather resident's belongings and noted R40's refusal to enter the building. An AMA form was taken out to resident in a vehicle to sign. AMA form dated 7/18/25 at 12p, was signed by R40 as well as social worker (SS)-A was scanned into R40's EHR. No documentation of recapitulation of stay or discharge summary was noted in R40's electronic health record (EHR). R40's discharge summary and recapitulation of stay was requested 7/29/25 and provided 7/30/29. The discharge summary progress note dated 7/18/25 12:37 p.m., noted as late entry indicated the director of nursing (DON) created the entry on 7/29/25 at 8:52 p.m., and noted resident left AMA and both resident and daughter were made aware by SS-A, facility would not be responsible to arrange home services. During interview on 7/31/25 at 3:30 p.m., registered nurse (RN)-A, case manager, stated discharge planning is discussed during the care conference. During the discharge process the discharge assessment was completed in the computer, this was reviewed and signed with the resident upon completion. If the resident was going home, they also reviewed the discharge instructions. RN-A stated for a resident who voiced intent to leave the facility AMA they would get ahold of the family and resident and ensure they understood and wanted to proceed. RN-A stated they would have filed a MAARC if the discharge was unsafe. RN-A stated when discharging AMA SS-A completed the paperwork, and entered the discharge progress note which included the recapitulation of stay. RN-A stated R40 had planned to discharge to the AL facility, her daughter had called and spoke to the business office, daughter had stated she was on her way to the facility, while there she voiced financial concerns, staff from the AL came over to speak with them and explain options available, and they still decided R40 would discharge home with her daughter. RN-A stated R40 and daughter were informed facility is not responsible when discharging AMA. During interview on 7/31/25 at 3:35 p.m., DON confirmed she did go back into R40's EHR and enter a discharge summary after requested by surveyor, as it had been missed. DON stated daughter had contacted facility when they were out of facility, DON stated SS-A completed AMA form with R40 while R40 was in a vehicle. DON stated when discharging a resident, they usually gave a summary to the resident that included: medications, recent labs, and follow up appointments. DON stated R40's daughter made it very clear that they would follow up with their own provider and not to worry about it. During interview on 8/01/25 at 11:38 a.m., director of operations (DOO) stated if they were made aware of resident's intent to discharge AMA, SS-A would meet with the resident and provide education as well as inform of risks. SS-A would also encourage resident to see their primary care provider, as the facility was unable to provide additional services or arrangements for services outside of the facility such as home care. DOO stated medical provider was notified of the AMA discharge. There should have been some sort of documentation, normal things but they were not required to provide much info, and no medication information was provided for AMA discharges. Facility discharge policy requested and not received.

Based on observation, interview, and document review, the facility failed to comprehensively assess and implement interventions to ensure proper wheelchair positioning and prevent potential complications for 1 of 1 resident (R21) reviewed for wheelchair usage. Further, the facility failed to ensure medications were administered per physician's order for 1 of 1 resident (R25) reviewed for assessment prior to medication administration. Findings include: R21 R21's annual Minimum Data Set (MDS) dated [DATE], identified R21 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R21's diagnoses included unspecified dementia with anxiety, atrial fibrillation, anemia, hypertension, peripheral vascular disease, hyperlipidemia, arthritis, non-Alzheimer's dementia, anxiety disorder, depression, hypomagnesemia, hypokalemia, and chronic venous hypertension with ulcer of left lower extremity. R21's care plan identified R21 had a self-care deficit and required assistance with transfers and locomotion in a wheelchair to reach desired destinations and utilized a wheelchair. Care plan also indicated on 7/21/25 R21 received hard back and seat custom wheelchair with foot pedals. During observation on 7/28/25 at 11:34 a.m., R21 was being pushed down hallway in her wheelchair with no foot pedals on. R21's feet were sliding on floor and feet bounced off the floor approximately four times. Staff did not provide reminders to R21 to hold her feet up. During observation and interview on 7/28/25 at 1:55 p.m., R21's foot pedals for her wheelchair were sitting in a basket that was placed on the left side of her recliner up against the wall. R21 stated staff assist her to the dining room for all meals. She had foot pedals for her wheelchair but were only used when she goes out to an appointment. R21 stated it was sometimes hard to keep her feet up when staff are pushing her down the hallway in her wheelchair. During observation on 7/30/25 at 11:41 a.m., R21 was being pushed down hallway in her wheelchair with no foot pedals on. R21's feet were sliding and bouncing on floor. Staff did not provide reminders to R21 to hold her feet up. During observation on 7/30/25 at 12:31 p.m., R21 was being pushed down hallway in her wheelchair with no foot pedals on. R21's feet were sliding on floor and feet bounced off the floor approximately four times. R21 was unable to hold her feet up off ground nor did staff provide reminders to R21 to hold her feet up. During observation on 7/31/25 at 7:42 a.m., R21 was being pushed down hallway in her wheelchair with no foot pedals on. Foot pedals were attached to wheelchair but were folded up and pushed under the seat of the wheelchair. R21's feet were sliding on floor and feet bounced off the floor approximately three times. R21 was unable to hold her feet up off ground nor did staff provide reminders to R21 to hold her feet up. During observation on 7/31/25 at 8:24 a.m., R21 was assisted out of the dining room and was brought to the medication cart with her feet sliding on floor. During observation on 7/31/25 at 8:24 a.m., R21 was being pushed down hallway in her wheelchair with no foot pedals on. R21's feet were sliding on floor and feet bounced off the floor several times. R21 was unable to hold her feet up off ground nor did staff provide reminders to R21 to hold her feet up. During interview on 07/31/25 at 3:22 p.m., licensed practical nurse (LPN)-A stated foot pedals are used when the resident is not about to pick up their feet or needed assistant with keeping their feet off the floor. LPN-A stated foot pedals should be used for residents who are not able to keep their feet up when staff pushed the wheelchair to and from destinations. LPN-A stated R21 should use foot pedals when staff are assisting her in her wheelchair to and from destinations. LPN-A stated it was important for foot pedals to be used for safety when escorting residents in a wheelchair to and from destinations and to prevent injuries. During interview on 8/1/25 at 10:39 a.m., nursing assistant (NA)-A stated foot pedals are used as needed. NA-B stated R21 has foot pedals that should be used if staff are assisting her with propelling wheelchair. NA-A stated R21 does not use foot pedals often. During interview on 8/1/25 at 10:46 a.m., trained medication aide (TMA)-B stated foot pedals should be used for any resident who had them and needed staff assistance transporting to and from any destination. TMA-A stated R21 does have foot pedals. During interview on 8/1/25 at 11:32 a.m., director of nursing (DON) stated foot pedals are not always on the wheelchair but are stored in resident's room to be used as needed. When a resident was exhibiting signs of not being able to keep feet held off floor when being transported to and from destinations, DON expected foot pedals be placed on wheelchair and used. She expected staff to use foot pedals in all observations noted above. DON stated it was important to use foot pedals on wheelchair during transport to prevent injury and that it was best practice. A wheelchair positioning policy was requested but was not provided. R25 R25's annual MDS dated [DATE], identified R25 had intact cognition and required moderate assistance with ADL's. R25's diagnoses included acute respiratory failure with hypoxia, atrial fibrillation, hypertension, benign prostatic hyperplasia, diabetes mellitus, hyperkalemia, depression, respiratory failure, obstructive sleep apnea, and mild cognitive impairment of uncertain or unknown etiology. During review of R25's electronic health record (EHR), signed physician's orders, print date of 7/30/25, indicated an order for the following medications with parameters for when medication should be held: Metoprolol Tartrate 100 mg (milligram) to be given by mouth two times a day for essential hypertension and to hold for heart rate less than 5 and systolic blood pressure less than 90. Amlodipine Besylate 10 mg to be given by mouth once daily in the morning for type II diabetes mellitus with diabetic polyneuropathy and to hold for heart rate less than 5 and systolic blood pressure less than 90. Medication Administration Record (MAR) and Treatment Administration Record (TAR) reviewed from 6/1/25 to 8/1/25, lacked documentation of obtaining and monitoring blood pressure and pulse prior to administration of medication from 6/1/25 to 8/1/25. Instructions with parameters were noted on the MAR. During interview on 8/1/25 at 10:53 a.m., TMA-B stated R25 had special monitoring for medication administration. TMA-B confirmed R25 should have blood pressure and pulse checked prior to administration of Metoprolol and Amlodipine. TMA-B stated she was aware of the parameters and stated she takes R25's blood pressure or pulse, prior to administering metoprolol to R25, and documented the results in the EHR. During interview on 8/1/25 at 11:16 a.m., TMA-A stated R25 should have blood pressure checked prior to administration of his Metoprolol and Amlodipine. If the blood pressure is too low, then the Metoprolol and Amlodipine were held. TMA-A stated she documented the blood pressure in the HER when she obtained it. During interview on 8/1/25 at 11:20 a.m., DON stated she expected provider's orders to be followed, including parameters of medication administration. DON confirmed R25's blood pressure and pulse should have been obtained prior to administration of the Metoprolol and Amlodipine. DON stated following these parameters were important as it was an order from the provider and so the resident does not have any bad outcomes of the medication if it was administered when it was not supposed to be. On 8/1/25 at 11:05 a.m., Attempted to reach out to consultant pharmacist and left message with no return call back. A Medication Management - Medication Administration policy, dated 4/16/24, indicated staff were to obtain and record any vital signs as necessary prior to medication administration.

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices during meal service for 3 of 3 dining observations. Specifically, staff failed to intervene when a resident (R25) was observed touching the tops of other residents' coffee cups during meal service, creating a risk for cross-contamination and transmission of communicable diseases.Findings include: During observation on 7/28/25 at 11:38 a.m., during a lunch observation in the main dining room, R25 was observed walking around the dining room and stopping at multiple tables. R25 was observed touching the tops/rims of coffee cups, that were placed on the seat of his walker, when handing them out to other residents. Staff present in the dining area did not redirect or intervene to prevent R25 from touching the drinkware of other residents. During observation on 7/30/25 at 11:39 a.m., during a lunch observation in the main dining room, R25 was observed walking around the dining room and stopping at multiple tables to pick up coffee cups. R25 was observed touching the tops/rims of coffee cups when handing them out to other residents. Staff present in the dining area did not redirect or intervene to prevent R25 from touching the drinkware of other residents. During observation on 7/31/25 at 8:06 a.m., during a breakfast observation in the main dining room, R25 was observed walking to a co-resident and asking if she would like more coffee. Co-resident was holding onto handle of coffee cup and handed it to R25 who gripped the coffee cup around the top/rim of coffee cup. Staff present in the dining area did not redirect or intervene to prevent R25 from touching the drinkware of other residents. During interview on 8/1/25 at 10:53 a.m., nursing assistant (NA)-B stated R25 liked to get coffee for other residents in the dining room and did so at every meal. During interview on 7/31/25 at 3:37 p.m., Infection Preventionist (IP) acknowledged that residents should not be touching the food or drink items of others, and staff should intervene to prevent such contact to avoid possible transmission of infectious agents. The IP further stated that this behavior was not in accordance with the facility's infection control protocols. A copy of the facility's Infection Prevention and Control policy related to dining services was requested on 8/1/25 but was not received by the time of the survey.

Based on interview and document review, the facility failed to promptly notify a physician of a change in condition for 1 of 3 residents (R1) reviewed when a right lower leg abscess worsened and required hospitalization . Findings include: R1's admission Minimum Data Set, dated dated dated [DATE], identified intact cognition without behaviors. He had a functional impairment of the upper extremities located on one side, used a walker, and a motorized wheelchair for mobility. He required substantial/maximal assistance for personal/toilet hygiene, dressing, bathing, partial/moderate assistance lying to sit, sit to stand, and all transfers. Ambulation was not attempted due to medical conditions or safety concerns. Medical diagnoses included peripheral vascular disease (PVD) (arteries became narrowed or blocked, reduced blood flow to extremities, most often feet and legs), cerebrovascular accident (CVA) (stroke), hemiplegia/hemiparesis (significant weakness or paralysis in one half of the body), and at risk for pressure ulcers. R1's care plan dated 3/6/25, identified he had an activities of daily living (ADL) self-care performance deficit related to CVA and weakness from acute illness. Staff were directed to report any changes in skin such as redness and bruising to nurse and observe/document/report to medical practitioner as needed (PRN) any changes in medical status, reasons for self-care deficit, expected course, and decline in function. He had potential for pressure injury development related to Braden scale (a tool used to assess the risk for developing pressure ulcers) score 13-14 (moderate risk) and surgical incision to right lower extremity (RLE). Staff were directed to administer treatments as ordered and observe for effectiveness, observe dressing to ensure it was intact, properly placed, report loose dressing to the nurse, stress the importance of frequent repositioning, and notification to family and medical provider of any new area of skin breakdown or worsening in status of current area. R1's progress notes from 3/1/25 through 3/4/25, identified: -3/1/25 at 5:54 p.m. Skilled Charting -Skin/wound integrity alterations: yes and no, moisture associated skin damage on buttocks. Treatments: application of ointments/creams/medications. No edema or pain. -3/2/25 at 11:31 a.m. Complained of right lower extremity pain 7 out of 10, refused Tylenol. -3/2/25 at 12:36 p.m. Received acetaminophen 500 milligrams (mg) orally for generalized pain in right leg. -3/2/25 at 1:22 p.m. Acetaminophen was effective. -3/2/25 at 1:50 p.m. Skilled Charting -Skin/wound integrity alterations: none. No edema or pain. -3/3/25 at 8:08 a.m. physical therapy (PT) service notes: R1 began therapy session via exercises on lower extremities. He was asked to complete the right lower extremity exercises, he stated he was unable to, due to pain 7 out of 10. PT assistant lifted his pant leg and saw a softball sized pocket of swelling on the mid-calf. PT brought him to director of nursing (DON) for assessment and requested no further lower extremity exercise or mobility until further assessed. -3/3/25 at 10:42 a.m. Right lower leg: pain 7/10, very tender and hot to touch, taut, 22 centimeters (cm) x 11 cm x 4 cm of a bulge coming out of the lower right side of leg, unable to move his leg or walk, winces and groans/moans when he tried to move his leg. Pain radiated up leg to top of knee. Provider notified phone call (PC), spoke to nurse, she was going to notify nurse practitioner (NP) and return PC back with direction/orders. -3/3/25 at 11:13 a.m. New orders per NP: ultrasound (US) RLE diagnosis (DX) swelling and rule out (r/o) deep vein thrombosis (DVT) (blood clot) and doxycycline 100 mg by mouth (po) two times a day (BID) times seven days. DON was aware. -3/3/25 at 12:24 p.m. Phone call to schedule US per order, they will call with estimated time of arrival to complete US. -3/3/25 at 5:48 p.m. Orders- administration note: Initial that pain was observed every shift. Document any verbal and/or non-verbal indicators of pain and interventions, including non pharmalogical interventions in pain progress note, two times a day. Severe pain noted, right lower edema, provider notified, US on RLE this evening at 5:00 p.m. -3/4/25 at 9:11 a.m. Electronic medication administration record (EMAR): Resident received Tylenol 500 mg orally for pain rated 7 out of 10. -3/4/25 at 12:32 p.m. Per NP, send R1 to emergency room (ER) for RLE. He agreed, consent for bed hold received. He signed form and emergency medical system (EMS) transported to local hospital at 12:50 p.m. -3/4/25 at 12:49 p.m. R1 was sent to ER due to suspected infection of the lower extremity. -3/4/25 at 3:39 p.m. PT service notes: He reported high pain in the right lower extremity with softball sized swelling on the mid-calf. Nursing updated and NP here to see pt today. R1's ER/hospital after visit summary dated 3/4/25, Reason for visit: cellulitis. Diagnoses: Hematoma and cellulitis of the right lower extremity. Instructions: The large lump on the outside of the right leg is a hematoma. We have concerned [sic] that hematoma which is a collection of old blood likely previous trauma is may [sic] infected. Please take the antibiotics as prescribed and return if you are having increasing right leg pain, swelling, fevers. Call your doctor now or seek immediate medical care if: you have signs your infection is getting worse such as: increased pain, new or worse swelling, warmth, or redness, red streaks leading from the area, pus draining from the area, a fever, or you get a rash. R1's progress notes from 3/5/25 through 3/11/25, identified: -3/5/25 at 7:47 a.m. Per ER visit with a diagnosis of hematoma (a collection of blood outside of blood vessels that can form in any part of the body from ruptured blood vessels that cause symptoms such as swelling, bruising, and pain)/cellulitis (a common bacterial infection of the skin and underlying tissue and causes redness, swelling, pain and warmth in the affected area) of the right lower extremity. Labs basic metabolic panel (BMP) (measures several key substances in the body including electrolytes, blood sugar, kidney function, and liver function), c-reactive protein (a protein produced by the liver in response to inflammation), an incision and drain was performed. Dressing clean, dry, and intact (CDI). -3/5/25 at 4:24 p.m. Non-pressure Ulcer/injury assessment: initial assessment completed on new area a surgical wound, measured length 0.7 cm, width 0.2 cm, and depth 0. Peri wound: bloody drainage noted surrounding skin warm and pink hued, no odor present. Doctor was notified of new skin condition on 3/4/25. New wound, seen inER on [DATE] and area was lanced to allow for drainage. -3/5/25 at 6:41 p.m. Skilled Charting -Skin/wound integrity alterations: yes, hematoma to right leg. Treatment: non-sterile dressing changes. No edema or pain. -3/6/25 at 8:09 a.m. PT service notes: he continued to have pain in RLE which limited his range of motion (ROM), standing, and ambulation. Nursing was aware of RLE pain. -3/6/25 at 10:04 a.m. Acetaminophen 500 mg administered for complaints of mild pain in right leg and rated pain at 6 out of 10. -3/6/25 at 11:55 a.m. Administration of acetaminophen was effective pain at 3 out of 10. -3/6/25 at 3:05 p.m. Skilled Charting -Skin/wound integrity alterations: yes, hematoma to right leg. Treatments: non-sterile dressing changes. No edema or pain. -3/6/25 at 3:07 p.m. Body audit completed. Alternations in skin integrity identified: Right lower leg (front) hematoma and small incision was drained at local hospital. Fingernails and toenails clean and trimmed. Inspection of heels indicated firm. Edema in lower extremities noted. -3/7/25 at 11:59 a.m. he was hesitant to work on standing, declined attempts to walk, refused to bear full weight on RLE, and had increased soreness during weight shifting, and remained limited by the pain. Nursing was aware of his RLE pain and monitored the swelling. -3/7/25 at 12:00 a.m. Regulatory visit by medical doctor (MD): . musculoskeletal exam: right lower leg showed a firm mass about 3 cm in diameter with a central incision which was clean, dry and no drainage. Lesion was not fluctuant (did not feel soft or squishy like a fluid-filled area but instead felt firm/solid), was not warm, red, or tender. -3/7/25 at 5:01 p.m. Skilled Charting -Skin/wound integrity alterations: pressure ulcer on buttocks. Treatments: cream. No edema or pain. -3/7/25 at 8:42 a.m. Acetaminophen 500 mg administered for pain 5 out of 10. -3/7/25 at 11:25 a.m. Follow up pain 6/10, administration of acetaminophen: ineffective. -3/7/25 at 5:21 p.m. Administration of acetaminophen 500 mg for pain 7 out of 10. -3/7/25 at 8:30 p.m. Follow up pain 0/0, was effective. -3/8/25 at 7:18 a.m. Skilled Charting -Skin wound integrity alterations: yes, pressure ulcer, location unidentified. Treatments: cream. Edema, yes, 2 plus (+) moderate pitting, indentation subsided rapidly. No pain. -3/8/25 at 7:21 a.m. He had a boil or cysts looking mass to the right lower leg and left elbow. It was warm to touch and looked as though it was forming pus. He complained of moderate to no pain in both right leg and left elbow. He had sat for house on wheelchair without elevating his legs. The resident was encouraged to ask for help in elevating his feet. -3/8/25 at 8:23 a.m. Acetaminophen 500 mg administered for pain 7 out of 10. -3/8/35 at 9:24 a.m. Follow up pain 7 out of 10, was ineffective. -3/8/25 at 12:21 p.m. Skilled Charting -Skin wound integrity alterations: no. Edema, yes, 1+ mild pitting, slight indention, no perceptible swelling of the leg. No pain. -3/8/25 at 4:43 p.m. Acetaminophen 500 mg administered for pain 7 out of 10. -3/8/25 at 7:36 p.m. Follow up pain 0 out of 10, was effective. -3/9/25 at 5:41 a.m. Skilled Charting -Skin wound integrity alterations: yes, pressure ulcer. Treatments: cream. Edema, yes, 2+ moderate pitting, indentation subsided rapidly. -3/9/25 at 8:36 a.m. Acetaminophen 500 mg administered for pain 7 out of 10. -3/9/25 at 11:24 a.m. Follow up pain 5 out of 10, was effective. -3/9/25 at 12:25 p.m. Skilled Charting -Skin wound integrity alterations: yes, other, right leg swollen. Treatments, none. Edema, yes, 1+ mild pitting, slight indentation, no perceptible swelling of the leg. -3/9/25 at 4:36 p.m. Acetaminophen 500 mg administered for pain for pain 7 out of 10. -3/9/25 at 8:41 p.m. Follow up pain: unknown. -3/10/25 at 3:33 a.m. Skilled Charting -Skin wound integrity alterations: yes, pressure ulcer. Treatments: cream. Edema, yes, 2+ moderate pitting, indentation subsided rapidly. No pain. -3/10/25 at 10:12 p.m. Acetaminophen 500 mg administered for pain 7 out of 10. -3/10/25 at 1:37 p.m. Follow up pain 0 out of 10, was effective. -3/10/25 at 5:26 p.m. Skilled Charting -Skin/wound integrity alterations: yes, pressure ulcers/buttocks, and hematoma to right calf. Treatments cream and non-surgical dressing changes. No edema or pain. -3/11/25 at 12:00 a.m. Provider update/visit: re-evaluation of his right lower leg. Appeared worse than visit one week ago when he was set to ER, incision and drainage (I & D) was attempted for abscess. Doxycycline and Cephalexin for seven days. Today right lower leg increased in size, warm, and redness. Denies fever or chills. Continues to appear a pocket of fluid collection left lateral aspect of leg down to ankle. Therapy reporting difficulty standing, weight bearing which is new for him. He is agreeable to ER evaluation for worsening abscess related to (r/o) osteomyelitis (infection of the bone). Signed by NP on 3/11/25 at 12:18 p.m. -3/11/25 at 6:03 a.m. Skilled Charting -Skin/wound integrity alterations: yes, hematoma to right leg. Treatments: non-surgical dressing change. Edema, yes, 2+ moderate pitting, indentation subsided rapidly. No pain. -3/11/25 at 7:39 a.m. Acetaminophen 500 mg administered . resident complained of severe moderate pain on his right leg, rated his pain at 7 out of 10. -3/11/25 at 9:21 a.m. Follow up pain 4 out of 10, was effective. -3/11/25 at 11:38 a.m. Occupational therapy (OT) notes: he stood for two minutes times three then declined working on any functional reaching tasks due to RLE pain 5 out of 10. -3/11/25 at 2:58 p.m. NP looked at resident's wound and was warm to touch . he was sent to ER for evaluation. -3/11/25 at 5:12 p.m. Skilled Charting -Skin/wound integrity alterations, yes hematoma to right leg, warm to touch, increased swelling. Sent to ER for evaluation. Treatments: non-surgical dressing change. Edema present 2+ moderate, pitting, indentation subsides rapidly. No pain. -3/11/25 at 6:59 p.m. Resident's right lower leg assessed by NP today at on-site visit. His wound was warm to touch and had increased swelling. Pain to touch and with movement on 4 to 6/10. No drainage noted. NP recommended resident be sent to ER for evaluation. Resident went to ER via non-emergent transport around 12:00 p.m. -3/11/25 at 11:56 p.m. Nurse called local hospital for follow-up; resident was admitted with cellulitis. Emergency department (ED) to hospital admission 3/11/25 through 3/14/25, identified discharge diagnoses: right distal lower extremity hematoma. Hospital course: presented toER on [DATE] with right leg discomfort and swelling. He had been recently seen inER on [DATE] with right leg pain and swelling and at that time had an elevated leukocytosis (white blood cells indicated infection). An incision and drainage (I&D) were performed for suspicion of abscess and infected hematoma of the right leg but appeared to be more of an old hematoma. There was some concern for cellulitis so was placed on a course of two antibiotics, Doxycycline and Keflex then discharged . He reported right leg pain and enlargement for one week. A magnetic resource imaging (MRI) of right calf was completed and showed heterogeneous (appeared uniformity in texture or composition) mass in the subcutaneous aspect of the lateral calf which appeared most consistent with hematoma. Ultimately was felt that it was a hematoma and there was no infection. Orthopedics recommended a heat and ice compression. Physical exam identified a 5 cm by 4 cm area of swelling and fluctuance (subject to change, variable, or capable of being moved or compressed) in the lateral aspect of his distal right lower extremity. No warm or redness noted. R1's progress notes from 3/14/25 through 3/15/25, identified: -3/14/25 at 3:23 p.m. Resident readmitted to facility after being hospitalized . diagnosis: hematoma of the right calf. -3/15/25 at 12:29 p.m. Skilled Charting -Skin wound integrity alterations: yes, hematoma to right leg, warm to touch, increased swelling resolving. Treatments: non-surgical dressing changes. Edema, yes, 2+ moderate pitting, indentation subsided rapidly. No pain. During an interview on 3/20/25 at 10:18 a.m. registered nurse (RN)-A stated R1 was admitted to the facility beginning of February 2025 with respiratory and cardiac issues. She saw him on 2/26/25 and 2/27/25 and was not aware of any skin concerns at that time. On 3/5/25 he returned from the hospital, staff would be expected to assess his right lower leg wound and dressing, complete daily dressing changes, assessments, and document. On 3/8/25 the staff nurse should have contacted the provider and updated them regarding a change in condition. He was already on an antibiotic but may had needed to go to ER and could have possibly avoided another visit. During an interview on 3/20/25 at 11:21 a.m. RN-B started she had seen R1 on 3/5/25 when he returned to facility from the hospital. She removed the dressing located on his right lower leg and noted bloody drainage without odor. She cleaned the wound with normal saline, completed the weekly non-pressure ulcer/injury assessment and applied a dressing. The floor nurses were responsible to monitor it and update her if there were changes. On 3/8/25 the staff nurse charted there was a change in condition and a provider should have been notified and updated to see what steps should have been taken next. R1 did not have a pressure ulcer but had been documented by staff nurses he did. The skilled assessments were completed and used to show a change in condition. A provider could have reached 24/7 and communicated with via email. During an interview on 3/20/25 at 11:57 p.m. nurse practitioner (NP) stated R1 was sent toER on [DATE] and diagnosed with cellulitis and started on antibiotics. MD saw him on 3/7/25. She saw him on 3/11/25, and his right lower leg was much redder, swollen, hot to the touch, and did not look any better than when she saw him on 3/4/25. There was fluid collection noted and she would empower the nursing staff to have updated and let the provider know. She had not been contacted from 3/5/25 to 3/11/25 with any concerns or change in condition. Staff would have been expected to complete a daily dressing change, skin assessments/monitoring of the wound, and error on the side of caution. He could have had osteomyelitis and possible sepsis, had taken antibiotics for two days with no improvement, should have been sent in right away instead. We maxed out for the facility management and may have not been able to meet his needs. During an interview on 3/20/25 at 1:14 p.m. medical doctor (MD) stated she had seen R1 at the facility during rounds on 3/7/25, and documented under the musculoskeletal section his right lower leg was clean, dry, no redness, swelling, approximately 3 cm in diameter, no tenderness, and no pus forming. He was placed on two antibiotics Doxycycline and Cephalexin, generally within 48 to 72 hours things should have started to improve. The nurse's documentation on 3/8/25 indicated a change in condition and she would have expected the nurse to have contacted a provider. R1 would have most likely been sent to ED sooner to determine if it were infected, and what to do next. During an interview on 3/20/25 at 2:09 p.m. RN-C stated she had documented on 3/8/25 at 12:21 p.m. a skilled assessment in R1's progress notes. She had too much in her head and forgot to click yes on skin alterations and entered no instead. R1 had refused to have his legs looked at on 3/8/25, and the night staff nurse had told her his right lower leg looked swollen on the outer side. Staff nurses would be expected to contact the provider if there was a concern and/or abnormal assessment regarding his right lower leg. During an interview on 3/20/25 at 2:33 p.m. licensed practical nurse (LPN)-A stated she had documented on 3/7/25 at 5:01 a.m. a skilled assessment on R1 which identified a pressure ulcer on his buttocks and had not included the right lower leg wound. On 3/8/25, a nursing assistant (NA) informed me his right lower leg did not look good. He had an area that was blistered, refused to off load, and encouraged to elevate his legs and was new to her. She stated on 3/8/25 at 7:31 a.m. she had written a progress note: R1 had a boil or cysts looking mass to right lower leg and left elbow. It was warm to touch and looked as though it was forming pus. He had no to moderate complaints of pain in both right lower leg and left elbow. She was not sure if that would have been considered a change in condition for R1, vital signs were normal and not much pain. She stated she had gotten off track at times, had forgotten things, and should have contacted a provider when he had a change in condition, and made aware of what was going on with him. The skin on his right lower leg was tight, looked as though something was going to pop open, puffy like it was swollen, without pain. She was not aware he had a surgical wound but saw there was a dressing over it. Nursing staff were expected to have completed a skilled nursing assessment every shift and included a skin assessment. She had entered R1 had a pressure ulcer in the clinical assessment and unsure if he had one. During an interview on 3/20/25 at 4:07 p.m. DON stated on 3/4/25, R1 was sent to ER, had fluid drained off his right lower leg, started on two antibiotics, a diagnosis of cellulitis, and sent back to facility on 3/5/25. On 3/8/25, the staff nurse should have called the provider when she noticed a change in R1's condition. Would have been important to get further direction and orders regarding sending him into ER. Mostly likely would have sent him in earlier. During an interview on 3/21/25 at 8:42 a.m. rehab director (PT) stated she had reported to nursing R1 complained of soreness in the right lower leg that was ongoing. On 3/3/25, his right lower extremity had a softball sized pocket of swelling, and she had taken him to the DON to have it assessed. Between 3/3/25 and 3/11/25, he had refused to walk due to pain in his right lower leg. On 3/11/25, she had reported he had refused to walk again. During an interview on 3/21/25 at 3:52 p.m. RN-D stated staff nurses were expected to complete a skilled assessment on R1 two times in a 24-hour period. She collected the information for the skilled assessment while in the room with the resident through observation/assessment, and vital signs. She documented a skill nursing assessment on 3/2/25, no pain, no skin issues. She had not recalled any skin issues. He had pain in the right lower leg and documented in error no pain. She was unable to recall if she had physically assessed/observed him during the 3/2/25, assessment. He returned from the hospital on 3/5/25, she completed a skilled assessment and documented no edema or pain. She stated R1 had a hematoma, a localized bump, pain in right leg when touched or moved. Pain was not documented in her assessment. She documented a skilled nursing assessment on 3/10/25, no pain, no edema, and pressure ulcer buttocks. She stated it was a documentation error, no pressure ulcer identified. She had completed a skill nursing assessment earlier in the day on 3/11/25, and he had increased swelling in his right lower leg later that day when dressing was changed, and NP had seen him. Staff were expected to notify a provider as soon as possible if there was a change in condition so that the resident would have received the treatment they needed. Facility policy Weekly Skin Assessment and Documentation Process dated 1/20/23, identified skin ulcers and non-ulcers will be assessed and documented weekly by the facility wound nurse. When the nurse on the floor observes a new skin/wound alteration they should utilize the fax forms to notify the physician/nurse practitioner or call and put the new order in point click care (PCC). If a skin/wound alteration exhibits any decline or non-healing when the floor nurse is completing treatment or wound nurse is assessing, that nurse will notify the physician, document the decline and notification on the assessment form, and in the nurse's notes. The hot chart and care plan will be updated as appropriate. The nurse will notify the DON for further support and guidance. Facility policy Notification of Change in Resident Health Status dated 2/8/23, identified resident's physician and resident's legal representative will be notified of a change in resident status when the following occur: a. A significant change in the resident's physical, mental, or psychosocial status for example, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications b. A need to alter treatment significantly, for example a need to discontinue an existing treatment due to adverse consequences, or to begin a new form of treatment, c. A decision to transfer or discharge the resident from the nursing home.

Based on interview and document review, the facility failed to implement treatment consistent to the resident's physician's orders and professional standards of practice, and revise interventions as appropriate for 1 of 3 residents (R1) when R1 was not sent sustenance with to his appointment. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 was admitted to the facility on [DATE], and R1 had diagnoses which included acute respiratory failure, pneumonia, and adult failure to thrive. Further, MDS identified R1 required substantial/maximal assistance with toileting hygiene and lower body dressing and R1 required supervision assistance with ambulation. R1's February 2025 Medication Administration Record (MAR) indicated R1 had an order for Osmolite (formula high in calories and protein to help patients gain and/or maintain healthy weight) 1.5 or equivalent formula, administer by Gtube (gastrostomy tube) with gravity flow four times a day related to malignant neoplasm of tongue. This administration was scheduled for 6:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. On 2/13/24 at 4:00 p.m., there was no evidence R1 received Osmolite as scheduled. On 2/20/25 at 11:00 a.m., R1's was documented as out of the facility without medications. R1's medical record lacked evidence of facility staff notifying R1's physician regarding the scheduled Osmolite when R1 had an appointment at the cancer center. R1's care plan as of 2/25/25, revealed R1 had an activities of daily living (ADL) self-care deficit and required staff assistance to use the toilet and with dressing. R1's care plan indicated R1 required tube feeding related to tongue cancer and need for supplemental tube feeding to meet nutritional needs and directed staff to administer tube feedings as ordered. R1's Progress Note dated 2/13/25, indicated registered nurse (RN)-A received a telephone call from R1's cancer center and the center reported R1 was incontinent at the center today and requested a bag be sent with R1 on infusion visits along with a change of clothes. In the future, facility will send clothes. R1's Nursing Note from the cancer center dated 2/20/25, indicated R1 presented to the cancer center as a two person assist (one to keep balance, one to clean resident) as resident was incontinent of urine four times and bowel once. R1 was unsteady on his feet throughout the day. Four new pairs of pants were given to R1 as well as one new shirt. R1 was not sent with any tube feedings or supplies to a 6-hour appointment. On 2/26/25 at 9:32 a.m., R1 was sitting in a recliner chair in his room watching television. R1 appeared to be comfortable and well groomed. R1 stated at times he was incontinent of urine and would notify staff to assist with changing brief and clothing. R1 stated he had appointments at the cancer center that lasted approximately 4 hours or longer each appointment, and R1 stated he does not get his tube feeding while at the appointments. On 9/26/25 at 10:36 a.m. RN-B stated R1 was independent with most of his ADLs like transferring and ambulation however R1 did require staff assistance for incontinence episodes. RN-B stated R1 had weekly appointments at the cancer center which required R1 to be out of the facility for most of the day, and RN-B stated she does not adjust his Osmolite administration times and RN-B had not consulted with R1's physician regarding adjusting the administration times for the days he was at the appointments. RN-B also confirmed she had never packed a bag for R1 to bring with his appointments with incontinent products or extra clothing. On 2/26/25 at 11:28 a.m., RN-A stated R1 required a tube feeding to ensure he was getting adequate nutrition and calorie intake due to being NPO (nothing by mouth). RN-A stated R1 had appointments at the cancer center that would take approximately 4 hours, and the facility was unable to send R1's Osmolite with to the appoint as the center can not manage the tube feeding. RN-A state the nurse from the cancer center had called her to report R1 had some incontinence episodes while at the appointment and had requested the facility pack a bag with incontinent products and extra clothes when R1 comes to future appointments. RN-A stated she had documented the request in R1's progress notes but was not sure if the information was communicated to other staff. On 2/26/25 at 12:04 p.m. nursing assistant (NA)-A stated R1 was independent with ADLs and would require minimal assistance by staff if R1 had an incontinent episode. NA-A was not aware of packing a bag for R1 when he would go out for appointments. On 2/26/25 at 12:46 p.m., an anonymous reporter (AR) stated R1 had appointments at the cancer center and at his appointment on 2/20/25, R1 was going to be at the center for over 6 hours and the facility staff did not send incontinence supplies, extra clothes, or administer his tube feeding. (AR) stated at the appointment R1 required the center's staff assistance with five incontinent episodes during his appointment. Further, AR was unsure how the cancer center was coordinating R1's care with the facility at this time, but stated communication occurred verbally by telephone with the facility most times. The cancer center had been in contact with facility staff prior to 2/20/25, regarding concerns they were having related to incontinent care and requesting staff to send R1 was the proper products to the appointments, however facility staff had not been following through. On 2/26/25 at 1:10 p.m., RN-C stated R1 was independent with ADLs and had incontinent episodes that may require staff assistance. RN-C stated R1 had appointment at the cancer center but was unsure how often his appointments were. RN-C stated the cancer center staff were not able to administer R1's tube feeding while at the appointment, so R1 would skip the tube feeding scheduled during the appointment and resume as scheduled when returning to the facility. RN-C confirmed she had not consulted with R1's physician about different options for the tube feeding schedule while R1 was at his appointment. Further, RN-C stated the cancer center was requesting facility staff to send extra incontinence products and clothes with R1 to his appointments, however RN-C did not revise R1's care plan or the nursing assistant's care guide sheets to include this. On 2/26/25 at 2:14 p.m., director of nursing (DON) stated R1 would leave the facility approximately around 9:30 a.m. for his appointments at the cancer center and return to the facility at approximately 2:00 p.m. DON stated she would expect staff to consult with R1's provider and attempt to stagger the tube feedings to ensure R1 received the ordered amount. The DON confirmed R1 had not received Osmolite on 2/13/25 or 2/20/25, but could not find a progress note as to why R1 did not receive the feeding or any notes consulting with R1's physician regarding not administering the Osmolite. The DON stated ensuring R1 received the ordered amount of Osmolite was important as this was R1's only nutrition right now. Staff were expected to send incontinent products and change of clothes with R1 to his appointment at the cancer center, and this was communicated to all staff on 2/13/24, by the 24-hour report. Care plans were expected to be revised by herself or RN-C, and DON confirmed R1's care plan lacked interventions and coordination of care for R1's chemotherapy appointments. In addition, staff were expected to coordinate resident's care with outside services by verbal updates. On 2/26/25 at 3:10 p.m., attempted interview with nurse practitioner (NP) -A was unsuccessful. On 2/26/25 at 4:06 p.m., DON stated she had not reviewed R1's Nursing Note from the cancer center dated 2/20/25,. The DON confirmed facility staff had not addressed the concerns from the cancer center. Requested facility policy for comprehensive care plans was requested but facility did not provide.

Base on observation, interview, and document review, the facility failed to store and label food properly, dispose of undated and expired food items, to reduce the risk of food borne illness. This deficient practice had the potential to affect 34 residents who were provided meals from the kitchen. Findings include: During initial tour of kitchen on [DATE], at 11:33 a.m., with dietary manager (DM) the following was observed: - in the room with the serving window, on the back wall was a three door free standing cooler. Behind the first door was two plastic serving cups of jello uncovered/undated, three plastic serving cups of fruit cocktail uncovered/undated. Behind the third door a meal that had been saved had no label of when it was placed in the cooler. - in the room with the serving window, next to the three door cooler stacked on the floor were three racks of hamburger and hotdog buns. DM stated these were outdated and needed to be returned to the bread company. There was no signage indicating to staff to not use the bread products and return to the bread company. - in the middle sink of a three-sink system, two bags of frozen fish which had been cut or torn open across the top were placed in a large metal steam dish, set in sink and had water running over and into the plastic bag containing the fish.Water was observed splashing against the sink, and back into the open containers of fish. - in dry storage area, a large open bag of breadcrumbs was noted. DM stated these were not to be used and acknowledged lacked signage directing staff to not use them. Two bags of dark chocolate chips were open, and the open end loosely rolled down and placed on shelf. There was no label indicating when opened, and bag was not adequately sealed. - in walk in cooler one open box of grated parmesan cheese was held closed with a black clip. No label indicating date opened. One large box labeled as Activities held strawberries, cheese and other covered items. No items in the box were labeled with date opened or use by dates. On the top left shelf closest to the walk-in freezer door, three apple pies were loosely covered with plastic wrap but lacked a label indicating date put in cooler and use by date. Three- and one-half logs of hamburger were observed in an uncovered plastic bin. DM stated she was unclear how long they had been there and indicated they had completely thawed out. The hamburger logs had no opened date and no use by date was noted. - in walk-in freezer, ice was built up around the door and across the threshold and three-fourths of the way up the right side of the door. Upon opening the door, DM looked inside the freezer, observed the items on the floor and open items frozen to the shelf and stated, 'this is really bad'. Just inside the door on the top shelf was a pile of light colored food in open bags that could not be identified. The items had frozen to the shelf and could not be easily removed. One case of chopped spinach, one case of hamburger patties, one case of french fries, one case of salisbury steak, two cases of country veggie blend and one case of biscuit dough were located directly on the floor of the walk-in freezer. - in the food preparation area, a roll out cart containing three bins: the front bin had a sealed plastic cover and labeled as flour; the second bin was loosely covered with plastic wrap but was not securely attached leaving an open area on the back approximately one inch. DM identified this as sugar and stated we have to get a new cover that fits. The third bin had a sealed plastic cover and was labeled flour. During second tour of kitchen on [DATE], at 05:02 p.m., the following observations were made: - in the three-door cooler, behind first door four cups of fruit cocktail with no label identifying open date or use by date were observed. - walk-cooler ice/frost was observed across threshold and up the right side of the freezer door approximately 12 inches. Inside freezer placed directly on the floor were the following: one case broccoli, one case white shrimp, two cases pumpkin pies, one case breaded chicken pieces, and two cases beef sirloin. During interview on [DATE], at 12:27 p.m., DM stated all food in any cooler or refrigerator must be covered and labeled with date opened to avoid potential food borne illnesses. DM acknowledged that staff was not labeling food appropriately, if at all and stated staff had been trained on the proper way to store food in the coolers and freezer to include rotating stock to use oldest items first, labeling any open products with date opened, no items stored directly on the floor, checking dates on open products and removing outdated items from coolers and freezers daily. During interview with administrator on [DATE] at 01:23 administrator stated the kitchen staff was contracted staff and not regular employees. Additionally, administrator stated she expected the DM to keep things running smoothly in the kitchen. A policy regarding food storage was requested but not provided.

Based on observation, interview and document review, the facility failed to assess residents for the ability to self-administer medications after staff set up, or obtain order for medication self-administration for 1 of 1 (R27) residents observed self-administering medication. Findings include: R27's significant change of condition Minimum Data Set (MDS) dated [DATE], indicated R27's brief interview for mental status (BIMS) revealed a score of 15 indicating R27 was cognitively intact. The MDS indicated R27 took high risk medications which included opioids (strong pain-relieving medicines) and anti-platelet medications (medications that prevent blood clots from forming). R27's diagnoses included atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), peripheral vascular disease (PVD-a blood circulation disorder) and renal insufficiency, renal failure, or end stage renal disease (poor function of the kidneys). R27's order summary report for active orders as of 5/1/24 lacked an order to self-administer medication after staff set up. During observation on 4/29/24 at 06:07 p.m., R27 was seated in his room eating. R27 reached behind him to the nightstand and picked up a white medication cup with an undisclosed number of pills in it and proceeded to dump pills into his mouth, took several sips of water and then continued to eat his meal. R27 could not identify the pills he had taken, nor how long they had been on the bedside table. R27 stated staff brought pills in and left them on the bedside table all the time. R27 denied staff stayed to verify he had taken the medications. During interview on 4/29/24 at 07:45 p.m., trained medication aide (TMA)-A stated R27 had three medications scheduled at 5 p.m. which included a vitamin, acetaminophen and Vascepa (a medication that reduces the risk of heart attack, stroke and other heart problems). TMA-A stated staff would sometimes leave the meds in the room with R27 because 'we know he is really good about taking them'. TMA-A stated R27 would require an order to self-administer medications that are set up by staff and left at the bedside to take independently. TMA-A acknowledged that R27 did not have an order to self-administer medication. During interview 5/1/24 at 12:28 p.m., registered nurse charge nurse (RN)-CN stated a medication self-administration assessment would need to be completed if a resident was requesting meds to be left at bedside to be taken independently after staff set up. RN-CN confirmed there was not a medication self-administration assessment completed for R27. During interview on 5/1/24, at 01:10 p.m., registered nurse case manager (RN)-CM stated all residents needed a self-administration assessment before staff can leave meds at the bedside to have resident self-administer. RN-CM acknowledged R27 did not have a self-administration assessment, or an order from the physician to self-administer medications. Director of nursing (DON) was not available for interview. Facility document medication administration-general guidelines, section B -Administration indicated medications are administered in accordance with written orders of the prescriber; medications are administered at the time they are prepared; medications are not pre-poured either in advance of the med pass; the person who prepares the dose for administration is the person who administers the dose; and , residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Facility document preparation and general guidelines with subtitle of self- administration of medications, indicated if a resident desired to self-administer medications, an assessment is conducted by the interdisciplinary team of the residents cognitive (including orientation of time), physical, and visual ability to carry out this responsibility during the care planning process.

Based on interview and document review, the facility failed to ensure competent staff implemented cardio-pulmonary resuscitation (CPR) and summoned emergency services in a timely manner for 1 of 1 resident reviewed who required CPR. This resulted in an immediate jeopardy (IJ) situation for R1, and had the potential to affect 7 of 7 other residents (R2, R3, R4, R5, R6, R7 and R8 ) who had identified a desire to receive CPR if their hearts should stop. The immediate jeopardy began on [DATE], when CPR was not provided by a CPR certified staff member, and non-emergency transportation was summoned instead of 911. The Administrator was notified of the IJ on [DATE] at 2:40 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of E, pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of the (YEAR) American Heart Association (AHA) professional guidelines indicated: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of death (e.g. rigor mortis, dependent livid, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services (EMS) in accordance with the resident's advance directives and any related physician order, such as code status, or in the absence of advance directives or a DNR order. Review of a facility report to the State Agency dated [DATE], indicated R1 had been found on the floor next to her bed and did not respond to touch or verbal communication, but was breathing. The report indicated RN-A had called the on-call medical doctor (MD) and gotten a telephone order to send R1 to the hospital via ambulance. RN-A then called the ambulance. The notes indicated when the ambulance arrived they took over CPR and declared time of death at 12:40 a.m. On [DATE] nursing assistant (NA)-A informed the executive director (ED) and the director of nursing (DON) he had initiated CPR at the direction of registered nurse (RN)-A, but he was not CPR certified. The report indicated a facility investigation had been initiated, and it had been determined RN-A had directed a non-CPR certified NA to initiate CPR. In addition, the investigation revealed RN-A had left R1 with the NA during the incident on multiple occasions, and had called the non emergency number for ambulance transport instead of 911, and when asked by dispatch if they should come regular or lights and sirens, RN-A had stated regular, despite R1's full code status. This investigation lacked any additional information regarding the facility policy, or facility wide training. R1's [DATE], Directive to Define Scope of Medical Care identified R1's wishes were To Resuscitate which included full CPR. R1's current face sheet identified [DIAGNOSES REDACTED]. R1's [DATE], Care Area Assessment (CAA) identified R1 required extensive assistance of one to two staff for all activities of daily living (ADL's), and a brief interview for mental status (BIMS) indicated R1 had moderate cognitive impairment. R1's [DATE], care plan identified CPR for the code status and interventions included: observe and notify the medical practitioner of any changes in medical status, review code status quarterly and as needed, and spiritual care per request. R1's [DATE], progress notes identified at 11:45 p.m. last night, (R1) was found on the floor sitting alongside her bed. Staff went in to assist (R1) off of the floor, but noticed (R1) was not responding to touch or verbal communication, but had a pulse and respirations with breathing present. (RN-A) called an on-call doctor at 11:50 p.m., and received a telephone order to send (R1) to hospital via ambulance. (RN-A) then called the ambulance to get a ride. Then staff alerted writer that resident went unresponsive at 11:55 p.m., and CPR was initiated. Staff and (RN-A) performed CPR until ambulance arrived. Ambulance arrived at 12:10 a.m., and the paramedics took over performing CPR. (RN-A) then called the family to notify them. At 12:40 a.m., the paramedics stopped performing CPR and declared time of death as 12:40 a.m., on [DATE]. During interview on [DATE] at 10:36 p.m., with the ED identified her expectation was that all licensed staff are certified in CPR and only the nurses should perform CPR. Our main concern was RN-A did not follow good practice. She should have been in control of the situation. When we were first notified that R1 passed away we did not have a concern until the next day when NA-A reported he was instructed by RN-A to perform CPR and was not certified. She further identified there had not been facility wide training after this incident and the facility did not have a policy related to emergency situations. Interview on [DATE] at 11:10 a.m., with NA-B identified he was certified in CPR and if directed by the nurse would initiate CPR and indicated there had been no facility wide training in the last month related to emergency situations or CPR. During interview on [DATE] at 11:16 a.m., LPN-A stated there had been no facility wide training regarding CPR or emergency situations in the last one month. During an interview with RN-B on [DATE] at 11:20 a.m., RN-B stated if she found a resident who had coded (not breathing/no pulse) she would do chest compressions then call 911. RN-B said she would have an NA initiate CPR if she knew they were CPR certified, and stated she would verify with the NA to make sure they were certified. RN-A further stated there had been no specific training regarding emergency situations or CPR provided. During an interview on [DATE] at 11:40 a.m., NA-A stated he had worked the evening shift on [DATE], and into the morning of [DATE]. NA-A stated he had assisted R1 from her chair to her bed around 8:,[DATE]:00 p.m. At approximately 11:40 p.m., R1 was found sitting on the floor next to her bed with her back against the bed. NA-A stated, initially R1 was breathing, but had stopped breathing so he immediately went and informed RN-A who had instructed him to start CPR. NA-A stated RN-A was making phone calls in the office trying to contact the physician. NA-A stated he ran back to R1's room and initiated CPR. He said he had been trained in CPR in ,[DATE] through Eagle Scouts (A Boy Scouts of America rank) by an online course. NA-A stated he was doing CPR without RN-A present as she was in and out of the room trying to make phone calls. Furthermore, NA-A stated he had received no additional training since that day, and did not know what he would do if this type of situation would happen again. NA-A stated he had reported the incident to the DON the following day, because he was concerned. During interview on [DATE] at 12:47 p.m., RN-A stated she had checked on R1 on [DATE], but was unaware of the time. RN-A stated she had found R1 sitting next to her bed. RN-A stated R1 had a pulse, respirations and was breathing stating, It looked like she was sleeping. RN-A further stated, R1 would normally wake up when someone spoke to her, but R1 didn't respond. RN-A said she'd tried to shake her shoulder and call her name, then attempted a light sternal rub to see if that would wake her up. RN-A stated R1 had just grumbled at that time. RN-A then left R1 so she could call the on-call doctor for an order to send her to the hospital. RN-A had been told by other staff that if a resident was going to be sent to the hospital a doctor's order was required. RN-A said she'd received an order from the on-call physician, and had then called the non-emergency number for transportation to the hospital. RN-A said she was almost off the phone with the ambulance service when NA-A came into the nurses' office and informed her R1 had stopped breathing. RN-A said she'd told NA-A, 30 compression and 2 breaths. RN-A acknowledged she did not tell the ambulance dispatch that R1 had stopped breathing. RN-A also stated she'd thought all NA's had their CPR certification, but confirmed she had not asked NA-A if he was certified. RN-A said she took over CPR for NA-A until the ambulance arrived. RN-A also stated that following the incident, she'd received education including: a MD order is not needed for transport if it is an emergency, call 911 and not the non-emergency number, and CPR cannot be delegated to staff that are not certified. Furthermore, RN-A stated she did not feel properly trained for emergency situations, and stated she did not think there was a facility policy on what to do in emergency situations. During an interview on [DATE] at 3:28 p.m., with family member (FM)-A, FM-A identified on [DATE] she had to shake R1 to wake her up stating, She (R1) had been sleeping the last three days. FM-A stated she'd previously asked multiple times about R1 being sent to the hospital, but staff would tell her R1's vitals were normal. FM-A shared a voicemail RN-A had left on her phone [DATE] at 12:16 a.m: We are doing CPR. [DATE] at 12:25 a.m., paramedics took over CPR. The ambulance operational supervisor was interviewed on [DATE] at 10:54 a.m The ambulance operational supervisor stated the ambulance crew had been dispatched routine, for a breathing resident that was a non-emergency call, just before midnight on [DATE]. Police officer (PO)-A was interviewed on [DATE] at 10:58 a.m. PO-A stated he was one of the officers arriving on the scene on [DATE]. PO-A stated, the call first came over the radio as a lift assist, but when they got on scene there was a male staff member performing CPR. PO-A said when he and another police officer arrived, the staff left the room. If the paramedics had questions we had to find the staff in an office about 100 feet away from (R1's) room. The staff members appeared discombobulated like they didn't know what to do in an emergency situation. The nurse was always on the phone when we went to ask questions in the office, and it was a struggle to get pertinent information. The staff were very concerned about getting (R1) back into bed after CPR had ceased. Review of the ,[DATE] - [DATE] facility video surveillance of the hallway outside R1's room identified RN-A left the room multiple times during the emergency situation. RN-A was not present when NA-A initiated CPR at 12:07 a.m. After the CPR began, the video surveillance revealed RN-A was not in R1's room for approximately seven minutes. When the paramedics arrived at 12:16 a.m., the video initially showed them entering the facility with a gurney, then one paramedic left and returned with two bags. In addition, the surveillance video included: -11:48 p.m., RN-A looked in R1's room, then came out of R1's room. -11:49.58 p.m., NA-A entered R1's room. -11:50.37 p.m., NA-A left R1's room. -11:50.5 p.m., RN-A entered R1's room with the vital sign machine. -11:51.2 p.m., NA-A and NA-C out side of R1's room, RN-A left R1's room. -11:52.26 p.m., RN-A walked very slowly to R1's room and stood outside of the room talking on the phone and did not enter the room at this time stood outside. -11:52.53 p.m., RN-A walked away from R1's room. -11:58.05 p.m., RN-A entered R1's room. -11:59.17 p.m., RN-A left the room and was on the phone. -12:00 a.m., RN-A walked away from R1's room and was on the phone pacing up and down the hallway. -12:01 a.m., RN-A continued to walk around in the hallway by R1's room on the phone, but did not go in R1's room. -12:07.11 a.m., NA-A ran out of R1's room and then ran back to R1's room. -12:09 a.m., RN-A ran down the hall and entered R1's room. -12:09.27 a.m., RN-A left R1's room. -12:10.08 a.m., RN-A returned to R1's room. -12:11.37 a.m., RN-A left R1's room. -12:14.29 a.m., RN-A returned to R1's room. -12:16.30 a.m., RN-A left R1's room. -12:16.49 a.m., paramedics arrived to R1's room with the gurney. A police officer then radioed something. -12:17 a.m., RN-A stood outside of R1's room. One paramedic left R1's room. -12:18 a.m., the paramedic returned with two bags in his hands. During additional interview with RN-A on [DATE] at 3:37 p.m., RN-A stated the first phone call she'd made was to the DON, but the DON never answered, and then she called the on-call doctor for an order to transport R1. During interview with the Medical Director and certified nurse practitioner (CNP) on [DATE] at 10:44 a.m., the Medical Director and CNP-A stated their expectation would be for the nurse (RN/LPN) to be in charge of the emergency situation. They stated for a resident who was unresponsive staff should have immediately called 911 if the resident was full code. The Medical Director stated, The nurse should have told dispatch when the resident stopped breathing. CNP-A stated there had previously been no indication R1's death was imminent. The medical director stated, A policy and procedure should be made available for staff in an emergency situations. It looks like we have some education to do here. Neither CNP-A or the medical director were aware that the family had previously requested R1 to be sent to the hospital. During interview on [DATE] at 11:55 a.m., the ED (executive director) and the interim DON stated they had revised their CPR policy on [DATE]. They stated the RN/LPN should supervise all emergency situations to ensure basic life support (BLS) was provided in a timely manner. The DON verified the RN should not have left the NA, and stated 911 should have been called immediately. The ED agreed with the interim DON's expectations. Review of records for R2, R3, R4, R5, R6, R7 and R8 , revealed each of these residents had also expressed a desire to have CPR performed if their hearts would stop or they stopped breathing. Review of the facility's ,[DATE] CPR policy, identified: If a resident experiences [MEDICAL CONDITION], facility staff will provide basic life support, including CPR prior to the arrival of EMS (emergency medical services). The facility will provide adequately trained, 24 hour staffing to initiate basic life support within minutes of a resident's cardiac or respiratory arrest. A policy regarding emergency situations was requested, but the ED stated the facility did not have a policy for emergency situations. The IJ that began on [DATE], was removed on [DATE], when the facility had implemented a systemic plan of correction that included review of current policies and procedures, re-education of nursing staff to the facility's CPR Policy, re-education of staff about when to call 911, and to ensure staff were aware they did not need to contact a physician for an order to transfer during an emergency. Additionally, the facility established a system to verify staff competence for CPR implementation.

Based on interview and record review, the facility failed to provide pain medication and/or comfort measures for 1 of 1 resident, R1, who had a new onset of [MEDICAL CONDITION]. This resulted in actual harm for R1 who experienced approximately 7 [MEDICAL CONDITION] before receiving any pain medication. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated the resident had severe cognitive impairment and required extensive staff assistance with all activities of daily living (ADL). R1's Care Area Assessment (CAA) for pain dated 6/9/16, indicated the resident had [DIAGNOSES REDACTED]. The resident had comfort medications available but had not required, much of them. The CAA indicated staff would, Administer PRN (as needed) pain medications as needed. The CAA did not specify how the resident exhibited pain. R1's Care plan dated 6/17/16, indicated the resident had a terminal prognosis requiring comfort care related to end stage disease process. Interventions included, Observe closely for non-verbal indicators of pain. Administer [MEDICATION NAME] as ordered, monitor for side effects of medication and breakthrough pain. The Care Plan did not instruct staff on specific non-verbal indications of pain for R1. R1's Pain assessment dated [DATE], indicated the resident had pain rated at an 8 (on a scaled from 1-10, 10 being the most severe pain) in the last 5 days which had limited the residents day to day activity. The summary of the assessment indicated R1, Reports pain/ discomfort from excess fluid that has resolved significantly since paracentesis today. (R1) has only used PRN [MEDICATION NAME] once since admission, none in the last 5 days. The pain assessment did not address any frequency of pain or how the resident exhibited pain. A physician progress notes [REDACTED]. The physician directed the resident to continue on comfort cares, and to continue to have the [MEDICATION NAME] and [MEDICATION NAME] available for R1's comfort as needed. No specific parameters of when to use the [MEDICATION NAME] and [MEDICATION NAME] were included in the physician progress notes [REDACTED].>R1's physician orders dated 8/2/16, included parameters for the medications [MEDICATION NAME] ([MEDICATION NAME]) [MEDICATION NAME] Concentrate, 1 mg every 2 hours as needed for anxiety, and [MEDICATION NAME] Concentrate solution, 5-10 mg every hour as needed for moderate to severe pain. R1's Progress Notes were reviewed and indicated the following: 8/6/16, at 3:54 p.m.- Resident has not offered any c/o (complaints of) pain or discomfort, resident took all med's as scheduled. Resident has been alert, pleasant, and cooperative. 8/7/16, at 1:57 p.m.- Written by Licensed Practical Nurse (LPN)-I, Resident was noted to have 2 episodes which resident was noted his whole body shaking rapidly for about 30-40 seconds. Resident noted to be unresponsive, but breathing after each episode. Resident episodes noted to be an hour and a half apart. (Family member) here at the time of both episodes. (Family member) stated that she knew this was coming and was expected and wishes to not seek further care for the resident. (Family member) still here at this time sitting with resident. Resident also noted to bite his bottom lip and tip of tongue during his episodes. Area cleansed and bleeding stopped. Although the progress note indicated the family member did not wish to seek further care for the resident, there was no corresponding documentation regarding what the family wishes were regarding R1's comfort. 8/7/16, at 3:53 p.m.- Written by LPN-I, Staff report that resident has 2 more [MEDICAL CONDITION] activity, one at 3:09 p.m. [MEDICATION NAME] about 1.5 minutes and one at 3:44 p.m. that lasted about 2 minutes. Resident remains unresponsive. Resident (family member) still here with resident at this time. 8/7/16, at 10:10 p.m.- Written by LPN-L, Resident is non responsive to verbal and tactile stimuli. Several [MEDICAL CONDITION] activities. Resp (respirations) 12 shallow/ deep labored. Resident has bitten several pieces of his tongue off on the left side, and small areas of his inner left cheek with large amounts of blood expelled. After [MEDICAL CONDITION] activity oral cares are given. Reposition for comfort with HOB (head of bed) 35 degrees, lying on his right side. Resident has facial grimacing/ moaning/ upper/ lower extremities jerking. Teeth clenching s/s (signs and symptoms) of pain. [MEDICATION NAME] 10 mg given to start. 8/8/16, at 10:59 a.m. resident passed away. Review of R1's Medication Administration Record (MAR) for August 2016, the resident received [MEDICATION NAME] sulfate 5 mg for the first time on 8/7/16, at 7:00 p.m., and then approximately every 2-5 hours until 8/8/16, when the resident passed away. During interview on 8/31/16, at 12:20 p.m. LPN-B stated when she saw R1 during the early morning hours of 8/8/16, the resident was resting comfortably. LPN-B stated nursing had reported after the resident was given [MEDICATION NAME] the evening of 8/7/16, R1 had no further [MEDICAL CONDITION]. LPN-B stated staff continued to give [MEDICATION NAME] every 1-3 hours per family request to ensure resident comfort. LPN-B stated if a resident had a change in condition, staff was directed to notify the on call physician. LPN-B stated R1 had active orders for [MEDICATION NAME] and [MEDICATION NAME] since 6/6/16, the medications were listed on R1's current MAR, and the medications were available at the facility. During interview on 8/31/16, at 12:40 p.m. LPN-C stated there was always an on call physician available to contact on the weekend or evening. LPN-C stated nursing had been trained if there was a urgent need for a resident, such as pain management or a change in condition, a physician should always be called. During interview on 8/31/16, at 1:05 p.m. nursing assistant (NA)-E stated she cared for R1 on 8/7/16. NA-E stated R1 had not had [MEDICAL CONDITION] prior to 8/7/16. NA-E stated the morning of 8/7/16, she told R1's nurse, LPN-I, the resident seemed, off. NA-E stated the resident was not responding, and she thought the resident had a small [MEDICAL CONDITION] early that morning before breakfast. NA-E stated she thought R1 possibly had a [MEDICAL CONDITION] because he was not responding and staring off into no where. NA-E stated at about noon she provided incontinent care to R1. When NA-E rolled R1 to his side, the resident shook and blood came from his mouth. NA-E stated she immediately called LPN-I to the room, and was directed by LPN-I to clean R1 up and monitor him, and LPN-I left the room. NA-E stated she left the facility about 2:00 p.m. on 8/7/16, and the resident had 2 more [MEDICAL CONDITION] after the one at noon prior to her leaving. NA-E stated she did not know specific time the resident had the other [MEDICAL CONDITION], or how long they lasted. NA-E stated she wrote the information down on a post it note and gave it to LPN-I before she left the facility. NA-E stated when the other 2 [MEDICAL CONDITION] occurred, R1's family member was present. R1's family member (FM)-H had asked NA-E if the nurse could give the resident something for pain. NA-E stated she asked LPN-I to obtain pain medication for R1, and LPN-I stated, No, I don't have any orders. NA-E stated she thought R1 was having non verbal symptoms of pain on 8/7/16, during the [MEDICAL CONDITION] such as moving his tongue around in his mouth and opening his eyes really big, however, he was not able to express any discomfort as the resident was not communicating. NA-E stated the resident was having a lot of bleeding from his mouth related to biting his tongue and cheek, and felt that was causing him pain also. NA-E stated she worked with R1 the following morning, 8/8/16, and R1 was resting comfortable and did not seem to be in any pain. NA-E stated LPN-I, Should have done more to keep him (R1) comfortable, when R1 was having [MEDICAL CONDITION]. NA-E stated on the morning of 8/8/16, staff were still swabbing out pieces of R1's tongue and cheek he had bitten off during the [MEDICAL CONDITION] the prior day. During interview on 8/31/16, at 1:35 p.m. NA-F stated she provided cares for R1 the morning of 8/7/16, and reported to LPN-I, Something was wrong with him. LPN-I told NA-F she had checked the residents vital signs and they were all within normal limits, and directed staff to continue to monitor the resident. NA-F stated she was unable to work with R1 the remainder of the day because it was too traumatic when the resident was having [MEDICAL CONDITION] and, Blood was coming out of his mouth. During interview on 8/31/16, at 2:05 p.m. director of nursing (DON)-A stated LPN-I should have updated the on call physician on R1's change of condition on 8/7/16. DON-A stated the orders for [MEDICATION NAME] and [MEDICATION NAME] were on R1's MAR on 8/7/16, and LPN-I should have administered the medication(s) for R1's comfort. DON stated there was also a on call nurse available at all times, and LPN-I also could have called the nurse for assistance or guidance if she was not aware R1 had orders for comfort medication. DON stated she was the on call nurse on 8/7/16, and LPN-I did not call her. During interview on 9/8/16, at 3:05 p.m. registered nurse (RN)-G stated on 8/7/16, she worked the day shift on the opposite end of the hall from LPN-I as the other medication nurse. RN-G stated on 8/7/16, shortly after breakfast (approximately 10:00 a.m.), a (unknown) NA came to get her and stated they needed help in R1's room and were unable to find R1's primary nurse, LPN-I. RN-G walked immediately to R1's room, and LPN-I had just entered the room. RN-G stated R1 was having a [MEDICAL CONDITION], and there was blood coming from his mouth. RN-G went to get towels to assist in cleaning R1, however, LPN-I told her she didn't need any help. RN-G stated she offered again to stay and help with R1, but was told she wasn't needed. RN-G stated the facility had 2 nurses working and split the resident assignments to administer medications and treatments, and RN-G was assigned to a different group of residents. RN-G stated she did not see R1 the remainder of the day, nor did LPN-I seek her assistance. During interview on 9/9/16, at 11:50 a.m. FM-H stated on 8/7/16, she had arrived at the facility to visit R1 about noon. When she arrived she was met at the door by NA-E, who told her R1 had 2 [MEDICAL CONDITION] and was unresponsive. Shortly after arriving at the facility, staff was going to provide incontinent care to R1 and FM-H waited outside the door in the hallway. FM-H stated when waiting in the hallway, she heard the aide calling for help so she opened R1's door and the resident was having a [MEDICAL CONDITION] and blood was coming from his mouth. FM-H stated the resident had another [MEDICAL CONDITION] at around 3:30 p.m. that lasted about 1.5 minutes. FM-H stated R1 seemed to be in pain because he was, squeezing his eyes closed, and, mopping his tongue from side to side. FM-H stated she asked the (unknown) NA to tell the nurse R1 needed something for pain. FM-H stated the NA returned approximately 5 minutes later and said LPN-I said, No, R1 did not have any pain medication available to give. FM-H stated R1 had another [MEDICAL CONDITION] after that, and she stepped outside the room to find LPN-I to, Demand medication! FM-H stated LPN-I told her she could not give R1 any pain medication because there were no physician orders. FM-H demanded LPN-I to go with her to R1's room, and stated to LPN-I, It looks like (R1) is in pain! FM-H stated LPN-I stated to her, Yes, it does, and then walked out of the residents room without saying anything further. FM-H stated she did not see LPN-I again. FM-H stated R1 had another [MEDICAL CONDITION] about 5:15 p.m. that lasted about 2.5 minutes, and R1 was, Chewing off pieces of his tongue and blood was spurting out (of his mouth). R1 had another [MEDICAL CONDITION] at 5:45 p.m. and, His eyes got big and he started chewing on his tongue; his legs jumped all over. FM-H stated she went into the hallway and screamed, Somebody help me! But the nurse never came. FM-H stated at approximately 6:15 p.m. the nurses were changing shifts, and the evening nurse, LPN-L, entered R1's room. FM-H stated LPN-L stated to her it appeared R1 was in pain. LPN-L left the room and came back about 10 minutes later with [MEDICATION NAME] for R1. FM-H stated R1 did not have another [MEDICAL CONDITION] after receiving the [MEDICATION NAME], and rested comfortably until he passed away on 8/8/16. FM-H stated she thought R1 had approximately 7 [MEDICAL CONDITION] throughout the day before receiving any pain medication. FM-H stated although R1 was on comfort cares, the resident never had [MEDICAL CONDITION] in the past, and she wanted LPN-I to call the physician because it looked painful and thought maybe the physician could provide R1 something to stop the [MEDICAL CONDITION]. FM-H stated LPN-I never offered to call the physician, and never offered any options to provide comfort to R1. LPN-I stated, (R1) should not have suffered that way; I can't get it out of my mind! During interview on 9/26/16, at 10:50 a.m. LPN-I stated if a resident had a significant change of condition, or there was an urgent need, a physician was on call 24 hours a day, and they would typically return the call within a few minutes. LPN-I stated she was R1's nurse on 8/7/16, and a (unknown) NA told her that morning around breakfast (9:00 a.m.), Something wasn't right with (R1). LPN-I stated R1 was different everyday, and had good days and bad days. LPN-I stated she was in the dining room about 12:00 p.m. and received a call on the walkie talkie R1 was having a [MEDICAL CONDITION]. LPN-I stated they made sure the resident was safe and checked his vital signs. LPN-I stated FM-H was at the facility and had requested the resident remain on comfort cares, which LPN-I interpreted as she did not want R1 sent to the hospital. LPN-I stated she was unsure how many [MEDICAL CONDITION] R1 had, but stated about 3:00 p.m. the resident had a [MEDICAL CONDITION] and bit his tongue and cheek, Which appeared painful. LPN-I stated she had not received a post it note from the NA regarding R1's [MEDICAL CONDITION], and verified she did not document all of R1's [MEDICAL CONDITION]. LPN-I stated whatever information was documented in R1's progress notes was all of the information regarding 8/7/16, that she had regarding specific information regarding the [MEDICAL CONDITION]. LPN-I stated she looked at R1's MAR and only saw medication orders for Tylenol, which she stated FM-H refused, and also liquid [MEDICATION NAME], but stated R1 didn't, Appear to be in distress or anxious. LPN-I verified although she looked at R1's MAR for pain medication orders, she, Just missed it. LPN-I stated she called an on-call physician sometime towards the end of her shift (5:00 p.m.- 5:30 p.m.), however, she was unsure who the physician was, what specific time she called, had not documented a call had been made, nor did she report to the oncoming nurse a call had been made to the physician. LPN-I stated she was unsure why she had not contacted a physician earlier to obtain orders for R1's comfort, and/ or to update them on the onset of the [MEDICAL CONDITION], which were new for R1. LPN-I stated on 8/7/16, there was another nurse in the building, RN-G. However, LPN-I did not ask for RN-G's assistance to obtain R1's medication orders, nor did she call the on call RN for assistance. LPN-I stated RN-G had offered assistance with R1 earlier on 8/7/16, but LPN-I stated she didn't feel any additional assistance was needed. During interview on 10/10/16, at 11:20 a.m. medical doctor (MD)-J stated the nurse should have contacted the on call physician on 8/7/16, regarding R1's change in condition. MD-J stated although the resident was on comfort cares, the nurse should have contacted the physician to ensure the resident was comfortable and had adequate medication to control the [MEDICAL CONDITION] and/ or pain. MD-J stated if a physician would have been contacted, [MEDICATION NAME] would have been the first medication of choice to try to control the [MEDICAL CONDITION], and than the [MEDICATION NAME] after that. The facility resource at the nurses station titled Change in Condition, When to Report to the MD (Medical Doctor)/ NP (Nurse Practitioner)/ PA (Physician Assistant), dated 2010, directed staff to report immediately, Pain unrelieved by current medications. Pain that is new or abrupt in onset. New onset [MEDICAL CONDITION], OR prolonged or uncomfortable [MEDICAL CONDITION] in someone with known [MEDICAL CONDITION] disorder.

Based on observation, interview and document review, the facility failed to provide ongoing consistent monitoring of fluid retention in accordance with physician directed guidelines to prevent complications related to [MEDICAL CONDITIONS] for 1 of 1 resident (R34) who had a [DIAGNOSES REDACTED]. In addition, the facility failed to ensure fluid monitoring was completed as ordered for 3 of 4 additional residents (R61, R46, R44) who required fluid monitoring, and failed to provide proper wheelchair positioning for 1 of 3 residents (R44) who was positioned improperly in her wheelchair. Findings include: R34's admission Minimum Data Set ((MDS) dated [DATE], indicated the resident had been admitted to the facility on [DATE]. The MDS further indicated R34 was cognitively intact and had [DIAGNOSES REDACTED]. R34's [DIAGNOSES REDACTED]. R34's care plan dated 10/3/16, also indicated R34 had [MEDICAL CONDITION] and directed staff to monitor weights daily and to update the medical doctor (MD) per parameters or facility protocol, to observe/document and report to medical practitioner as needed any signs or symptoms of [MEDICAL CONDITION], dependent [MEDICAL CONDITION] of legs and feet, crackles and wheezes, weakness and fatigue. R34's hospital Discharge Summary dated 9/13/16, indicated the resident had experienced an acute [MEDICAL CONDITIONS] (abnormal heart rhythm characterized by rapid irregular beating), [MEDICAL CONDITION] (low sodium level in the blood) and cardiomegaly (enlarged heart). This hospital Discharge Summary further indicated R34's weight as 187 lbs (pounds). R34's hospital Orders Discharge Report dated 9/13/16, included an order to 'call physician if you gain 3 lbs or more over night, or 5 lbs in a week.' The report further identified R34 as being on a regular diet with a daily fluid restriction of 1000 cubic centimeters (cc). The Sterling Park Health Care Center Medication Review Report dated and signed by the physician 9/13/16, also verified R34 was on a regular diet with 1000 cc fluid restriction and indicated orders to weigh daily, update physician of a 3 pound weight gain over night or 5 pounds in a week. During observation on 10/18/16, at 6:52 p.m. R34 was sitting in her room in a chair with oxygen on per nasal cannula at 2 liters. There was no water pitcher observed in her room. Review of R34's Fluid Monitoring sheet completed by nursing from 9/13/16 to 10/19/16, revealed no documented entries of fluid intake, the sheet was blank, indicating monitoring had not been conducted. During interview on 10/19/16, at 4:38 p.m. licensed practical nurse (LPN)-B confirmed nursing had not been filling out the fluid monitoring sheets according to R34's fluid restriction, however stated dietary staff complete fluid monitoring during meal times. During interview on 10/19/16, at 5:00 p.m. the dietary manager (DM) stated dietary staff had been completing R34's fluid monitoring daily during meal time. The DM also stated nursing was supposed to complete monitoring during non-meal times. The DM provided fluid monitoring sheets from 9/14/16 to 10/01/16, which identified R34's fluid intake during meals ranged from 360 to 1440 cc. The documentation indicated R34 had exceeded her daily 1000 cc fluid restriction seven times during meals. The DM further stated she does not compare nursing and dietary totals to the actual fluid intake for the day and stated she was unsure who was responsible for completing this. Review of R34's Weights and Vitals Summary form from 9/13/16 to 10/01/16, identified the following: 9/14/16- 197 lbs 9/15/16- 197 lbs 9/16/16- no weight recorded 9/17/16-no weight recorded 9/18/16- 196 lbs 9/19/16- 196 lbs 9/20/16, 9/21/16 and 9/22/16 - no weights recorded 9/23/16- 196 lbs 9/24/16 and 9/25/16 - no weights recorded 9/26/16-204 lbs - 8 lb weight gain in 3 days. 9/27/16- 204 lbs 9/28/16 and 9/29/16- no weights recorded 9/30/16- 205 lbs 10/1/16 admitted to hospital Although R34 was to be weighed daily, weights were not recorded for 9 out of the 17 days, despite having weight gain of up to 8 lbs identified. Review of R34's record indicated the following communication to her physician: On 9/26/16, a fax was sent (no time) to R34's primary physician which indicated (R34) had complaints of not feeling well. O2 sats (oxygen saturation in blood, normal saturation 95-100%) 80% on RA (room air). Two liters of oxygen was administered and saturations ranged from 88-91%. Blood pressure 126/75, pulse 79, respirations 20 and temperature 98.5, which were all in normal range crackles heard in bilateral lungs. The nurse wrote, Are you interested in checking any labs or chest x-ray at facility? There was no physician response identified from this fax communication and the fax did not address R34's 8 lb weight gain. A Progress Note from the facility nurse dated 9/26/16, at 2:31 p.m. indicated, Left message with MD (medical doctor) to follow up on faxed information sent earlier today. Requested follow up response yet today. There was no indication the physician had responded, nor did the facility document any further communication with the physician about the resident's low oxygen concentration, crackles in her lungs or the 8lb weight gain. A Progress Note dated 9/27/16, at 3:02 p.m. titled Care Conference Review indicated the interdisciplinary team had reviewed the resident's new oxygen use and indicated the MD had been updated with no response yet. The note indicated the resident had been oxygen dependent in the past and does not have needed supplies at home if needed upon discharge. Resident was offered physician appointment and voiced she would feel more comfortable being evaluated by MD. A physician appointment was scheduled for 9/28/16. A St Cloud Medical Group Progress Note documented by a certified nurse practitioner (CNP) dated 9/28/16, included: R34 presents with one week history of chest pain. These symptoms have been worsening. She has not had a fever or chills. The report further indicated, Provider did notice that while the O2 tank is new and full, the oxygen was not on. Dial at zero with no flow. Patient states she has been set to two liters, oxygen to be titrated per prior order. The report's Physical Examination note indicated the resident had non labored breathing, lungs clear, no crackles present, no wheezes present however, the report did not include a current weight. The report also identified a chest x-ray was completed, had shortness of breath, [MEDICAL CONDITION] and was back on oxygen a couple weeks ago. A St. Cloud Medical Group-Center for Diagnostic Imaging-Radiology- X-ray imaging Report date of 9/28/16, identified moderate cardiomegaly with vascular cephalization (pulmonary [MEDICAL CONDITION]), increased lower lung zone interstitial prominence (tissue and space around the air sacs of the lungs) and new small bilateral pleural effusions (excess fluid built up by the lung). Appearance is concerning for fluid overload/[MEDICAL CONDITION]. [MEDICAL CONDITION] hyperinflation, as can be seen in the setting of [MEDICAL CONDITION]. A handwritten note on the bottom of the fax from the facility to the physician indicated, Any new orders. The medical record lacked a response from the physician regarding new orders, even though R34 had SOB (shortness of breath), chest discomfort and increased weight. A fax dated 9/30/16 (no time indicated), identified the resident's weight today was 205 lbs, and on 9/23/16, was 196 lbs. She continues to need oxygen at two liters to maintain oxygen saturation greater than 90%. Has not been compliant with fluid restriction of 1000 cc/day and met that by lunch yesterday. Currently not on any diuretics. Although the facility fax was sent this was the first notice in the medical record that R34's physician had been notified of the weight gain that had occurred as of 9/26/16 and there was no indication the physician had responded to this fax. A physician fax sent to the facility on [DATE], at 12:35 p.m. indicated, Send to ER (emergency room ) for eval. A Progress Note dated 10/01/16, at 6:13 p.m. (late entry as a response to 12:35 p.m. fax from physician to send to ER) indicated, this morning resident had shortness of breath and difficulty breathing, O2 saturations 55% on 3.5 liters of oxygen by nasal cannula, nebulizer treatment administered and O2 saturations increased to 90%. Resident closely monitored during shift. After breakfast with therapist present at bedside resident O2 sat 84% and rechecked again no higher than 77%. The director of nursing (DON) who was present in the building contacted the resident's on call physician and received order to transfer to the hospital. During interview on 10/19/16, at 4:04 p.m. registered nurse (RN)-B acknowledged they had missing weights for this resident. RN-B stated the nursing staff working with the medication carts are responsible for the daily weights and notification of the weight gain to the physician. RN-B stated she'd been responsible for the medication cart on 9/30/16, had weighed the resident, and had sent a fax to the MD notifying him of R34's weight gain. During telephone interview on 10/19/16, at 4:53 p.m. LPN-D from St. Cloud Medical Group stated R34's physician had responded to the fax he had received on 9/26/16, at 1:17 p.m. He faxed orders to the facility to complete a chest-X-ray, start [MEDICATION NAME] (diuretic to remove fluid) 20 mg (milligrams) today and daily for two days and go to ER if worsens. The physician further ordered lab work, CRP (C-reactive protein) an acute phase reactant which is a protein made by the liver and released in blood with in few hours after tissue injury or the start of infection), basic BNP (b-type natiruretic peptide) hormone proceed by your heart response to changes in pressure inside the heart, these changes can be related to heart failure. R34's medical record lacked evidence these orders were received and implemented. During interview on 10/19/16, at 5:10 p.m. the facility LPN-B, stated they had not received the faxed orders from 9/26/16 even though the clinic indicated they faxed the nursing home. Therefore, R34 had never been placed on [MEDICATION NAME] until her hospitalization on [DATE]. A Hospitalist History And Physical dated 10/1/16, at 5:34 p.m. indicated R34 had stated she'd noticed shortness of breath last night and this morning it was fairly severe and was accompanied by chest tightness. She had a productive cough of white sputum, mild fever, no chills, nausea, vomiting or diarrhea. She does not feel that she has gained weight though her discharge weight from 9/13/16, and today's weight showed a 17 pound weight gain. While changing into a hospital gown her oxygen saturations dropped to 71%. Patient was given 80 mg (milligrams) of [MEDICATION NAME] intravenously, started on [MEDICAL CONDITION] (bi level positive airway pressure, continues positive airway pressure). The patient was admitted to the hospital on [DATE] and remained there until 10/6/16. A St. Cloud Hospital Orders Discharge Report dated 10/6/16, indicated R34 had been hospitalized for [REDACTED]. The orders indicated she was to be weighed daily for consideration of [MEDICATION NAME] changes and that she was placed on a 2000 cc fluid restriction and to contact the physician if she had shortness of breath, swelling of feet, decreased exercise tolerance and/or excessive tiredness. During interview on 10/20/16, at 11:21 a.m. the facility director of nursing (DON) stated on 9/26/16, R34 was noted to have been gaining weight so the nurses faxed her MD but didn't receive a response so the nurses called the MD with still no response. The DON stated the resident had a care conference on 9/27/16, and it was decided to have her seen by her MD with an appointment made for 9/28/16. At the appointment a chest x-ray was ordered, she worsened and was hospitalized . However, the DON was unable to located any documentation in the medical record to verify the physician had been notified of R34's weight gain until 9/30/16, four days after the 8 lb weight gain. During a telephone interview on 10/20/16, at 11:46 a.m. a St. Cloud Medical Group certified medical assistant (CMA) stated the clinic had faxed orders to the nursing home on 9/26/16. The CMA stated that when a fax does not go through, the clinic staff would get a rejection notice and would re-fax the orders. The CMA stated she was unsure why the nursing home would not have received them. During a telephone interview on 10/20/16, at at 1:28 p.m. R34's primary physician stated he had received the fax from the facility on 9/26/16, and had ordered [MEDICATION NAME], labs, a chest x-ray and to send to the emergency room if worsens. He said he had placed parameters and guidelines in place to prevent hospitalization . Including orders for the facility to monitor weights, fluid intake, and to notify him if there was a weight gain. The physician stated he signed the orders on 9/26/16, at 1:17 p.m. and faxed it back to the nursing home. He was not certain why they did not receive them. The physician said, if the nursing home had not heard back they should have called again and stated If faxes were not working calling is always an option. During interview on 10/21/16, at 9:12 a.m. the facility's director of nursing (DON) stated she was aware of the concerns with the nursing staff and the need to use judgement when to fax and when to call a physician. The DON stated she would be implementing a system so this issue would not occur again. Even though R34 had physician orders [REDACTED]. The facility failed to consistently monitor R34 for these parameters, and notify the physician when R32 had decreased oxygen saturations which required supplemental oxygen, changes in her respiratory status and a weight gain of 8 lbs. As a result of inconsistent monitoring and inadequate physician notification and follow up, R34 experienced actual harm and was hospitalized 5 days for heart failure. A facility Change In Condition When To Report To The MD/NP/PA undated indicated to report to them immediately of weight gain associated with respiratory symptoms, weight gain or >3 lb. in one day or 5 lb. in one week. The report further indicated to notify of abrupt onset of shortness of breath with pain, fever or respiratory distress. LACK OF FLUID RESTRICTION MONITORING: R61's Inpatient Discharge Summary dated 10/11/16, identified R61 had stage IV [MEDICAL CONDITION] and diastolic [MEDICAL CONDITION]. R61 had been scheduled for surgery during hospitalization , however it had been postponed due to, Deteriorated kidney function and [MEDICAL TREATMENT] was started, Shortly after. Further, the summary identified R61 to have a [MEDICAL TREATMENT] diet ordered with a 1500 ml (milliliter) fluid restriction. A subsequent physician order [REDACTED]. During observation on 10/18/16, at 4:57 p.m. R61's room had a blue water pitcher and small glass of red colored juice on the bedside table. The water pitcher was untouched, however the glass of red juice was only half full. During subsequent observation on 10/19/16, at 1:19 p.m. R61 was seated in her room visiting with her family. R61 had been served a lunch meal along with two 240 cc glasses of red colored juice, and two coffee cups with light brown colored fluid inside. R61 had consumed over 50% of three of the four provided cups of fluids. R61 stated she was unaware of any fluid restrictions in place for her diet adding staff wanted her to drink as much fluid as possible, (They) try to get me to push fluid because of the kidney. When interviewed on 10/19/16, at 2:15 p.m. nursing assistant (NA)-A stated R61, Usually eats in her room, adding she was unaware if R61 had any restrictions on her diet or fluid intake, I honestly am not sure. NA-A stated the staff member removing R61's meal tray from her room should be recording the fluid intake on a flowsheet kept by Dietary though, At the end of every meal. R61's untitled dietary flowsheets dated 10/13/16, through 10/18/16, identified R61's name and three separate columns to record each of the three meal's fluid intakes. However, only six entries were completed with fluid intake being recorded for the six day period. The remainder of the spaces provided to document the fluid intake were either left blank, or had, RT (room tray) written in them. During interview on 10/19/16, at 2:19 p.m. NA-E stated R61 eats, In her room most of the time, and meal and fluid intakes were recorded, In the computer. NA-E stated he thought R61 had a fluid restriction in place, but added he was unsure, The nurse should know. NA-E stated any residents on fluid restrictions should not have water mugs placed in their rooms. NA-E and the surveyor observed R61's room at 2:24 p.m. with a blue water pitcher on the bedside table. NA-E stated R61 should not have had a water pitcher placed in her room adding there was, Not much in there (water). Further, NA-E stated the water consumed by residents in the bedside pitchers was not tracked to his knowledge. R61's untitled flowsheet dated 10/16, identified R61 had a 1500 ml fluid restriction in place with, 2000 ml restriction being written along the side of the form on 10/17/16. The form had each day of the month with times written to cover a 24 hour period including a, 24h (24 hour) total, row at the bottom. However, R61 had only one entry completed on the flowsheet which identified she had consumed 400 ml of fluid on 10/14/16 at 0800. The remainder of the flowsheet was left blank, and no 24 hour totals were identified. When interviewed on 10/19/16, at 2:25 p.m. licensed practical nurse (LPN)-E stated R61 was, Newer to [MEDICAL TREATMENT] and staff were monitoring her fluids and meal intakes, As best we can. LPN-E stated nursing staff was responsible to track R61's fluid intakes on flowsheets kept in the Medication Administration Record [REDACTED]Troubles with breathing. Further, LPN-E reviewed R61's fluid intake flowsheet and stated it should be filled in and completed to monitor how much fluid she was taking in, We need to educate staff on keeping track of that. During interview on 10/19/16, at 3:47 p.m. registered nurse (RN)-A stated R61 started [MEDICAL TREATMENT] when she was hospitalized in the beginning of October 2016 and admitted to the facility on a 1500 ml fluid restriction. RN-A stated R61's physician increased the restriction to 2000 ml shortly after admission, and staff were expected to monitor R61's fluid intake on the flowsheet(s) in the MAR. Further, RN-A reviewed the flowsheets with only a single entry recorded and stated staff should have completed the intake monitoring because too much fluid, Could cause fluid overload. When interviewed on 10/19/16, at 4:03 p.m. the [MEDICAL TREATMENT] registered dietician (RD)-A stated staff should be monitoring R61's fluid intake in order to provide, A general idea on how much fluid they (R61) are consuming. RD-A stated fluid monitoring was important for a [MEDICAL TREATMENT] patient as it, Helps us discern if the patient is actually gaining fluid weight or body weight, and ensure R61 was being, Dialyzed correctly. Further, RD-A stated a lack of monitoring on a new [MEDICAL TREATMENT] patient could cause, Issues with volume overload and shortness of breath, and she expected the facility to monitor R61's fluid intake, It's an ongoing thing. A facility [MEDICAL TREATMENT] Audit policy dated 5/2015, identified, All resident's (sic) receiving [MEDICAL TREATMENT] services will have appropriate nursing interventions in place assure optimal care/outcomes. Further, the policy directed the physician orders [REDACTED]. R46's 60-Day Minimum Data Set ((MDS) dated [DATE], identified R46 had severe cognitive impairment and received a therapeutic diet. R46's Internal Medicine progress note dated 9/21/16, identified R46 had been seen by the physician for, Followup on her sodium, as she, Does have [MEDICAL CONDITION] (low sodium levels). R46's attached laboratory results identified her sodium level to be 138 mm/L (millimoles per liter) which is toward the low end of the identified reference range (136-146 mmol/L). R46's signed physician orders [REDACTED]. During observation on 10/20/16, at 12:06 p.m. R46 was seated in her recliner chair in her room. R46 had a small bedside table to her left side which had a blue water mug sitting on top. R46 stated the staff, Bring a new one in the morning and at night, for her to drink. The water mug was picked up by the surveyor and was approximately 50% full. R46 stated she drank some water already that day adding, I should drink more than I do. Further, R46 stated she did not think she was on any fluid restriction from the physician. On 10/20/16, at 12:11 p.m. nursing assistant (NA)-C observed the blue water mug on R46's bedside table and stated she should not have one given to her because she was on a fluid restriction. When interviewed on 10/20/16, at 2:46 p.m. registered nurse (RN)-B stated R46 was on a, 1500 cc fluid restriction, for her low sodium levels. R46's Medication Administration Record [REDACTED]1500 ml (milliliters), being identified. The form had each day of the month with times written to cover a 24 hour period including a, 24h (24 hour) total, row at the bottom. However, R46 had only three entries completed on the flowsheet which identified she had consumed 60, 100 and 180 cc's of fluid on three separate days. The remainder of the flowsheet was left blank, and no 24 hour totals were identified. During interview on 10/20/16, at 2:57 p.m. the certified dietary manager (CDM)-A stated dietary was responsible to record the fluid consumed at meals for residents, however not for the fluids consumed in the room or outside of meal times, My understanding was that it was nursing (responsible). Further, CDM-A stated nursing should be tracking and totaling all of R46's fluids in a 24 hour period to ensure she did not breach her ordered restriction. \ When interviewed on 10/20/16, at 3:29 p.m. RN-B stated R46's fluid restriction was not being monitored consistently, There is some lacking documentation. RN-B stated the night shift nurse should be totaling the fluids consumed and recording it on the flowsheet to ensure R46's fluid restriction was not breached and help, Keep her sodium levels regular. R44's quarterly Minimum Data Set ((MDS) dated [DATE], identified R44 had intact cognition and received a therapeutic diet. R44's Inpatient Discharge Summary dated 6/3/16, identified R44 had been hospitalized for [REDACTED]. R44's care plan dated 6/6/16, identified R44 had a, Potential nutritional problem and directed staff to, Provide, serve diet as ordered . 2000 cc fluid restriction present. Further, the care plan directed staff, Offer snack and fluid b/w (between) meals per coffee socials, snack carts, water pitcher at bed side and with med pass. R44's physician order [REDACTED]. R44's progress notes dated 10/14/16, identified R44 had a weight gain which, Appears to be r/t increased fluid balance. Further, the note identified this concern had been, Discussed with nursing and orders were in place, To monitor fluid balance. During observation on 10/20/16, at 10:54 a.m. R44 was seated in her room next to her bedside table. R44 had a 1/2 full cup of coffee and a blue colored water mug on her bedside table which was approximately 50% full. When interviewed on 10/20/16, at 10:55 a.m. nursing assistant (NA)-C stated R44 was, Independent with eating and drinking and was currently on a fluid restriction so staff don't, Put anything in her room, for her to drink. NA-C observed R44's bedside table with a water mug and cup of coffee and stated she, Didn't notice it before the surveyor had pointed it out adding the previous shift, Probably overlooked that. NA-C stated was not supposed to have a water mug in her room. Further, NA-C stated the nursing staff was responsible to record meal intakes for R44, but Dietary was responsible to record her fluid intake for meals. R44's untitled dietary flowsheets dated 10/6/16, through 10/19/16, identified R61's name and three separate columns to record each of the three meal's fluid intakes. R44's meal fluid intake ranged from a total of 250 ml to 1130 ml of according to the flowsheets, however there was no recorded information to identify the amount of fluids consumed from the bedside containers. During interview on 10/20/16, at 11:01 a.m. licensed practical nurse (LPN)-C stated she was unaware R44 had current orders for a fluid restriction. LPN-C stated R44 had, Really bad [MEDICAL CONDITION] (swelling of the legs caused by fluid) and were, Weeping really bad, when R44 first admitted to the nursing home adding R44 had current orders for [MEDICATION NAME] (a diuretic medication). LPN-C stated nursing staff was not tracking any of R44's consumed fluids, including the water and fluids provided at her bedside, to ensure she did not breach her restriction adding, It would have been nice to know. When interviewed on 10/20/16, at 11:08 a.m. registered nurse (RN)-B stated R44 had been on a fluid restriction since coming from the hospital for an exacerbation of her heart failure in June 2016 adding staff, Are supposed to monitor their fluid intake. RN-B stated nursing staff should have placed a tracking sheet in R44's Medication Administration Record [REDACTED] to ensure fluid restrictions were not breached. Further, RN-B stated R44 should not have bedside water mugs placed in her room and nursing should have been tracking her total fluid intake, So that we don't exacerbate their current medical conditions. R44's Medication Administration Record [REDACTED]. When interviewed on 10/20/16, at 3:50 p.m. the director of nursing (DON) stated she was aware fluid restrictions weren't being monitored adding, They (staff) have nobody right now, who is responsible to ensure it was completed. Further, the DON stated the dietary and nursing staff should be coordinating to ensure all fluid intake was monitored, There's not a system in place at the current time to do that. A facility policy on fluid monitoring was requested, but none was provided. LACK OF PROPER WHEELCHAIR POSITIONING: R44's quarterly Minimum Data Set ((MDS) dated [DATE], identified R44 had intact cognition and used a wheelchair for mobility. During observation on 10/17/16, at 2:30 p.m. R44 was seated in her room in a standard wheelchair. Her buttocks was positioned towards the front of the seat portion of the chair causing her to lean back with her head on the left handle. R44 had a one-half circle shaped cushion placed behind her in the chair, however her buttocks was seated so far forward it caused her back to not contact the cushion while seated in the chair. During additional observation on 10/19/16, at 10:18 a.m. R44 was seated in her room in the same standard sized wheelchair. R44 continued to have her buttocks positioned toward the front of the cushion and her head resting on the left handle of the wheelchair causing her to appear reclined in the standard wheelchair. On 10/19/16, at 10:21 a.m. nursing assistant (NA)-A observed R44 seated in her standard wheelchair with the surveyor. NA-C stated R44 appeared, A little uncomfortable in her wheelchair adding her head appeared, Kinda tilted back, and, Was not upright. NA-A she had noticed R44 to have poor positioning in her wheelchair before even being seen to, Sleep in the dining room like that. NA-A stated she had not reported these positioning concerns to nurses as, They see just as much as I would. Further, NA-A stated she was unaware if therapy had ever worked with R44 on her wheelchair positioning. On 10/19/16, at 10:47 a.m. registered nurse (RN)-B observed R44 seated in her standard wheelchair and stated she, Doesn't look like she's very comfortably positioned. RN-B stated occupational therapy (OT) had worked with R44 for wheelchair positioning in the past, however was not currently seeing her for any positioning concerns. Further, RN-B stated R44 should be seated upright in the wheelchair for her comfort and to reduce her risk of skin breakdown, Those are the main things we look for. R44's Occupational Therapy Plan of Care dated 7/17/15, identified R44 had, Difficulty with positioning in w/c (wheelchair) which puts her at risk of falling, and listed a goal of, Will sit symmetrically in wheelchair and have reduced skin breakdown/pressure areas and falls . Further, R44's Therapist Progress & Updated Plan of Care dated 8/13/15, identified R44 required, Contact guard assist to sit symmetrically in wheelchair in order to safely sit upright with hips back in w/c. During subsequent interview on 10/19/16, at 12:29 p.m. RN-B stated R44 had not been referred to OT since October 2015, for her wheelchair positioning because staff had not reported it as a concern. RN-B stated she expected staff to report observed positioning concerns to her so she could of, Requested an order for [REDACTED].>The OT responsible for R44's care was not available for interview during the survey. A facility wheelchair positioning policy was requested, but none was provided.

Based on observation, interview, and document review, the facility failed to ensure resident falls were comprehensively assessed and interventions implemented to prevent falls for 4 of 5 residents (R32, R48, R11 and R66) reviewed with falls. The facility failed to investigate and comprehensively assess resident falls to determine if new interventions could be implemented, nor did the facility assure the interventions were currently in place or were consistently implemented in preventing falls which resulted in multiple fractures for R32 and a significant head injury for R48. The facility's failure resulted in an immediate jeopardy, with serous harm and injury for R32 and R48. In addition to the residents in immediate jeopardy, the facility failed to comprehensively assess falls resulting in potential for harm that that was not immediate jeopardy for 2 out of 5 residents (R11 and R66) in the sample with falls. The immediate jeopardy was identified on 12/19/13 when the facility failed to comprehensively assess and implement interventions to prevent ongoing falls. The administrator, director of nursing, corporate nurse, and executive director were notified of the immediate jeopardy (IJ) for R32 and R48 on 12/19/13, at 6:00 p.m. The immediacy was removed on 12/20/13, at 2:00 p.m. but noncompliance remained at an isolated scope and severity level, of actual harm that was not immediate jeopardy. Findings include: R32 had 23 falls in the past 10 months, with significant fractures. The facility had not compressively assessed, or implemented consistent interventions to decrease the risk of falls for R32, which resulted in an immediately jeopardy. R32 quarterly Minimum Data Set ((MDS) dated [DATE] identified R32 had moderate cognitive impairment, required extensive assistance with activities of daily living (ADL's) except eating, and was frequently incontinent of bladder. R32 was currently in an assessment period and the facility provided the Care Area Assessment (CAA) related to falls dated 12/12/13 which indicated "Resident at high risk for falls due to history of multiple falls, incontinence, impaired decision making, inability to identify safety concerns, orthostatic blood pressure changes, and Parkinson's disease with shuffling gait and poor trunk control. Resident does have 'good days' and 'bad days.' At times resident will lean significantly in her wheelchair due to poor trunk control and she does have a positioning cushion in her wheelchair. Resident does have anti rollback device on wheelchair. Alarms and safety concerns have been discussed with family at length and negotiated risk is in place. Family wishes to have no limitations on residents mobility and would like her to be allowed to freely move in her wheelchair and do not want resident to feel restricted in any way. Family does understand consequences of resident falls." R32's care plan dated 10/29/13 indicated resident "is at risk for falls related to history of Parkinson's with behavioral disturbance, poor safety decisions, and need for assist with ADL's and toileting. Had fall on 5/1/13 with right hip fracture and pelvic ring fracture...pelvic fracture 9/20/13 due to fall 9/17/13." The facility interventions were "Anti-rollback mechanism to wheelchair to prevent any falls... has asked not to offered toileting more than upon rise, HS (hour sleep), before meals, and with staff assisted repositioning to prevent falls... family is opposed to TABS alarm placement for fall notification... room close to nursing station to facilitate more frequent monitoring for self transfers... non-slip product on top of wheelchair cushion to prevent sliding out of wheelchair, remove wheelchair pedals when not being propelled by staff... would like phone placed on bed after bed is made in morning to ease access... ensure remote is within her reach when in her room..." The current nursing assistant (NA) worksheet dated 12/17/13 which the facility identified the NA use to provide care to R32 instructed staff to "assist resident to lie down when displaying poor posture and between meals... fall prevention: If walking independently provide gentle cues. Do not force to sit in wheelchair. If in room alone assure over bed table over legs, use side cushion when leaning. Reposition every 2-3 hours." The facility provided a Negotiated Risk Agreement signed by R32's family on 10/3/13. The agreement indicated the following, "The purpose of this negotiated risk agreement is to describe residents choice with respect to the following issue: Walking independently with the use of a wheel walker, or pushing her wheelchair which parties acknowledge is a valid exercise of his/ her resident rights. The negotiated risk agreement will identify the residents choice, outline the risks and possible consequences of residents choice, identify alternatives offered to decrease risk, and then describe the final agreement between the parties. Risks: Consequences include: falling, falling may result in injury up to and including death. Final agreement between the parties evidencing resident final choice following a discussion of the risks and the plan of action to decrease risk is as follows: staff will give verbal cues on safety when witnessing a potential risk and may shadow (R32) to ensure safety while not encroaching on (R32) comfort or right to ambulate." During observation on 12/17/13 at 11:22 a.m. R32 was sitting in her wheelchair in her room. The call light was on the floor behind the resident, the bedside table was sitting next to the resident, and the phone was on the nightstand. R32 was leaning over trying to pick up Kleenex that was on the floor. The wheelchair rolled back slightly each time the resident leaned forward in an attempt to pick up the Kleenex on the floor. The surveyor requested assistance from nursing assistant (NA)-B. During interview on 12/17/13 at 11:34 a.m. NA-B stated R32 will use her call light "sometimes". She stated if staff places her bedside table in front of her with all of the supply's, she will generally not move around the room in her wheelchair. NA-B verified R32's room was not set up according to the care plan, with the bedside table in front of the resident to prevent falls. During observation on 12/18/13 at 10:20 a.m. R32 was sitting in her wheelchair in her room. The bedside table was sitting against the wall with the telephone on it and the call light was wrapped around the grab bar on her bed, both were about 4-5 feet away from R32, and she was unable to reach these items. R32 was sitting on a wheelchair cushion, however, there were no anti slip pad observed on the wheel chair cushion. During interview on 12/18/13 at 10:25 a.m. R32 stated she needed to turn the call light on when she has to use the bathroom but sometimes she is unable to get to her call light so she just goes to the bathroom by herself. During interview on 12/18/13 at 10:36 a.m. director of nursing (DON) verified R32 should have her bedside table placed in front of her with the telephone, newspaper, remote control, and call light within reach. The DON stated R32 does not always use her call light when she needs to go to the bathroom. As the DON was leaving R32's room, the resident stated, "Can you please help me to the bathroom before you leave?" During observation on 12/18/13 at 1:15 p.m. R32 was observed sitting in her wheelchair in her room. The call light was pinned to the bed behind her approximately two feet, the newspaper was on the bed and the phone was under the newspaper. The remote control was on the bed and there was hockey on the television. There was no anti slip mat observed on R32's wheelchair cushion as instructed in the care plan. During interview on 12/18/13 at 1:20 p.m. MDS nurse verified R32 was suppose to have the call light available as well as the remote control, newspaper, and phone; and they were currently all out of reach. MDS nurse stated the anti slip mat was under the wheelchair cushion and it was not visible. MDS nurse was not aware the plan of care indicated R32 was to have a anti slip mat on top of the wheelchair cushion to prevent the resident from slipping out of the wheel chair. During observation on 12/19/13 at 8:50 a.m. R32 was in her room sitting in her wheelchair sleeping. The bedside table was behind her wheelchair with the remote control on it. The call light was wrapped around the grab bar on the bed which was about four feet behind the resident. During observation on 12/19/13 at 11:20 a.m. R32 was in her room sitting in her wheelchair sleeping. The bedside table was behind her wheelchair with the remote control on it. The call light was pinned to the bed, approximately 3-4 feet away from the resident. Record review identified R32 had 23 falls from February 2013- December 2013. The facility provided for each fall a Resident Incident Report, Progress Notes, and a word document untitled which the facility stated was a "summary" of each fall. The falls were reviewed as follows: 2/5/13- 11:30 a.m. "Resident was found on the floor of her room on her hands and knees near the bathroom door. Resident stated that she was trying to fill her pop bottle with water in the bathroom. Resident was not incontinent at time of fall and her pad was dry. Resident had been assisted to the bathroom between 10:00-10:30 a.m. which is appropriate per her care plan. Again, family does not want to add any fall interventions which would restrict resident in any way from getting up on her own." During interview on 12/17/13 at 11:00 a.m. DON stated no new interventions were put into place after the fall on 2/5/13 because R32 had refused her Parkinson's medications and the facility felt the fall was related to not taking her medications. 2/8/13- 12:00 p.m. "Resident was found on floor of her room sitting against the closet. Resident stated she was trying to walk over to her roommate to talk with her about something. Residents roommate not in the room at the time of fall... Resident was not incontinent at time of fall and her pad was dry... Again, family does not want to add any fall interventions which would restrict resident in any way from getting up on her own." During interview on 12/17/13 at 11:00 a.m. DON stated no new interventions were put into place after the fall on 2/8/13 because R32 had refused her Parkinson's medications and the facility felt the fall was related to not taking her medications. 2/15/13- 4:00 p.m. "Resident was found in her room sitting next to her bed. Wheelchair was also near the resident and it appeared that the resident had been in her wheelchair and was attempting to self transfer out of wheelchair when she fell ... Resident was not incontinent at time of fall and denied need to use toilet... Family again deny use of any devices that would restrict (R32) from getting up on her own." 2/15/13- 10:00 p.m. "Resident was found on floor of her room by staff. Fall was unwitnessed, It appeared that resident attempting to self transfer from her wheelchair... Staff toileted resident approximately one hour prior... Again, family does not want further interventions to restrict resident from self transferring even with risks explained." During interview on 12/17/13 at 11:00 a.m. DON stated no new interventions were put into place after the fall on 2/15/13 because R32 had refused her Parkinson's medications and the facility felt the fall was related to not taking her medications. 2/18/13- 3:15 p.m. "In review of video, appeared resident grabbed rail in hallway and was sliding out of her wheelchair, attempted to stand, wheelchair slid out from behind her and resident fell to the floor... No cushion or Dysum (anti slip mat) ..." The intervention listed was, "Make sure anti slip product and cushion are in wheelchair at all times." During interview on 12/17/13 at 11:00 a.m. DON stated the intervention to add the cushion in R32's wheelchair and the Dysum were initiated on 2/18/13. DON verified R32's plan of care indicated the Dysum was dated on 2/12/13 as the start date, however, DON was not able to identify where that start date came from. 3/4/13- 9:20 p.m. "Resident was found on the floor of her room next to her closet. It appeared that resident had been in her wheelchair previously and slid out of wheelchair as wheelchair found directly behind resident. Resident was last toileted at 2:30 p.m.... Staff did place nonskid pad in residents wheelchair to prevent her from sliding out of wheelchair in the future." Included in the Incident investigation was the resident was wet at the time of the fall and the resident had been offered assistance with toileting at 4:00 p.m. and 7:00 p.m. but the resident had refused. During interview on 12/17/13 at 11:00 a.m. DON stated the intervention was to place a Dysum non slip pad to the residents wheelchair. DON verified this was the intervention put into place after the prior fall on 2/18/13. DON stated there was no further investigation as to why the Dysum was not in R32's wheelchair according to the plan of care. 3/13/13- 3:15 p.m. "Resident was found in her room on her hands and knees. She stated she gently slipped off her wheelchair and fell to her knees when she was trying to pick something up..." There was no indication if the anti slip cushion or Dysum was in the wheelchair. The summary of the fall indicated, "On 3/14/13 (Nurse Practitioner) was here for rounds and ordered a chest X-ray and various other orders due to increased confusion and decreased breath sounds." Review of the chest X-ray dated 3/14/13 indicated R32 was found to have "fracture of the left second through sixth ribs." Handwritten on the bottom of the X-ray by a (unknown) facility nurse was on 3/14/13 a message was left with R32's physician and NP, and on 3/15/13 a copy of the results were faxed to R32's physician and NP. However, there was no follow up note from the NP or physician, nor was there any assessment or investigation as to how R32 received four fractured ribs on the left side. During interview on 12/17/13 at 11:00 a.m. DON stated after the fall on 3/13/13 the NP saw R32 and ordered a chest X-ray related to decreased breath sounds. She stated the chest X-ray revealed R32 had 4 broken ribs, however, the facility had no investigation or communication with the NP or the physician regarding R32's broken ribs. DON stated R32 was diagnosed with [REDACTED]. No new specific fall interventions were implemented at this time. There was no indication that an assessment was completed to determine how R32 fractured her ribs, or if they were related to her multiple falls. 3/15/13- 7:10 p.m. "Resident was found by staff on the floor in her room. It appeared that resident had gotten up and was ambulating independently...Residents (family) does continue to want negotiated risk in place and would like resident to freely get up unassisted." During interview on 12/17/13 at 11:00 a.m. DON stated after the fall on 3/15/13 the facility completed a 3 day bowel and bladder diary and assessment. DON stated there was no pattern of voiding noted so the residents toileting schedule was to toileted every 3 hours and as requested by the resident. 3/18/13- 5:00 p.m.- "Resident was found lying on her left side on the floor of her room...Last time toileted was 'after lunch.' Resident was dry at time of fall." During interview on 12/17/13 at 11:00 a.m. DON stated she was not sure the specific time R32 had last been toileted before the fall on 3/18/13 as this was not part of the initial incident report investigation. DON verified no new interventions were implemented after the fall on 3/18/13. 3/27/13- 7:50 p.m. "Resident was found in her room, lying on her left side next to her wheelchair. Stated she put her newspapers on the floor, then knelt on the floor to pick them up and decided to lie down on the floor..." The investigation also indicated the residents phone was on the floor. The interventions put into place were, "Assess for proper placement of items resident may need; make sure they are within reach." During interview on 12/17/13 at 11:00 a.m. DON stated on 3/27/13 the facility nurses observed R32's room to ensure the "room setup" was appropriate for the resident. DON verified that included ensuring the residents call light is within reach, the tray table be placed in front of R32 with telephone, newspaper, pop/water, and remote control for the television on the table and within the residents reach. 3/29/13- 6:30 a.m. "Resident was found sitting with legs in bathroom and sitting with her bottom on the carpet in her room. Resident stated she was coming out of the bathroom and 'I sat down.'..Resident has it care planned and signed negotiated risk that no alarms or anything that would restrict her being able to move be in place." During interview on 12/17/13 at 11:00 a.m. DON stated no specific fall interventions were implemented after the fall on 3/29/13 because the resident had been refusing her Parkinson medications 2 days prior to the fall. 3/31/13- 3:45 p.m. "Resident was found sitting on the floor in her room next to her wheelchair and over-turned tray table... Assessed room for placement of items resident may be reaching for, rearranged appropriately." During interview on 12/17/13 at 11:00 a.m. DON stated she did not know what the resident was attempting to do nor was she sure how the residents room was arranged prior to the fall as this wasn't part of the assessment. The DON stated there were no specific fall interventions put in place after the fall on 3/31/13 because she thought the resident had been refusing some of her Parkinson's medications prior to the fall. The DON stated education was done with staff to ensure R32's call light was within reach, however, she was unable to verify why this education was completed as she was not sure if the resident had her call light near her at the time of her fall. 4/22/13- 6:30 p.m. "Resident was found by staff on the floor in her room. Resident was unable to describe what she was trying to do prior to falling. Resident was sitting with her back leaning up against the door to her room, her wheelchair was next to her in the upright position...last toileted prior to supper, 4:30 p.m., and was incontinent of bladder at time of fall. Have discussed use of alarms or interventions for falls with daughter, continues to wish to not have anything in place that could limit residents ability to transfer or move when she wishes to." During interview on 12/17/13 at 11:00 a.m. DON stated resident had been refusing medications prior to fall. She stated there was no further investigation or interventions implemented after the fall on 4/22/13. 5/1/13- 6:45 a.m. "Resident was found lying on her right side, up against the closet. Resident was unable to report what occurred or what she was trying to do prior to fall... last toileted at 5:30 a.m. and was continent at time of fall... Resident complained of right hip pain." The facility contacted the physician to obtain an X-ray which displayed a hip fracture and pelvis displacement. R32 was transferred to the hospital for surgery and returned on 5/4/13. The facility intervention after this fall was "assure resident is set up with appropriate items she may need (snack, magazine, etc.)." The X-ray results dated 5/1/13 identified R32 had a "right intertrochanteric hip fracture with up to roughly 6 mm (millimeters) of displacement... Fractures of the right superior and inferior pubic rami are again noted. There is increased displacement compared to prior exam. An associated sacral ala fracture is suspected but not identified with certainty." During interview on 12/17/13 at 11:00 a.m. DON stated the intervention was to make sure staff kept the residents 'items' within reach. DON stated the investigation did not include where items were placed in the residents room when she fell on [DATE]. There was no indication the facility had comprehensively assessed R32 multiple falls from her wheel chair while she was in her room alone and implement appropriate interventions to decrease R32 risk of falls. 5/22/13- 4:40 p.m. "Staff found resident lying on floor in her room on her right side...Resident had been repositioned by staff multiple times due to leaning in her wheelchair... NA staff member recognized resident was leaning forward in her wheelchair. The staff member repositioned her to a safe position, and then went to get assistance. When staff returned she was laying on the floor... When resident is displaying poor posture, staff are to assist her to bed." During interview on 12/17/13 at 11:00 a.m. DON stated the resident had refused her Parkinson's medications on 5/21/13, and staff was instructed to lay resident down in bed if she was leaning in her wheelchair. 6/1/13- 11:00 a.m. "Resident was found by staff sitting on her bottom near the bathroom, leaning on her elbows. Resident attempted to self-transfer and stated she slid very slowly to the floor...Resident was last toileted at 9:00 a.m., and was incontinent at time of fall... Resident is to be offered toileting every hour, re-education was provided to NA." The investigation did not identify where the resident slid from and if the anti slip cushion was in the residents wheelchair. During interview on 12/17/13 at 11:00 a.m. DON stated the resident refused her Parkinson's medications on 6/1/13. DON stated she was not sure if the residents anti slip Dysum was on her wheelchair cushion as that was not part of the fall investigation. 6/16/13- 5:15 p.m. "Resident was ground lying on her right side with legs bent to her chest. Was attempting to reach for something when she slid out of her wheelchair. Resident stated she was going to throw a piece of paper away and slid out of wheelchair. Was complaining of severe pain from left hip to upper right side of her body... ambulance was called... no fractures or other injuries. Educated family on use of anti-roll back brakes for the wheelchair which were applied at this time." During interview on 12/17/13 at 11:00 a.m. DON stated anti lock brakes were added to R32's wheelchair after the fall on 6/16/13. DON stated she was not sure if the anti slip Dysum was in the residents chair as this was not part of the fall investigation. 8/18/13- 4:15 p.m. "Resident was found on the floor of her room by NA. Resident stated she gently lowered herself to the floor. Staff reports from that shift resident was leaning significantly through the shift. Staff approached resident multiple times to let down, but resident kept declining..." During interview on 12/17/13 at 11:00 a.m. DON stated resident was educated to lay down while leaning in wheelchair. 8/25/13- 2:10 p.m. "Resident was found lying on the floor of her room after staff responded to her yelling 'help me!' When staff asked what she was doing she stated 'reaching to turn the stove off.' It appeared as if resident was previously in her wheelchair. Residents water pitcher noted to be on the ground and carpet was wet from water pitcher... discussed need for PT (physical therapy) or OT (occupational therapy) evaluation. Previous interventions continue from last evaluations which include anti roll back brakes. Family did not want to continue with staff approaching resident every hour to offer toileting as this was making resident more anxious and confused. At this time therapy evaluation not felt to be appropriate." During interview on 12/17/13 at 11:00 a.m. DON stated she was unsure when the intervention for R32 to be toileted every hour was put into place. However, she stated the resident and her family requested staff to not ask resident "so often" to go to the bathroom as the resident didn't like to be bothered that often. DON stated she thought at this time R32's toileting plan was changed to upon waking, before and after meals, and before bed. DON also stated she was unsure if the resident had fallen out of her bed or out of her wheelchair. 9/17/13- 4:40 p.m. "Resident was found on the floor by the NA. She was lying on her back and grasping her left hip. groin area and expressing severe pain...ambulance was contacted and resident was transported to the St. Cloud hospital. Prior to her fall activity staff had reported that she found resident standing in her room. She entered the room and had resident sit back in her wheelchair, and asked if there was something the resident needed. Resident pointed and stated, 'I need that over there,' though nothing was noted to be present...When found on the floor nurse asked what she was trying to do and resident stated she was trying to 'get out of here.' Resident had been asked at 4:00 p.m. if she needed to toilet but resident refused. Family had requested that no alarms be placed on resident as to not limit her mobility. Resident has anti-roll back brakes applied to her wheelchair, toileting plan in place and followed correctly." Resident returned to the facility from the hospital on [DATE]. Review of a Trauma Admission note dated 9/17/13 indicated R32 had a pelvis X-Ray which identified "evidence of old right hip fractures with new (acute) fractures of the left inferior pubic ramus and parasymphyseal region of the left pubic bone." R32 was admitted to the hospital. During interview on 12/17/13 at 11:00 a.m. DON stated the facility did not put new interventions in place after the fall with fracture on 9/17/13, nor did the facility investigate the fall to ensure the room was set up according to R32's care plan. There was no indication the facility had comprehensively assessed R32 multiple falls from her wheel chair while in her room and implement interventions to decrease R32 risk of falls. 11/9/13- 8:05 p.m. "Resident was found on the floor by NA sitting on the floor. Resident was sitting in front of her wheelchair...Resident was not incontinent at time of fall, but did void post fall. Staff did see resident ambulating in her room independently previously during the shift and did intercept resident. Staff did question if resident had slipped out of her wheelchair due to proximity of wheelchair behind the resident. Dycem non slip material placed in residents wheelchair post fall." During interview on 12/17/13 at 11:00 a.m. the DON stated the Dycem non slip material which was ordered on [DATE] was never discontinued, and she was unsure it was not in the residents wheelchair on 11/9/13. DON verified staff were not following R32's care plan to prevent falls if the Dycem was not in place. 11/27/13- 2:00 p.m. "NA found resident on floor between her nightstand and table in her room with back against the wall. Resident stated she was just walking around... had been toileted 30 minutes prior to the fall..." During interview on 12/17/13 at 11:00 a.m. DON stated no new interventions were implemented after the fall on 11/27/13 nor was the residents room set up included as part of the fall investigation. 12/6/13- 9:00 p.m. "Resident was found by NA on the floor of her bathroom... resident was not incontinent at time of fall and staff did assist resident to the toilet and she did void post fall. Resident had been approached by staff multiple times after supper to use the toilet and she declined each time." This information was listed on the summary of the fall, however, the actual investigation did not identify when the resident was last toileted. During interview on 12/17/13 at 11:00 a.m. DON stated R32's plan of care on 12/6/13 was to assist the resident to the bathroom every 2 hours, however, she was unaware when this toileting plan was implemented and when it was discontinued. DON stated R32 was also reminded to use the call light when she needed assistance. DON stated R32 was "sometimes" able to use her call light but was "inconsistent" with the use. The DON also verified none of the incident reports or the fall investigations include if the residents call light was on or within reach, and the resident will often propel herself in her wheelchair around her room, so her call light is often not near her. The DON stated the facility had never talked about providing R32 with a pendent call light (one that could be worn around her neck), although the facility had the pendent call light system and several other residents in the facility were currently utilizing the pendent call light system. The DON stated staff needed to be more "aware" of R32 and the facility had talked about doing hourly rounds to ensure all residents safety, but this was not implemented for R32. The DON stated R32 had been seen by both PT and OT "off and on" for strengthening the last year. During interview on 12/17/13 at 2:15 p.m. R32's FM-I stated she was aware of the residents frequent falls and visits the resident often. R32's call light is often in different places and not within R32's reach. However, FM-I stated she wasn't sure the resident would always be cognitive enough to use the call light when she needed assistance. During interview on 12/18/13 at 1:10 p.m. physical therapist (PT)-H stated he had last worked with R32 towards the end of October 2013 for safe transferring. PT-H stated at that time it was recommended staff no longer walk R32 related to her instability and varying degrees of weakness from day to day. During interview on 12/18/13 at 1:05 p.m. NA-D stated R32 was to be toileted every 2 hours. NA-D stated R32 was supposed to have her bedside table in front of her with her remote control, phone, newspaper, and call light on. She stated the resident roams around her room so she often can not get to her call light when she needs it. During interview on 12/19/13 at 9:08 a.m. the occupational therapist (OT)-D stated she had worked with R32 on and off since May 2013. The OT-D stated in May 2013 she recommended staff toilet resident every hour because it appeared many falls were near the bathroom in the residents room. OT-D stated staff told her that family and R32 did not want the hour toileting because staff was "pestering" her to often. OT stated she then recommended to staff they should be doing at least hourly checks to ensure the resident was safe and had everything she needed. She was unsure if and when the one hour checks were implemented by the facility. OT-D stated she had anti lock brakes added to the residents wheelchair, but was not aware the resident had been sliding out of the wheelchair so R32's wheelchair cushion had never been reevaluated. OT-D verified if she was aware R32 had been slipping out of the wheelchair there are other cushions that could have been tried which may have prevented the resident from sliding out of the wheelchair. During interview on 12/19/13 at 9:50 a.m. nurse consultant (NC)-C stated although the investigation documentation may not be complete, R32's falls were fully investigated. NC-C verified the facility provided all the documentation they had available related to R32's falls. Even though R32 had 23 falls in the past 10 months, with some of the falls resulting in significant fractures which required hospitalization . The facility had not compressively assessed, or implemented consistent interventions to decrease the risk of falls for R32. R48 had six falls, from 10/7 thru 11/24/13, in which she sustained multiple head injuries with significant changes in her vital signs and neurological exam. The facility did not comprehensively assess her falls and consistently implement interventions to decrease her risk for falls, which resulted in an immediate jeopardy for R48. R48's admission Minimum Data Set ((MDS) dated [DATE], included [DIAGNOSES REDACTED]. The MDS indicated R48 had severe cognitive impairment, required extensive assistance for all activities of daily living (ADL's), and had fallen prior to admission. The fall Care Area Assessment (CAA) dated 10/16/13, included R48 was at risk for falls related to poor balance and cognitive deficit, care planning would occur due to these risks. R48's Fall Risk assessment dated [DATE], identified risk factors for falls, including use of antihypertensives medication, a blood pressure was included of 166/67, howeve