Every finding on record at The Estates at Excelsior LLC

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice, including failure to document clinical indications for medications, failure to monitor medications as ordered (including failure to monitor heart rate parameters prior to medication administration), and failure to ensure PRN psychotropic medications had appropriate stop dates, for 5 of 6 residents (R2, R5, R6, R16, and R26) reviewed for unnecessary medications.Findings include: R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had intact cognition and required assistance with activities of daily living (ADLs). R2's diagnoses included heart failure (a condition where the heart cannot pump blood effectively), hypertension (high blood pressure), end-stage renal disease [ESRD] (advanced kidney failure requiring dialysis or transplant), anxiety disorder (a condition involving excessive worry or fear), depression (persistent sadness or loss of interest), and unspecified atrial fibrillation (an irregular and often rapid heart rhythm). Review of R2's electronic medical record (EMR) identified medications were administered without documented medical diagnoses or clinical indications to support their use, including: Calcitriol (medication used to treat low calcium levels and/or hypoparathyroidism) Oral Capsule 0.25 mcg, give 0.25 mcg by mouth one time a day, start date 03/25/2025. Gabapentin (medication used to treat certain seizure disorders and/or nerve pain) Oral Capsule 300 mg, give 1 capsule by mouth at bedtime, start date 12/04/2024. Further review of physician orders, progress notes, and care plans lacked documentation identifying the conditions being treated for these medications. R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had mild cognitive impairment and was independent with activities of daily living (ADLs). Diagnoses included cardiomegaly (enlarged heart), atrial fibrillation (rapid, irregular heartbeat), hypertension (high blood pressure), congestive heart failure (chronic condition where heart muscle too weak or stiff to pump blood efficiently), chronic kidney disease, anxiety, delusional disorder, and dementia. R5's order summary report printed 3/2/26, included order for metoprolol tartrate 75 mg by mouth twice daily, hold for SBP less than100 or heart rate less than 55. Review of R5's medication administration records for January, February and March 2026, failed to indicate R5's heart rate was monitored and recorded for R5's metoprolol. When interviewed on 4/6/26, at 11:15 a.m. registered nurse (RN)-C stated R5 had parameters to check blood pressure for each done of the metoprolol, but heart rate was not being monitored. RN-C reviewed R5's electronic medical record (EMR) stated the order did have a parameter to hold the medication if the heart rate was less than 55, however they were not monitoring R5's heart rate. When interviewed on 4/7/26, at 2:05 p.m. director of nursing (DON) stated when a resident had parameters for medication administration the expectation was the nurses would check and record the blood pressure and/or heart rate as ordered, if the medication was held due to the blood pressure or heart rate the expectation was to document in a progress note the medication was held an reason. Following the parameters was important for resident safety. R6's significant change MDS dated [DATE], identified R6 had intact cognition and required assistance with ADLs. R6's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), hypertension (high blood pressure), anxiety disorder (a condition involving excessive worry or fear), depression (persistent sadness or loss of interest), and seizure disorder (a condition causing recurrent seizures). Review of R6's EMR identified physician's orders for the following PRN psychotropic medications without a 14-day end date or documented stop date: Haloperidol (antipsychotic used to treat schizophrenia, acute psychosis, Tourette syndrome, and severe behavioral problems) Oral Tablet 0.5 mg, give 1 tablet sublingually every 1 hour as needed for agitation or moderate nausea; start date 01/21/2026. Lorazepam (used for short-term anxiety relief, anxiety-related insomnia, and status epilepticus) Oral Tablet 0.5 mg, give 1 tablet by mouth every 2 hours as needed for anxiety or sleep; start date 01/21/2026. Further review of R6's physician orders, progress notes, and medication records lacked evidence these medications were time-limited or included a stop date. Review of R6's EMR also identified a physician's order for orthostatic blood pressures, initiated on 1/26/26; however, review of the treatment administration record (TAR) for February 2026 and March 2026, as well as nursing documentation, lacked evidence orthostatic blood pressures were consistently monitored and documented as ordered. R16's quarterly MDS dated [DATE], identified R16 had moderate cognitive impairment and required assistance with bathing and was independent with all other ADLs. R16's diagnoses included polyneuropathy (damage to multiple peripheral nerves causing weakness, numbness, or pain), hypertension (high blood pressure), anxiety disorder (a condition characterized by excessive worry or fear), schizophrenia (a chronic mental disorder affecting thinking, perception, and behavior), and adverse effect of unspecified antipsychotics and neuroleptics (negative side effects from medications used to treat mental health conditions). Review of R16's EMR identified a physician's order for orthostatic blood pressures, initiated on 10/25/24; however, review of the TAR for October 2025, February 2026, and March 2026, as well as nursing documentation, lacked evidence orthostatic blood pressures were consistently monitored and documented as ordered. R26's 5-day MDS dated [DATE], identified R26 had intact cognition and required assistance with ADLs. R26's diagnoses included heart failure (a condition where the heart cannot pump blood effectively), hypertension (high blood pressure), anxiety disorder (excessive worry or fear), depression (persistent sadness or loss of interest), and paroxysmal atrial fibrillation (an irregular heart rhythm that starts and stops suddenly). Review of R26's EMR identified medications were administered without documented medical diagnoses or clinical indications to support their use, including: Calcium Carbonate-Vitamin D (used to treat or prevent low calcium levels, supporting bone health, muscle function, and nerve health) Oral Tablet 600-5 mg-mcg, give 2 tablets by mouth in the morning, start date 08/06/2024. Diltiazem HCl ER (calcium channel blocker used to treat high blood pressure, chronic stable angina, and certain heart rhythm disorders) 240 mg capsule extended release, give 1 capsule by mouth in the morning, start date 07/25/2024. Fluticasone Propionate (corticosteroid nasal spray used to treat seasonal, perennial, and nonallergic rhinitis symptoms) Nasal Suspension 50 mcg/act, 1 spray in both nostrils in the morning, start date 07/13/2024. Folic Acid (used to treat anemia) Oral Tablet 1 mg, give 1 tablet by mouth in the morning, start date 07/13/2024. Montelukast Sodium (used to treat asthma, prevent exercise-induced bronchoconstriction, and relieve allergy symptoms) Oral Tablet 10 mg, give by mouth in the morning, start date 07/25/2024. Omega-3 Fatty Acids (used for heart and brain health, reducing inflammation, and lowering blood triglycerides) Oral Capsule 1000 mg, give by mouth in the morning, start date 07/13/2024. Further review of R26's physician orders, progress notes, and care plans lacked documentation identifying the conditions being treated for these medications. Review of R26's EMR also identified a physician's order for orthostatic blood pressures, initiated on 12/3/25; however, review of the TAR for December 2025, January 2026, February 2026, and March 2026, as well as nursing documentation, lacked evidence orthostatic blood pressures were consistently monitored and documented as ordered. During interview on 4/6/26 at 11:32 a.m., the registered nurse (RN)-A stated admission orders were entered upon admission and nursing staff were responsible for double-checking them. RN-A further stated nurses should clarify and add diagnoses or clinical indications if they were not present or were identified as missing. RN-A stated orthostatic blood pressures were completed if they were on the TAR and involved obtaining blood pressures with the resident lying, sitting, and standing, typically at 15-minute intervals. RN-A stated he was aware of residents ordered for orthostatic blood pressures, including R26 and R15. During interview on 4/6/26 at 11:48 a.m., the registered nurse case manager (RN)-B stated nursing staff were responsible for ensuring diagnoses or clinical indications were documented for each medication. RN-B stated that, while most medications typically had associated diagnoses, vitamins and supplements did not always have documented indications. RN-B further stated diagnoses or indications should be included so staff, including agency nurses, understood the reason a resident was receiving each medication. RN-B confirmed diagnoses or indications were not documented for the identified medications for R2 and R26. During interview on 04/06/2026 at 1:51 p.m., the registered nurse case manager (RN)-B stated orthostatic blood pressures were typically obtained when therapy (PT) completed their evaluation and might be monitored during the first week. RN-B stated she could not recall any residents currently requiring ongoing orthostatic monitoring and was not aware of any residents with active orthostatic blood pressure orders at that time. RN-B stated she would expect staff to obtain blood pressures in lying, sitting, and standing positions, if able, and report results. RN-B confirmed orthostatic blood pressures were not completed for R16. RN-B also stated PRN haloperidol and lorazepam were often used for hospice residents and were typically managed by hospice staff. RN-B confirmed R6's PRN lorazepam and PRN haloperidol orders did not include stop dates. During interview on 4/6/26 at 2:17 p.m., the director of nursing (DON) stated all medications should have a corresponding diagnosis documented so the person administering the medication understood the reason it was prescribed. The DON further stated orthostatic blood pressures should be completed when ordered by the physician and documented on the MAR/TAR, including measurements in lying, sitting, and standing positions. The DON stated this monitoring was important to assess for conditions such as dizziness or falls and confirmed that if ordered, orthostatic blood pressures must be completed and documented. The DON further stated if a resident was unable to tolerate any position, this should be documented in the medical record. The DON stated PRN psychotropic medications should include a 14-day limit or a clearly defined stop date unless clinically justified and documented. During interview on 4/7/26 at 11:02 a.m., the consultant pharmacist (CP) stated orthostatic blood pressures should be obtained on an ongoing basis, such as monthly, when indicated. The CP stated orthostatic measurements should include obtaining a blood pressure in one position (lying or sitting) and repeating the measurement in another position after 5–10 minutes. The CP further stated if a resident was unable to stand or complete any position, this should be documented. The CP indicated this monitoring was important to identify significant drops in blood pressure that could increase the risk for falls. The CP also stated PRN psychotropic medications should include a 14-day stop date, and if continued beyond 14 days, a new physician order with documented rationale should be obtained. The CP stated the provider should document justification if a stop date was not included and indicated lack of a stop date was not appropriate. The CP further stated for hospice residents, extended use may be appropriate if clinically justified and documented. The CP stated medications should have a documented diagnosis or clinical indication, as administration without a documented diagnosis would not support the reason for use. Review of the facility's Psychotropic Medication Use Policy, dated 5/25, identified psychotropic medications must be supported by a documented diagnosis and clinical indication in the medical record. The policy required ongoing monitoring for effectiveness and adverse consequences, including completion of ordered monitoring such as orthostatic blood pressures. The policy further required PRN psychotropic medications be limited to 14 days unless the physician documented a clinical rationale for continued use and specified duration. The policy also required documentation of non-pharmacological interventions, interdisciplinary involvement, and ongoing evaluation to ensure medications were necessary and appropriate. Facility police on following medication orders with parameters was requested, however none was provided.

Based on record review and interview, the facility failed to ensure a thorough post-fall assessment, including root cause analysis, was completed and appropriate interventions were implemented and reflected in the care plan following repeated falls, for 1 of 2 resident (R2) reviewed for accidents.Findings include:R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had intact cognition and required assistance with activities of daily living (ADLs). R2's diagnoses included nontraumatic subdural hemorrhage (bleeding between the brain and its outer covering not caused by injury), anemia (a condition with a decreased number of red blood cells, leading to fatigue and weakness), coronary artery disease (narrowing or blockage of the heart's blood vessels), heart failure (a condition where the heart cannot pump blood effectively), hypertension (high blood pressure), end-stage renal disease [ESRD] (advanced kidney failure requiring dialysis or transplant), diabetes mellitus (a condition affecting blood sugar regulation), cerebrovascular accident [CVA] (stroke; interruption of blood flow to the brain), traumatic brain injury [TBI] (damage to the brain caused by an external force), anxiety disorder (a condition involving excessive worry or fear), depression (persistent sadness or loss of interest), respiratory failure (a condition where the lungs cannot provide enough oxygen or remove carbon dioxide), unspecified atrial fibrillation (an irregular and often rapid heart rhythm), acute respiratory failure with hypoxia (sudden inability to get enough oxygen into the blood), hypoglycemia (low blood sugar), hypokalemia (low potassium levels in the blood), and cardiomyopathy (disease of the heart muscle that affects its ability to pump effectively).Review of R2's electronic medical record (EMR) identified R2 experienced four falls on 6/30/25, 10/14/25, 2/17/26, and 3/6/26.Review of the Incident Review and Analysis dated 6/30/25, identified R2 was found on the bathroom floor after yelling for assistance. Although contributing factors such as end-stage renal disease and muscle weakness were identified, the facility failed to select or implement any new interventions following the fall. Documentation reflected only existing measures, including the bed in a low position, call light within reach, and gripper socks. There was no evidence of a comprehensive root cause analysis or development of individualized interventions to address fall risk following this incident.Review of the Incident Review and Analysis, dated 10/14/25, identified contributing factors including muscle weakness, unlocked wheelchair brakes, and refusal to call for assistance. Although potential interventions such as auto-lock wheelchair brakes and use of a night light were identified, there was no evidence these interventions were implemented. The facility failed to address R2's known behavior of refusing assistance with individualized or alternative interventions. There was no evidence of a comprehensive root cause analysis or effective intervention development following this fall, resulting in continued risk for subsequent falls.Review of the Incident Review and Analysis, dated 2/17/26, indicated R2 was found on the floor at approximately 1800 hours, yelling for help after falling while ambulating to the bathroom. Documentation identified contributing factors included end-stage renal disease and fatigue following dialysis treatment earlier that day. The report indicated R2 struck his head and was transferred to the emergency room for evaluation. Further review of the incident analysis revealed the facility identified contributing factors; however, no additional or individualized interventions were developed or implemented following the fall. The only interventions noted included the bed in a low position, call light within reach, and use of gripper socks. The section for possible interventions was left blank.Review of the Incident Review and Analysis, dated 3/6/26, identified R2 sustained a head injury with active bleeding after attempting to ambulate independently to the bathroom. Although contributing factors such as weakness and dialysis-related needs were identified, the facility failed to develop and implement new or individualized interventions. Documentation reflected only existing interventions, including the bed in a low position, call light within reach, gripper socks, and signage to call for assistance. There was no evidence the facility conducted a comprehensive root cause analysis or implemented effective interventions following this fall, resulting in continued risk for injury, as evidenced by repeated falls.Review of R2's care plan, with a print date of 3/30/26, identified a problem of fall risk related to traumatic subdural hemorrhage without loss of consciousness, initiated on 11/10/2023, with a goal for R2 to remain safe and free from falls.Interventions included: Physical therapy (PT) per physician orders, initiated on 11/10/2023 Follow PT and occupational therapy (OT) instructions for mobility function, initiated on 11/10/2023 Keep R2's room clean and free of clutter, initiated on 11/10/2023 Ensure the call light was within reach, initiated on 11/10/2023 Follow facility fall protocol, initiated on 11/10/2023During interview on 4/6/26 at 9:59 a.m., nursing assistant (NA)-A stated when a resident fell, staff were expected to notify the nurse and assist the resident as needed. NA-A stated R2 had previously been independent; however, in the two months prior to his death, he had become weak, required assistance, and used his call light to request help.During interview on 4/6/26 at 11:23 a.m., nursing assistant (NA)-C stated when a resident fell, staff were expected to notify the nurse. NA-C stated R2 had required assistance with transfers for several months due to weakness.During interview on 4/6/26 at 11:32 a.m., registered nurse (RN)-A stated the facility's process following a fall included completing an assessment, conducting neurological checks when indicated, implementing interventions, and updating the care plan. There was no evidence this process was consistently followed for R2, as new interventions were not implemented and the care plan was not updated following repeated falls.During interview on 4/6/26 at 12:05 p.m., registered nurse case manager (RN)-B confirmed the facility's process included identifying root cause and updating interventions and care plans following falls; however, RN-B acknowledged there was no follow-up and no implementation of new interventions after R2's repeated falls. RN-B further stated R2 had a history of self-transferring, which was a known risk factor. RN-B confirmed the facility failed to analyze known behaviors and implement effective, individualized interventions to prevent recurrence of falls.During interview on 4/6/26 at 2:17 p.m., the director of nursing (DON) stated a root cause analysis should be completed after each fall to identify contributing factors and guide the development of interventions. The DON further stated care plans should be updated to reflect changes in condition and interventions following a fall. The DON confirmed there was no evidence consistent root cause analyses were completed for R2 and acknowledged the care plan was not updated to reflect interventions following the repeated falls.Review of the facility's Fall Prevention and Management policy, dated 11/25, indicated staff were responsible for completing a post-fall assessment, conducting an incident review and analysis to identify root causes and contributing factors, and implementing individualized interventions to prevent recurrence. The policy further required staff to revise or add interventions when falls continued, monitor the effectiveness of interventions, and update the resident's care plan to reflect changes. The facility failed to follow its policy, as evidenced by the lack of consistent root cause analyses, failure to implement new or individualized interventions following repeated falls, and failure to update R2's care plan to address identified risk factors, placing the resident at continued risk for injury.

Based on document review and interview, the facility failed to ensure pneumococcal immunization was offered and/or administered in accordance with current standards of practice for 1 of 5 residents (R27) reviewed for immunizations.Findings include:A pneumococcal vaccine timing resource from the Centers for Disease Control and Prevention (CDC) dated 3/2025, identified recommended vaccination schedules for adults. The guidance indicated adults aged 50 years and older with no prior pneumococcal vaccination should receive either Pneumococcal 20-valent Conjugate Vaccine (PCV20) or Pneumococcal 21-valent Conjugate Vaccine (PCV21). For those who previously received Pneumococcal 13-valent Conjugate Vaccine (PCV13) and Pneumococcal Polysaccharide Vaccine (PPSV23), additional vaccination with PCV20 may be considered based on shared clinical decision-making between the patient and provider.R27's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and able to make needs known. R27's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition where the heart cannot pump blood effectively), hypertension (high blood pressure), renal failure (decreased kidney function or kidney failure), diabetes mellitus (a condition affecting blood sugar control), anxiety disorder (excessive worry or fear), depression (persistent sadness or loss of interest), and schizophrenia (a chronic mental disorder affecting thinking, perception, and behavior). The MDS and immunization section did not indicate R27 was up to date on the pneumococcal vaccination.Review of R27's electronic medical record (EMR) lacked documentation a pneumococcal immunization had been offered or administered. There was no evidence of prior vaccination, medical contraindication, or refusal documented in the medical record.During an interview on 4/6/26 at 11:34 a.m., R27 stated she would have been interested in receiving any vaccinations for which she was eligible.During an interview on 4/6/26 at 2:17 p.m., the director of nursing (DON) stated the facility was responsible for ensuring residents were assessed for pneumococcal vaccination status and that the vaccine should be offered unless previously received, medically contraindicated, or refused. The DON confirmed there was no documentation that R27 had been offered or had received the pneumococcal vaccine.The facility Pneumococcal policy dated 2/24, indicated all residents were to be assessed for pneumococcal immunization status within 5 days of admission and offered the vaccine within 30 days, if indicated, unless previously vaccinated or medically contraindicated. If immunization status was unknown, staff were to verify through the resident's physician or the Minnesota Immunization Information Connection (MIIC). The policy required adherence to current CDC guidelines for vaccine recommendations.The policy further indicated residents or their representatives were to receive education regarding the benefits and risks of vaccination, with documentation of education and consent in the medical record. Vaccinations were to be administered per physician order and documented, including the date, administrator, and site. If the vaccine was contraindicated or refused, this was to be documented in the medical record.

Based on record review and interview, the facility failed to ensure a functional maintenance program (FMP) was implemented to maintain the resident's highest practicable level of functioning, as recommended by therapy services, for 1 of 1 resident (R28) reviewed for rehabilitation and restorative nursing services.Findings include:R28's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and required assistance with activities of daily living (ADLs). R28's diagnoses included progressive neurological conditions (disorders that worsen over time and affect the brain or nervous system), cerebral palsy (a group of disorders affecting movement and muscle coordination due to brain injury or abnormal development), hemiplegia (paralysis affecting one side of the body), malnutrition (a condition resulting from inadequate intake of nutrients), other abnormalities of gait and mobility (difficulty walking or moving normally), thyrotoxicosis (a condition caused by excessive thyroid hormone in the body), contracture of right and left lower leg muscle (permanent tightening of muscles that limits movement), muscle weakness (reduced strength in the muscles), and dysphagia (difficulty swallowing). The MDS did not indicate any range of motion exercises.R28's physical therapy Discharge summary dated [DATE], indicated a functional maintenance program (FMP) was established and staff were trained to provide a range of motion (ROM) program. The discharge summary specified R28 was to receive complete range of motion exercises to bilateral lower extremities (BLE) three times daily to reduce the risk of contractures. The summary further indicated R28's prognosis to maintain current level of function (CLOF) was excellent with consistent staff support and participation in the FMP.Review of R28's electronic medical record (EMR) on 4/2/26, revealed no evidence a functional maintenance program was implemented following discharge from therapy. There was no documentation to indicate ROM exercises were initiated, scheduled, or routinely completed as recommended.Review of the CNA (certified nursing assistant) report sheet for Group 2, undated, identified MUST DO ROM EXERCISES ON LOWER EXTREMITIES under the resident's other information section, which was bolded and in all capital letters. However, there was no supporting documentation in the EMR to confirm these interventions were carried out.During observation on 3/31/26 at 3:55 p.m., R28 was lying in bed with his left arm and both legs elevated in the air due to contractures.During observation on 4/2/26 at 8:56 a.m., R28 was assisted to the common area to watch television. R28's left wrist was observed to be contracted at approximately a 90-degree angle. The R28's lower extremities were also contracted and leaned to the left; pillows were in place to provide appropriate support.During interview on 4/6/26 at 9:59 a.m., nursing assistant (NA)-A stated no ROM exercises were being performed.During interview on 4/6/26 at 11:23 a.m., NA-C stated staff turned and repositioned R28, as he was unable to do so independently. NA-C further stated there were currently no range of motion (ROM) exercises being performed for any residents.During interview on 4/6/26 at 1:51 p.m., registered nurse case manager (RN)-B stated physical therapy (PT) establishes range of motion (ROM) programs, and staff should complete them if they are included on the Treatment Administration Record (TAR). RN-B confirmed a ROM program was not in place for R28.During interview on 4/6/26 at 2:17 p.m., the director of nursing (DON) stated ROM exercises would be expected to be completed unless otherwise directed by hospice. The DON stated if ROM exercises were ordered, they should have been care planned and entered into the Medication Administration Record (MAR) so staff were aware they were required to perform them. The DON acknowledged ROM exercises were noted on the CNA group sheets, indicating staff were expected to perform them.The facility policy regarding range of motion (ROM) and functional maintenance programs was requested but was not received.

Based on observation, interview, and record review, the facility failed to ensure safe mobility and transportation of a resident by staff, resulting in the risk for injury, for 1 of 1 residents (R26) reviewed for quality of care.Findings include:R26's 5-day Minimum Data Set (MDS) dated [DATE], identified R26 had intact cognition and required assistance with activities of daily living (ADLs). R26's diagnoses included heart failure (a condition where the heart cannot pump blood effectively), hypertension (high blood pressure), seizure disorder (a condition causing recurrent seizures), anxiety disorder (excessive worry or fear), depression (persistent sadness or loss of interest), chronic obstructive pulmonary disease (COPD; a lung disease that makes it hard to breathe), paroxysmal atrial fibrillation (an irregular heart rhythm that starts and stops suddenly), paresthesia of the skin (abnormal sensations such as tingling or numbness), and long-term use of systemic steroids (ongoing use of medications that reduce inflammation but can have side effects).Review of R26's electronic medical record (EMR) on 4/1/26, including the comprehensive care plan, failed to identify interventions addressing safe wheelchair positioning or the use of foot pedals during transport.During observation on 3/31/26 at 12:32 p.m., R26 was assisted from his room to the dining room in a wheelchair without foot pedals; his feet were observed bouncing on the floor.During observation on 4/1/26 at 2:50 p.m., R26 was assisted from his room to the therapy room in a wheelchair without foot pedals; his feet were observed bouncing on the floor during transport.During observation on 4/2/26 at 8:57 a.m., R26 was assisted from the dining room to the common room in a wheelchair without foot pedals; his left foot bounced off the floor twice.During observation on 4/2/26 at 1:22 p.m., R26 was assisted from his room to the common area in a wheelchair without foot pedals; his left foot was observed sliding on the floor.During observation on 4/3/26 at 8:10 a.m., R26 was assisted from his room to the dining room in a wheelchair without foot pedals; his feet were observed sliding on the floor during transport.During interview on 4/6/26 at 11:32 a.m., registered nurse (RN)-A stated if a resident's feet were observed sliding on the floor during wheelchair transport, the resident should be assessed and foot pedals should be in place. RN-A confirmed R26 did not have foot pedals on the wheelchair or in the room.During interview on 4/6/26 at 9:59 a.m., nursing assistant (NA)-A stated staff offered foot pedals to all residents; however, some residents refused due to preferring to self-propel. NA-A stated R26 did not refuse use of foot pedals but did not use them. NA-A stated R26's feet would slide on the floor during transport and staff had to repeatedly remind him to lift his legs.During interview on 4/6/26 at 11:23 a.m., NA-C stated R26 did not use foot pedals and his feet would slide on the floor during transport, requiring staff to repeatedly remind him to lift his feet. NA-C further stated staff assisted R26 with mobility to and from different areas of the facility.During interview on 4/6/26 at 1:51 p.m., registered nurse case manager (RN)-B stated residents who independently mobilized with their feet may not use foot pedals; however, foot pedals should be in place when a resident was being pushed down the hallway by staff.During interview on 4/6/26 at 2:17 p.m., director of nursing (DON) stated when a resident was not independently self-propelling, foot pedals should be in place during wheelchair transport. The DON stated if staff were pushing the resident, they should ensure foot pedals were applied, as the resident's feet could become caught or injured. The DON further stated if staff offered to assist with transport, they were expected to obtain and apply the foot pedals prior to moving the resident. The DON acknowledged transporting a resident without foot pedals could place the resident at risk for harm.A facility policy regarding wheelchair use and foot pedals was requested but was not received.

Based on observation, interview, and record review, the facility failed to provide assistance and/or cueing with activities of daily living, including grooming, dressing and maintaining personal hygiene, for 2 of 2 residents (R13, R16) reviewed for ADL care.Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated cognitively intact and independent with ADLs. Diagnoses included hypertension, sleep apnea, congestive heart failure, diabetes, muscle weakness and unsteadiness on feet. R13's care plan revised 6/25/25, indicated self-care deficit related to diabetes, obesity and hypertension. Care plan interventions included R13 would be accepting assistance with self-care, hair would be washed by nursing staff and cut at beauty shop as needed. Nails would be cut by nursing staff and R13 would receive assistance from one staff for personal hygiene and grooming. R13's order summary printed 3/2/26, indicated an order to apply brace to right knee every morning for pain. On 3/30/26 at 11:17 a.m., R13 was observed to have grey color hairs about an inch long on chin. R13 rubbed her chin, stated this is my goatee isn't it lovely? R13 stated she had asked staff several times to help her with the chin hairs, stated It's gross, don't they know us ladies have issues with chin hairs? R13 stated she was supposed to wear a brace on her knee but had difficulty getting in correctly, although was able to remove it independently. R13 stated they had not been wearing the brace due to staff not assisting with putting it on. R13 stated when the brace was worn she had less pain in the right knee. Knee brace was observed on end of R13's bed. On 3/31/26 at 11:11 a.m., R13 observed in front common area participating in an activity, continued to have long hairs visible on chin. No knee brace observed on R13's right knee. On 4/1/26 at 2:59 p.m., observed R13 laying on the bed watching television, continued with long grey hairs on chin. Knee brace observed on end of R13's bed. On 4/6/26 at 9:51 a.m., R13 participated in an activity in front common area, continued to have grey hair on chin about one inch in length, no knee brace observed on R13's right knee. When interviewed on 4/6/26 at 11:53 a.m., nursing assistant (NA)-B stated R13 needed assistance with grooming. NA-B does not ask R13 about shaving, It might upset her. NA-B stated they had never assisted R13 with a knee brace, nor were they aware there was one. When interviewed on 4/6/26 at 1:42 p.m., NA-A stated R13 needed assistance with incontinent care, help with socks, shoes and pants. NA-A stated there was no knee brace. When interviewed on 4/6/26 at1:52 p.m., registered nurse (RN)-C stated the expectation was for residents to be shaved on shower days or when a need was observed before that. RN-C stated R13 was sensitive about being asked if she wanted assistance with shaving of chin hair so staff would wait until R13 requested assistance with shaving. RN-A stated R13 was able to remove the knee brace, R13 usually had the knee brace on when out of bed. R13 was ablet to take it off independently. When interviewed on 4/7/26 at 12:05 p.m., director of nursing (DON) stated R13 was able to get up independently. But required assistance of one staff with grooming. DON was not sure if R13 had a knee brace. DON reviewed R13's orders, stated R13 had an order for right knee brace to be applied in the morning. DON stated the expectation was for staff to assist with shaving at least weekly, more often if whiskers were observed for dignity and ordered braces were expected to be applied for safety and pain control R16's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and required assistance with bathing. R16 was independent with all other activities of daily living (ADLs). R16's diagnoses included polyneuropathy (damage to multiple peripheral nerves causing weakness, numbness, or pain, typically in the hands and feet), hypertension (high blood pressure), anxiety disorder (a condition characterized by excessive worry or fear), schizophrenia (a chronic mental disorder affecting thinking, perception, and behavior), muscle weakness (reduced strength in the muscles), adverse effect of unspecified antipsychotics and neuroleptics (negative side effects from medications used to treat mental health conditions), colostomy status (a surgically created opening in the abdomen to divert stool into a bag), and neuroleptic-induced parkinsonism (movement symptoms such as tremors or stiffness caused by antipsychotic medications). Review of R16's electronic medical record (EMR), including nursing notes and ADL documentation, failed to identify evidence staff had offered assistance with changing clothing, provided reminders or cueing to change soiled garments, or addressed concerns related to hygiene and appearance. During observation on 03/31/2026 at 12:02 PM, R16 was sitting in the dining room at a table alone. R16 was wearing a red polo shirt, black sweatpants, and yellow gripper socks. During observation on 4/1/26 at 9:03 a.m., R16 was lying in bed with eyes closed and was wearing the same clothing as the previous day, including a red polo shirt with visible stains, black sweatpants, and yellow gripper socks. During observation on 4/1/26 at 2:54 p.m., R16 was lying in bed with eyes closed and continued to wear the same clothing as the previous day (red polo shirt with visible stains, black sweatpants, and yellow gripper socks). During observation on 4/1/26 at 3:06 p.m., R16 exited the room and ambulated to the common area, wearing the same clothing as the previous day (red polo shirt with visible stains, black sweatpants, and yellow gripper socks), then returned to the room and lay down. During observation on 4/2/26 at 8:50 a.m., R16 was sitting in the dining room eating breakfast and continued to wear the same red polo shirt with visible stains, black sweatpants, and yellow gripper socks. During observation on 4/2/26 at 12:10 p.m., R16 was observed ambulating in the hallway toward the dining room for lunch, wearing the same red polo shirt with visible stains, black sweatpants, and yellow gripper socks. During observation on 4/3/26 at 7:16 p.m., R16 was lying in bed with eyes closed and continued to wear the same red polo shirt with visible stains, black sweatpants, and yellow gripper socks. During observation on 4/6/26 at 9:52 a.m., R16 was lying in bed with eyes closed and continued to wear the same clothing observed the previous week, including a red polo shirt with visible stains, black sweatpants, and yellow gripper socks. During interview on 4/6/26 at 11:32 a.m., registered nurse (RN)-A stated staff should ask residents if they had showered and may prompt up to three times. RN-A stated R16 was very independent; however, if staff observed the resident wearing the same clothing, they should approach the resident and offer assistance with changing clothing. RN-A further stated nursing assistants should notify the nurse if the resident refused assistance. During interview on 4/6/26 at 9:59 a.m., nursing assistant (NA)-A stated R16 required assistance with dressing, particularly with lower body clothing, and was independent with upper body dressing. NA-A stated clothing should be changed daily; however, R16 sometimes preferred to wear the same clothing. NA-A further stated if staff observed R16 wearing the same soiled clothing, they should approach and offer assistance with changing; however, NA-A stated he did not document when this occurred. NA-A indicated R16 did not have a history of refusing cares. During interview on 4/6/26 at 11:23 a.m., NA-C stated R16 required assistance with dressing and staff assisted him with changing clothing daily. NA-C stated R16 sometimes refused assistance; however, refusals were not documented. During interview on 4/6/26 at 1:51 p.m., registered nurse case manager (RN)-B stated staff were expected to assist residents with changing clothing daily. RN-B stated if a resident refused, staff could not force care, as it was the resident's preference; however, staff should encourage the resident and re-offer assistance, particularly if the same clothing was observed. RN-B further stated R16 did not require assistance with most ADLs, except for changing the colostomy bag, and indicated staff should have ensured R16's clothing was changed. During interview on 4/7/26 at 1:01 p.m., director of nursing (DON) stated the expectation was that if a nursing assistant observed a resident wearing the same clothing for multiple consecutive days, the nursing assistant should notify the nurse, who would assess the resident and follow up. The DON stated if the resident adamantly refused assistance, this should be reported to the DON. The DON further stated residents with self-care deficits should be set up with assistance for dressing, and documentation should clearly reflect the reason for the deficit and the need for assistance. DON was unable to provide evidence these interventions were implemented for R16. The facility's Activities of Daily Living (ADLs)/Maintain Abilities Policy, dated 3/31/23, indicated the facility was responsible for providing person-centered care that supported each resident's preferences, choices, and quality of life. The policy required staff to provide necessary care and services based on the resident's assessment to maintain or improve ADL abilities, unless decline was clinically unavoidable. The policy identified ADLs to include hygiene (bathing, dressing, grooming, oral care), mobility, toileting, dining, and communication, and required staff to assist residents who were unable to perform these tasks to ensure proper hygiene, nutrition, and overall well-being.

Based on interview and document review the facility failed to revise and update comprehensive care plan for 2 of 5 residents (R7 and R30) reviewed for comprehensive care plans.Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and required assistance with activities of daily living (ADLs). Diagnoses included hypertension, dementia, anxiety and pressure ulcer of sacral regions stage 3. R7's care plan revised 6/25/25, indicated ecchymotic area (superficial bruise caused by blood leaking from broken blood vessels into skin) to both upper and lower extremities and moisture-associated skin damage (MASD) on gluteal right (right buttock). R7's care plan goal was to remain free from skin breakdown. A skin and wound evaluation dated 9/29/25, indicated R7's right gluteus MASD resolved (healed) 10/8/25. However, R7's care plan was not revised to indicate R7's MASD had resolved. Progress note dated 2/9/26 at 2:22 p.m., indicated new skin issue coccyx pressure ulcer/injury stags 3 - full thickness skin loss, wound acquired in-house. However, R7's care plan was not revised to indicate R7 had developed a stage 3 pressure ulcer to the coccyx. Progress note dated 2/26/26 at 10:49 a.m., indicated new skin issue right lateral midfoot pressure ulcer/injury stage 3 - full thickness skin loss, acquired in-house on 2/23/26. However, R7's care plan was not revised to indicate R7 had developed a stage 3 pressure ulcer/injury to right lateral midfoot. When interviewed on 4/6/26 at 2:12 p.m., nurse manager registered nurse (RN)-B stated she updated wounds on care plans as soon as she was informed there was a new wound. RN-B stated she did not review the progress notes but relied on the nurse to inform her directly of new skin concerns. When interviewed on 4/7/26 at 12:05 p.m., director of nursing (DON) stated the expectation was to customize care plans which included identification of what the skin concern was, where the wound was located, what date the concern was identified and interventions/care of the wound(s). R30's admission MDS dated [DATE], indicated cognitively intact, and dependent on staff with ADLs. MDS section B - hearing, vision and speech ability indicated R30 had minimal hearing difficulty and had no hearing aids. R30's pressure ulcer/injury CAA dated 3/20/26, indicated R30 had a potential for pressure ulcers due to needed assistance with bed mobility. Further the CAA indicated R30's potential for pressure ulcers was further complicated by frequently incontinent of bowel and utilized brief daily to manage. R30 did not currently have a pressure ulcer, R30 was at risk for skin breakdown. R30's communication CAA dated 3/20/26, indicated R30 had minimal hearing loss as evidenced by speaker having to increase volume and speak distinctly. R30 did not wear hearing aids. R30 was at risk for missed messages, isolation, depression, and further hearing loss. R30's care plan dated 3/9/26, indicated R30 had an alteration in communication, used hearing amplifier, with an intervention for staff to assist with communication devices. However, R30 did not have a hearing amplifier. When interviewed on 3/30/26 at 1:58 p.m., R30 stated he had a hard time hearing, requested surveyor to raise voice. During observation on 3/31/26 at 6:20 p.m., R30 was on speaker phone in his room. Writer was able to hear conversation from the hallway; resident was not using a hearing amplifier. During observation on 4/1/26 at 9:25 a.m., R30 was reading the paper with television on, volume up loud, R30 was not utilizing a hearing amplifier. During interview on 4/7/26 at 12:00 p.m., R30 stated he had hearing aids in the past, but they no longer worked. R30 stated he would like some kind of hearing aid or an amplifier but the facility had not offered him a hearing amplifier. When interviewed on 4/6/26 at 1:42 p.m.NA-A stated R30 was a bit hard of hearing, had to speak louder when they talked to R30. R30 did not have any hearing devices. When interviewed on 4/6/26, at 2:12 p.m., RN-B stated care plans were updated quarterly with MDS or if there was a change. RN-B stated R30 did not wear any hearing aids and did not have a hearing amplifier. When interviewed on 4/7/26 at 12:05 p.m., director of nursing stated if the resident was not using or did not have a device that was on the care plan she expected the care plan to have been updated to reflect the current status of the resident. Facility Care Planning policy revised 11/2024, indicated The care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident. The plan of care will be utilized to provide care to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes.

Based on interview and record review, the facility failed to ensure the resident's right to make choices regarding her living environment and personal possessions was honored by removing items from her room without prior notice and by failing to follow care plan interventions and ACP recommendations for 1 of 1 resident (R22) reviewed for resident rights.Findings include:R22's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition and required assistance with activities of daily living (ADLs). R22's diagnoses included osteoarthritis of the knee (degenerative joint disease causing pain and stiffness in the knee joint), hypertension (high blood pressure), renal insufficiency (reduced kidney function), diabetes mellitus (a condition affecting blood sugar regulation), anxiety disorder (excessive worry or fear), depression (persistent sadness or loss of interest), adjustment disorder with anxiety (emotional or behavioral response to stress causing anxiety), and personality disorder (a pattern of thinking and behavior that differs from cultural expectations).R22's comprehensive care plan printed 4/1/26, identified at risk for alterations in behavior related to trauma. The care plan noted R22's hoarding tendencies had escalated following the loss of personal belongings when her brother discarded items previously stored for her. The care plan further identified R22 had a long-standing history of hoarding behaviors, was in contact with the Office of Ombudsman for Long-Term Care (OOLTC) for advocacy and received psychological support services through ACP.The care plan included interventions to support R22's emotional well-being and autonomy, including:Staff would utilize trauma-informed care when working with R22.Staff would provide direct communication and maintain clear boundaries when discussing hoarding behaviors.Staff would avoid involving R22's brother in discussions related to cleaning due to her trauma history.The facility would issue a 30-day notice prior to assisting with cleaning R22's room and would notify the OOLTC when such notice was provided.R22 would be supported in expressing needs and engaging with services.The care plan also reflected ACP recommendations, which included working collaboratively with R22 to gradually remove one to two items per week to minimize distress and support coping.Review of R22's electronic medical record (EMR) revealed no documentation the required 30-day notice was provided to R22 prior to cleaning her room [ROOM NUMBER]/13/25. Further review identified no documentation the OOLTC was notified. Review of R22's progress notes on 4/1/26 indicated the following:Progress note dated 8/13/25 at 4:34 p.m., indicated the administrator, nurse manager (NM), business office manager (BOM), and social services designee (SSD) entered R22's room to clean it out and removed multiple belongings, including magazines, bags, and other items. Documentation indicated R22 became upset and combative when items were removed and verbalized the items were important to her.Progress note, dated 8/13/25 at 9:37 p.m., indicated R22 was so upset following the room clean-out that she called the police at approximately 8:30 p.m. Law enforcement responded and spoke with R22 and the administrator, after which R22 calmed.Regulatory provider visit note dated 8/14/25, indicated R22 remained upset that her room had recently been cleared out due to concerns she was hoarding.During interview on 3/31/26 at 6:22 p.m., R22 stated four facility staff entered her room and removed multiple personal belongings without prior notice. R22 stated this caused her significant distress and reported staff kept violating her room.During interview on 4/2/26 at 2:31 p.m., the ombudsman stated she had no knowledge of R22 and was not notified of any planned room clean-out or intervention.During interview on 4/6/26 at 11:23 a.m., nursing assistant (NA)-C stated R22 had difficulty letting go of items and reported management would occasionally enter her room to clean it. NA-C stated he was not aware of any specific interventions in place to address R22's hoarding behaviors.During interview on 4/6/26 at 2:17 p.m., director of nursing (DON) stated interventions for R22's behaviors should be addressed in the care plan and consistently implemented. The DON stated staff should engage R22 in more in-depth discussions and follow through with interventions so they become routine. The DON further stated if the current approach was not effective, the facility could re-consult ACP to determine alternative interventions.During interview on 4/6/26 at 3:07 p.m., the administrator stated R22 had a long-standing history of accumulating belongings, which he reported was related to childhood trauma, including experiences of having items taken away as punishment. The administrator stated R22 often kept large amounts of items in her room, which at times created safety concerns, including limited space for staff to safely use equipment such as a Hoyer lift and reposition her. The administrator stated staff, including himself, the NM, SSD, and the BOM, entered R22's room to remove items and reduce clutter while attempting to preserve some belongings. He stated R22 was upset during this process and confirmed a formal 30-day notice was not provided prior to the clean-out. The administrator further stated ACP recommendations were received by the facility and typically discussed during meetings for possible incorporation into the care plan, and that non-pharmacological interventions should be included in the care plan and implemented by staff. However, the administrator stated he was not aware of the care plan intervention requiring a 30-day notice prior to cleaning R22's room and was not aware of ACP recommendations to work with R22 to gradually remove one to two items per week.A request was made for the facility's policy regarding resident room cleaning, resident rights, and handling of personal belongings; however, the facility failed to provide the requested policy.

Based on observation, interview, and document review, the facility failed to ensure residents were assessed, determined safe to self-administer medications, and that self-administration practices were consistently implemented in accordance with physician orders and facility policy for 2 of 2 residents (R22 and R17) reviewed for self-administration of medications. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition and required assistance with activities of daily living (ADLs). R22's diagnoses included osteoarthritis of the knee (degenerative joint disease causing pain and stiffness in the knee joint), hypertension (high blood pressure), renal insufficiency (reduced kidney function), diabetes mellitus (a condition affecting blood sugar regulation), anxiety disorder (excessive worry or fear), depression (persistent sadness or loss of interest), adjustment disorder with anxiety (emotional or behavioral response to stress causing anxiety), and personality disorder (a pattern of thinking and behavior that differs from cultural expectations). During review on 3/31/26, R22's electronic medication record (EMR) indicated most recent self-administration of medications assessment, dated 7/14/23, indicated R22 was permitted to self-administer certain medications. There was no evidence of subsequent reassessments completed quarterly or with any change in condition or physician orders. Review of physician orders revealed conflicting and unclear directives regarding R22's ability to self-administer medications, including: An order dated 7/14/23 indicated the resident may self-administer diclofenac gel and nystatin powder and keep them at bedside. An order dated 10/30/24 indicated the resident may order and self-administer multiple supplements, including turmeric, [NAME] oil, biotin, phytosterol [NAME], coq10, zinc, vitamin e, alpha-lipoic acid, cholest, women's multivitamin, and osteo bi-flex. An order dated 3/6/25 indicated diclofenac may be kept at bedside for self-administration, with nursing to provide teaching on application. An order dated 10/28/25 indicated staff were to administer medications and R22 was no longer permitted to self-administer medications. During observation on 3/31/26 at 6:22 p.m., R22 asked the surveyor what time it was. After the surveyor responded 6:25, R22 stated she could take her medications at that time. R22 then removed a paper medication cup from the left side of her wheelchair, which had been placed between her hip and the wheelchair seat, containing acetaminophen, and self-administered the medication while conversing with the surveyor. During observation on 3/31/26 at 3:57 p.m., R22 had five bottles of medications/supplements present in her room. Three bottles (magnesium 400 mg, alpha lipoic acid 200 mg, and [NAME]-c 1000 mg) were observed sitting on the bedside table. Two additional bottles (osteo bi-flex and multi-50+ for her) were observed on top of the nightstand within reach of the resident. During review on 4/2/26, R22's EMR failed to identify a current assessment evaluating R22's ability to safely self-administer medications following the change in physician orders discontinuing self-administration on 10/28/25. During interview on 4/6/26 at 11:32 a.m., registered nurse (RN)-A stated R22 was no longer on a self-administration program due to concerns she would pocket medications and not take them as directed. RN-A further confirmed staff were responsible to ensure R22 took her medications as prescribed. During interview on 4/6/26 at 1:51 p.m., registered nurse case manager (RN)-B stated residents who participate in a self-administration of medications (SAM) program should be alert and oriented, and assessments should be completed at least quarterly or with any significant change. RN-B stated that, in practice, residents at the facility were not routinely self-administering medications; however, with a provider order, staff may set medications at the bedside for the resident to take, such as during meals. RN-B further stated residents may request to take supplements, which should be reviewed and approved by the nurse practitioner (NP). RN-B indicated staff could set up medications and leave them at bedside under certain orders but acknowledged she did not complete SAM assessments. Upon review of R22's physician orders, RN-B expressed surprise regarding the 10/28/25 order indicating R22 was no longer permitted to self-administer medications. During interview on 4/6/26 at 2:17 p.m., director of nursing (DON) stated residents participating in a SAM program should have an assessment completed in the EMR at least quarterly to ensure they remained able to safely self-administer medications. The DON stated R22 should not have any medications in her room. The DON further stated if a resident declined medications at the time of administration, nursing staff would retain the medications and allow the resident to take them when ready under staff supervision. The DON confirmed R22's last self-administration assessment was completed on 7/14/23. R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had severe cognitive impairment. R17's diagnoses included hypertension, weakness, moderate intellectual disabilities, and adult failure to thrive. During observation on 4/6/26, at 1:30 p.m. registered nurse (RN)-A set up Lasix (a diuretic) to administer to R17. Upon entering room R17 was in the bathroom. RN-A placed the medication cup that contained Lasix on the overbed table that was next to R17's bed then exited the room. RN-A did not inform R17 that the medication was on the table. When interviewed after exiting the room RN-A stated R17 had an order for self-administration and would take the medication when done in the bathroom. RN-A stated he did not complete self-administration assessments, that was the nurse manager. R17's electronic medical record (EMR) was reviewed, although R17 had an order which identified may self-administer all medications after setup by staff, the EMR lacked evidence a self-administration of medication assessment had been completed to ensure R17 was safe and able to administer medications left at bedside by nursing. Further, R17's care plan, printed 3/30/26, lacked any evidence R17 had been care planned for self-administration of medication, or any interventions to ensure monitoring and/or safety with self-administration. When interviewed on 4/6/26, at 2:12 p.m. nurse manager registered nurse(RN)-B stated she did not complete any self-administer of medication assessments. RN-B stated, we do not have a form or assessment to assess the residents to ensure they are safe to self-administer medications, RN-B stated it was up to the doctor or the nurse practitioner to provide the order. When interviewed on 4/7/26, at 12:05 p.m. director of nursing (DON) stated for a resident to be able to self-administer medications there was to be an order from the provider and a self-administration of medication assessment was required to be completed to ensure the resident was competent to self-administer the medications. DON reviewed R17's EMR and stated there was an order for self-administer but was unable to locate a self-administer assessment in R17's EMR. DON stated she did not believe R17 had the capability to self-administer and was not comfortable with R17 doing so. Facility Self-Administration of Medication policy dated 2/2024, indicated the interdisciplinary team (IDT) assessed each residents cognitive and physical abilities to determine whether self-administration of medications was safe and clinically appropriate for the resident. Further, the policy indicated the ability to self-administer medications was documented in the medical record and the care plan.

Based on observation and interview, the facility failed to ensure a catheter bag containing urine was concealed from public view for 1 of 3 residents (R3) reviewed for dignity.Findings include:R3's admission Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment and required staff assistance with activities of daily living (ADLs). R3's care plan dated 2/13/26, indicated an alteration in elimination related to foley catheter, with interventions including staff to monitor foley catheter output and foley catheter care per policy. When observed on 4/2/26 at 12:48 p.m., R3 was in his wheelchair, staff was propelling wheelchair from the dining room towards R3's room. Foley catheter was observed hung from the side of wheelchair armrest uncovered with urine visible. R3 stated he was embarrassed and preferred the bag not to be hung out in the open for everyone to see, R3 further stated he was embarrassed. When interviewed on 4/6/26 at 1:42 p.m., nursing assistant (NA)-A stated there were blue privacy bags for urine bags. It was expected to place the privacy covers on wheelchairs and used them every time the resident came out of their room. NA-A was unsure why R3 did not have a privacy bag. When interviewed on 4/7/26 at12:05 p.m., director of nursing (DON) stated catheter bags were expected to be placed in a privacy bag at all times especially when out in public for the privacy of the resident and the dignity of both the resident with the catheter and other residents in the area. Facility policy regarding covering of catheter bags was requested, however, none was provided.

Based on document review and interview the facility failed to ensure COVID-19 immunization was offered and/or administered in accordance with current standards of practice for 1 of 5 residents (R27) reviewed for immunizations.Findings include:A Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Guidance, current at the time of survey, indicated individuals should receive recommended COVID-19 vaccinations, including booster doses, when eligible, unless medically contraindicated or refused. Long-term care facilities were responsible for assessing vaccination status and ensuring residents were offered recommended vaccines.R27's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and able to make needs known. R27's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition where the heart cannot pump blood effectively), hypertension (high blood pressure), renal failure (decreased kidney function or kidney failure), diabetes mellitus (a condition affecting blood sugar control), anxiety disorder (excessive worry or fear), depression (persistent sadness or loss of interest), and schizophrenia (a chronic mental disorder affecting thinking, perception, and behavior). The MDS immunization section did not indicate R27 was up to date on COVID-19 booster vaccination.Review of R27's electronic medical record (EMR), including immunization records, revealed no documentation a COVID-19 booster had been offered or administered. Further, review of physician orders and progress notes lacked evidence of assessment for booster eligibility, discussion with the resident or representative, or documentation of refusal or contraindication.During an interview on 4/6/26 at 11:34 a.m., R27 stated she would have been interested in receiving any vaccinations for which she was eligible.During an interview on 4/6/26 at 2:17 p.m., the director of nursing (DON) stated the facility was responsible for ensuring residents were assessed for and offered COVID-19 booster vaccinations when eligible. The DON confirmed there was no documentation R27 had been offered or received a COVID-19 booster.The facility's COVID-19 vaccination policy dated 12/6/24, indicated all residents were to be assessed for COVID-19 vaccination status and eligibility upon admission or within 5 days. Residents were to be offered vaccination within 30 days of admission, when indicated, unless already vaccinated or medically contraindicated. If a resident's vaccination status was unknown, staff were to verify it through the physician, medical records, or the state immunization registry (e.g., MIIC). The policy further indicated the facility followed current CDC immunization guidelines for vaccine type, timing, and eligibility. Residents or their representatives were to receive education on the benefits and potential side effects of the vaccine, and informed consent was to be obtained prior to administration. Vaccinations were to be administered per physician order and documented in the medical record. Contraindications or refusals were to be documented, including the date of refusal. Documentation was to include the date of vaccination, lot number, expiration date, administrator, and injection site. The Infection Preventionist or designee was responsible for conducting periodic audits to ensure compliance.

Based on interviews and documentation review the facility failed to protect 1 of 1 resident (R1) from abuse, when R1 bit the director of nursing (DON). DON responded by pushing R1 on the bed, struggling with her until physically separated by nursing assistant (NA)-A and licensed practical nurse (LPN)-A. Then the DON rushed back in the room and pushed R1 down a second time and yelled out profanity and threatened to make R1's life a living hell. R1 suffered a bruise and pain to her left chest and shoulder. In addition, R1 had increased anxiety and fear of the DON returning to the facility. The immediate jeopardy began on 11/14/25, when the DON responded to a resident biting her with physical and verbal abuse, the facility did not recognize this as abuse until 11/16/25, when the witness called the administrator to recant her original statement regarding the DON's actions towards R1. The administrator and regional clinical nurse (RNC)-A were notified of the immediate jeopardy at 4:04 p.m. on 11/26/25. The immediate jeopardy was removed and the deficient practice was corrected on 11/17/25, prior to the survey and was therefore issued at Past Noncompliance (PNC). Findings include: R1's care plan dated 4/10/24, indicated she had altered mood and behaviors related to major depression and anxiety. She could be resistant to cares and argumentative. She made verbally aggressive comments to staff. Targeted behavior monitoring included verbal outbursts and crying. Interventions dated 8/15/25, included providing support, validation and comfort measures. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had normal cognition, mild depression and no behaviors during the seven days look back. She received anxiety and depression medication. She had diabetes, high blood pressure, abnormal weight loss with protein malnutrition, weakness, major depression, anxiety disorder, bipolar disease, and cognitive impairment. DON's written statement dated 11/14/25, indicated R1 lunged at DON's chest and would not let go. DON attempted to get R1 off, but R1 bit DON's right elbow. DON asked for R1 to stop biting but R1 only bit harder. DON pushed R1 on the bed, but R1 got up again and lunged at her. R1 would not let DON go. DON asked R1, are you fighting me? and pushed R1 again on to the bed. Staff arrived at the room to quell the situation. DON cleaned her wound and called the police. R1's written statement dated 11/14/25, indicated the DON entered her room and moved her table. R1 felt constricted and did not know what to do. R1 was not proud of biting the nurse. The police entered R1's room, and R1 gave her statement. R1 also apologized to the DON. NA-A's written statement dated 11/14/25, indicated she saw R1 attacking the DON and biting her. NA-A separated them and notified the administrator. The administrator's written statement dated 11/14/25, indicated he went to R1's room, she was alone in her room. He asked R1 what happened. R1 told the administrator she felt constricted in her room and when the DON moved her table, R1 did not know what to do. R1 bit the DON and was not proud of it and felt sorry. The administrator left the room to check on the DON. LPN-A's written statement dated 11/14/25, indicated when she entered R1's room, LPN-A saw the DON and R1 in a tussle. The DON showed her where R1 bit her. The DON walked back towards R1 and pushed her on the bed. R1 and DON started to struggle with each other. The DON told R1 she was going to get her a roommate that she could not bully. NA-A's second written statement dated 11/14/25, indicated when she first entered R1's room she observed the DON struggling with R1. NA-A pulled the DON away from R1. The DON walked back to R1 and pushed her again and started to hit her. Once separated, the DON told R1 she was going to make her life a living hell. R1's progress note written by the DON on 11/14/25 at 4:25 p.m., indicated she went to R1's room to ensure the room was shared 50/50. While she attempted to move R1's tray table, R1 sprung toward her biting her. She pushed R1 off her, but she continued to kick and charge after her. Staff came into the room to calm R1 down. She left the room with staff to check her bite wound. R1's progress note dated 11/14/25 at 6:55 p.m., the administrator indicated he first learned about the situation when he was in another resident's room. He started his investigation by talking with the DON and police. R1 told him the DON was moving her table, and she felt constricted. She did not know what to do and ended up biting her. She said she was not proud of her actions. She felt safe, and he left the room. The DON told him she was moving R1's table when she bit her. She yelled out and sat R1 on the bed. When staff entered the room, R1 was still combative but no one else was harmed and the incident was deescalated. The roommate was moved to another room for safety, and the police and nurse practitioner (NP) were notified. The police wanted to take R1 to the hospital for a mental health exam, but the ambulance would take 2-4 hours to transfer. They felt with the room change, and police interventions a transfer was not necessary. R1's skin assessment note dated 11/15/25, indicated a bruise on R1's left chest near her shoulder. Administrator's written statement dated 11/16/25, indicated he received a phone call from NA-A who wanted to change her statement to reflect the DON's rough handling of R1 on 11/14/25. The administrator was out of town and instructed her to write down her statement and put it under his office door. He would read it when he returned on 11/17/25. R1's social worker progress note dated 11/17/25 at 2:26 p.m., indicated R1 told her a staff member attacked her and should have been placed on administrative leave. Now when she lays down, she's afraid someone will attack her especially if she thinks she hears her [DON's] voice. She reported not trusting the staff member anymore and she wanted to speak to a psychologist about the incident. R1's nursing progress note dated 11/17/25 at 4:40 p.m., RCN-A indicated during a skin assessment R1 had a bruise on her upper left chest the size of a thumb. She rated her left shoulder pain at a 6 out of 10. On 11/17/25, the administrator provided Abuse Prohibition/Vulnerable Adult training to 21 staff. The abuse policy was reviewed to include all staff were responsible to report any situation consider abuse or neglect. The supervisor would be notified immediately, along with the administrator. All forms of abuse was reviewed. Staff were trained all incidents of abuse needed to be reported to the state within 2 hours. R1's Associate Clinic of Psychology (ACP) note dated 11/18/25, indicated R1 Reported increased depression and anxiety rated at a 6 out of 10 after the incident with the DON. She reported feeling increased anxiety and angry once she received a roommate. Since the incident she was worried about being homeless because she bit the nurse and would be discharged . Interview on 11/25/25 at 1:48 p.m., LPN-A stated when she entered R1's room, she observed the DON tussling with R1. The two were separated and LPN-A told the DON to leave the room. The DON told her R1 bit her. NA-A was trying to calm R1 down when the DON reapproached R1 pushing her to the bed and threatening to make her life a living hell. The DON was physically removed from the room. She felt the administrator was misled about the situation prior to talking to LPN-A because the administrator spoke to the DON first and LPN-A read the DON's progress note detailing the DON's side of the story. When LPN-A spoke with the administrator, she felt confused about what she saw and was unsure how to tell him what she observed. Interview on 11/25/25 at 2:59 p.m., NA-A stated when she entered R1's room, she saw R1 on the bed, and the DON was hitting R1. NA-A separated the two and the DON walked towards the door. While NA-A was attempting to calm R1 down, the DON came back and pushed R1 down on the bed again and started fighting with her. It took two staff to pull the DON off R1. In 20 years, NA-A had never witnessed a staff member fighting and cussing with a resident. She felt intimidated by the DON, so did not tell the truth on her first written statement. Interview on 11/25/25 at 3:41 p.m., R3 stated the DON brought her to room [ROOM NUMBER] to discuss her complaint with R1 regarding the shared space. She observed the DON move R1's table, and R1 was standing behind her shaking her fist. R1 then ran up and started biting the DON. R3 ran out of the room frightened by R1 and what R1 would do to her. Interview on 11/25/25 at 4:06 p.m., DON stated R1's tray table was pushed into R3's space. DON told R1 the table could not push against the privacy curtain and moved it away. R1 pushed the table back and when DON went to move the table again, R1 lunged at her biting her elbow. The more DON told R1 to stop biting, the harder she bit. DON pushed R1 to a sitting position on the bed, but R1 got up again. DON asked R1, You want to fight me? when the other staff arrived. DON was angry and in a lot of pain. DON left the room to clean her wound. After the police spoke with R1, R1 apologized to her. DON added, when R1 stood up again she was frightened and in shock. She realized she should have left the room but I got upset. Interview on 11/26/25 at 10:34 a.m., the administrator stated after the incident on 11/14/25, he reached out to his supervisor. He was instructed to have the DON fill out a workers' compensation form. He had R3 transferred to another room for safety and spoke with the police. The police did not have any concerns and offered to transfer R1 to the hospital but there would be a delay. He spoke with NA-A and LPN-A but what they told him was unclear to the actual events. He did not interpret what they were saying was an indication of rough handling by the DON. He interviewed the DON but did not receive her written statement until 11/17/25. Once he spoke with NA-A on 11/16/25, he immediately told his supervisors to escalate the investigation. The DON was suspended pending the investigation. He called the facility to complete a skin assessment, and a small bruise was found on R1's chest. He reported his findings to the state on the evening of 11/16/25 at 6:54 p.m. Interview on 11/26/25 at 1:39 p.m., registered nurse (RN)-A stated while talking with R1 after the incident she thought she heard the DON and became anxious. RN-A told R1 the DON was not at the facility. If she had been at the incident, she would have reported the DON's actions towards R1 to the administrator right away. The facility policy Abuse Prohibition and Vulnerable Adult policy dated 4/20/25, indicated all staff are required to report a situation of abuse immediately. A prompt investigation would include determining probable cause. All staff who witness abuse are responsible to report the incident by notifying their supervisor immediately. If the alleged perpetrator was a staff member, they would be suspended immediately pending the investigation findings. If the alleged perpetrator was a department head, their supervisor would be notified or [NAME] President of Social Services and Behavioral Health. Definition of abuse was a willful infliction of injury. Suspected abuse would be reported to the state no later than 2 hours after the incident. Employees are encouraged to report any reasonable suspicion of a crime and they would be protected from retaliation. The PNC IJ began on 11/14/25, was removed on 11/17/25, when it was verified the facility implemented the following:- All staff were re-educated on what constitutes abuse, when to report and what allegations to report.- DON was suspended, then terminated.

Based on observation, interview, and document review, the facility failed to offer a snack to residents on a routine basis when meals were greater than 14 hours apart. This had the potential to affect all 35 residents residing at the facility. Findings include: R187's 6/5/25, admission Minimum Data Set (MDS) assessment identified her cognition was intact and had no behaviors. R187 was independent with transfers, required assistance from staff with hygiene, and was occasionally incontinent of urine. She had diagnosis of heart failure, diabetes, and COPD. She was at risk for pressure ulcers and took insulin daily. Review of R187's baseline care plan identified she required assistance with bathing, dressing, hygiene, mobility, and transfers. Interview on 6/9/25 at 7:35 P.M., with R187 during the initial screen, she reported she had never been offered a snack during this stay or her last stay at the facility. She reported she was also not aware she could request a snack and stated, it would be nice to have a snack to get through the night. Interview on 6/9/25 at 7:40 p.m., with registered nurse (RN)-D reports sometimes they have a snack basket at the desk, she identified they have some people who are given a snack, but they do not have a snack cart to pass. RN-D reports if nursing wants a snack for the residents they must go ask the kitchen. Interview on 6/10/25 at 11:28 a.m., with the dietary manager identified the kitchen should be putting some snack in a basket at the nurse's station daily. He confirmed no snacks were put out yesterday and he was not sure what the process was. He agreed they are not getting snacks out for residents daily and identified he was working to correct the problem at that moment. Interview on 6/10/25 at 12:20 p.m., with the registered dietitian identified she agreed with the above findings, she reports they have residents at the facility that would benefit from having snacks and fluids offered at minimum once daily. She reports she was new to her role as the facilities dietitian so she was not familiar with all the facilities processes and stated this was something she could help them improve. Interview on 6/10/25 at 2:13 p.m., with the administrator identified he agreed whole heartedly they have a problem with their process for offering residents snacks. In addition, he agreed they have 15 hours between supper and breakfast and residents should have a substantial snack along with a beverage offered in the evening to get them through to the next meal and he was currently working with the dietary manager to correct the concern. Review of the facility provided undated Snacks Between Meal and Bedtime Policy identified staff were to place a snack on a table in front of the resident, provide assistance as needed. When the resident was finished with the snack staff were to assist resident with clean up, reposition them, document the amount eaten, and report to the charge nurse if the resident refuses a snack. The policy lacked any mention what time or how frequently a snack should be offered.

Based on observation and interview, the facility failed to ensure infection control practices were maintained in the kitchen when 1 of 1 staff were observed eating in the facility food preparation area. This had the ability to affect all 35 residents. Findings include: Observation on 6/11/25 at 7:28 a.m., of cook-A in the kitchen leaning over the food preparation counter near the microwave eating a sub sandwich. On the counter was a plate with food on it. Cook-A finished her sandwich, crumpled up a wrapper that said Subway on it and sat it on the hot holding steam table counter. Interview on 6/11/25 at 1:06 p.m., with the dietary manager identified staff should not be eating in the kitchen. Cook-A has some physical challenges, and the staff break room is located down a flight of stairs in the basement. He identified he has asked her in the past to at minimum step outside the kitchen door into the back hallway when she is eating her lunch. Interview on 6/11/25 at 1:26 p.m., with Cook-A identified she should not have been eating in the kitchen at a food prep counter. She reports she normally eats her lunch in the employee break room in the basement. Interview on 6/11/25 at 3:13 p.m., with the registered dietician identified she was made aware of the staff eating in the kitchen at the food prep counter. She agreed this was an infection control concerns, and all staff should only be eating in the designated staff break room. A policy was requested; however, nothing was provided before the end of the survey period.

Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 35 residents. Findings include: Review of the QAPI meeting minutes from March 2025 through May 2025 that was provided, identified department heads were bringing data forth to QAPI on various topics such as; pressure injuries which was above national average, falls with trends identified, psychoactive medications, activities of daily living (ADL)'s assistance with a sharp increase in help needed, infection control with an upward trend of antibiotics identified, hospitalizations with 6 unplanned hospitalizations identified. There were no identified goals, no specific action plans of what the facility was going to do to make improvements, and no analysis of any data brought forward to the committee for the areas identified. Interview on 6/12/25 at 3:58 p.m., with administrator identified that the facility wanted to do better and there was room for improvements. There was work that needed to be done and he wanted to approach the multiple areas in a holistic manor. He agreed that the QAPI meeting minutes lacked identification of goals, action plans, and analysis of data brought forth. As a new interim administrator, he wanted to make improvements and did see that there were areas that needed to be improved. The survey would help the facility to hold accountability and make improvements. On 6/12/25 at 4:00 p.m., a message was left for medical director, with no return call. On 6/16/25 at 11:30 a.m., a message was left for medical director, with no return call. Review of the undated, Quality Assurance and Performance Improvement (QAPI) policy identified the QAPI committee would oversee areas for improvement, develop an action plan, and analyze the results of the plan. The facility would maintain evidence of the ongoing QAPI program with documentation of data, analysis, and implementation and evaluation of actions for improvement activities.

Based on interview and document review, the facility failed to have evidence of a goal, an action plan, and analysis of data brought forth for the identified Performance Improvement Projects (PIP). This had the potential to affect all 35 residents residing at the facility. Findings include: Review of QAPI minutes provided from March 2025 through May 2025 identified the facility PIP plan for 2025 as follows: March 2025: 1) Call light response times, a trend had been identified. The facility was going to initiate call light audits, identify a root cause, and provide staff education. The director of nursing and nurse manager would provide oversight. There was no goal identified. 2) Notification of change in condition, identified there was an action plan however, there was no documentation of what the action plan was. There was no identified goal, or analysis of any data that had been brought forward to the committee. 3) Enhanced barrier precaution identified there was an action plan however, there was no documentation of what the action plan was. There was no identified goal, or analysis of any data that had been brought forward to the committee 4) Air mattress monitoring identified there was an action plan however, there was no documentation of what the action plan was. There was no identified goal, or analysis of any data that had been brought forward to the committee April 2025: 1) Call light response times, a trend had been identified. The facility was going to initiate call light audits, identify a root cause, and provide staff education. The director of nursing and nurse manager would provide oversight. There was no goal identified. Documentation remained the same from previous month. 2) Notification of change in condition, identified there was an action plan however, there was no documentation of what the action plan was. There was no identified goal, or analysis of any data that had been brought forward to the committee. Documentation remained the same from previous month. 3) Air mattress monitoring identified there was an action plan however, there was no documentation of what the action plan was. There was no identified goal, or analysis of any data that had been brought forward to the committee. Documentation remained the same from previous month. QAPI minutes lacked identification of the PIP of enhanced barrier precaution or analysis of the data brought forth and decision to end the PIP project. May 2025: 1) Notification of change in condition, identified there was an action plan however, there was no documentation of what the action plan was. There was no identified goal, or analysis of any data that had been brought forward to the committee. Documentation remained the same from previous month. QAPI minutes lacked identification of the PIP of call light response times or analysis of the data brought forth and decision to end the PIP project. The QAPI minutes also lacked identification of the PIP of air mattress monitoring or analysis of the data brought forth and decision to end the PIP project. Interview on 6/16/25 at 1:03 p.m., via email communication identified the facility had no material or details of the PIP projects other than what was mentioned in the QAPI minutes. On 6/12/25 at 4:00 p.m., a message was left for medical director, with no return call. On 6/16/25 at 11:30 a.m., a message was left for medical director, with no return call. A policy was requested but not provided by end of the survey.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employee would be able to return to work after an illness, dependent upon their symptoms for 3 of 3 sampled staff (housekeeping aide (HA)-A, speech therapist (ST)-A, and certified nursing assistant (NA)-A. This had the potential to affect all 35 residents. Findings include: Review of Employee Absence Report sheets from February through June 2025 identified the following areas of documentation: employee name, department, job title, symptom onset, illness reported, last shift worked, resolution date, return to work, specimen source, and treatment results. However, the facility did not accurately complete the logs to ensure all necessary information was monitored or identified how staff were cleared to return to work. Review of the February 2025, employee illness log identified: housekeeping aide (HA)-A was noted to have called in to work with symptoms of fever on 2/20/25. HA-A returned to work on 3/03/25. Review of February 2025 resident infection log identified the facility had coronavirus disease (COVID) outbreak in the facility. Review of the March 2025, employee illness log identified: speech therapist (ST)-A was noted to have called in to work with symptoms of sore throat on 3/06/25. ST-A returned to work on 3/17/25. The log identified ST-A had completed a COVID test, however the log lacked evidence of the results. Review of March 2025 resident infection log identified no residents with COVID. Review of the June 2025 employee illness log and matching timesheets identified certified nursing assistant (NA)-G was noted to have called in to work with symptoms of diarrhea (loose watery stools) on 6/02/25. NA-G returned to work on 6/04/25. There was no mention when or if HA-A, ST-A or NA-G symptoms resolved prior to returning to work. Interview on 6/12/25 at 4:22 p.m., with administrator identified employees who were ill reported their symptoms to the director of nursing (DON). Employees was to notify the DON of their next day of work. The DON was to review the employee health status for clearance to return to work. Administrator identified NA-G symptoms had improved once NA-G had returned to work. However, the administrator was not aware if NA-G had potential norovirus or if NA-G was prescribed medications to treat diarrheal symptoms. Administrator would expect employee illness logs to reflect accurate documentation and tracking of employee illnesses, review facility and Center of Disease Control (CDC) policies of when an employee was to return to work. Review of November 2024, Infection Prevention and Control Program policy, under section: Monitoring Employee Health identified the facility staff, contractors, vendors, visitors and volunteers was to report infections such as, draining skin wounds, active respiratory infections or frequent diarrheal stools to the infection preventionist (IP). Review of December 2024, Return to Work Criteria for Healthcare Workers (HCW) policy identified employees requested to return to work was self- monitor for symptoms and seek evaluation from IP or designee, if symptoms reoccur or worsen. HA-A and ST-A timecards was requested but not provided.

Based on observation, interview, and document review, the facility failed to act promptly and provide resolution for resident concerns related to the dietary department failure to post upcoming menus. Findings include: Review of resident council minutes identified the following: 1.) January 2025, 4 residents attended the meeting, 2 residents voiced a concern that the menu was not posted, and the facility did not provide them to the residents. A Resident Council Departmental Response Form noting an identified issue: residents state the lunch and dinner menu was never posted, they never get a menu and when they ask the kitchen staff what the next meal is, they are often told food' or I don't know. The Response/Actions Taken: Due to cooler and freezer space we did not have the room to store all the ingredients on the menu. Moving forward we will be working with the director of nutrition to make ends meet. He was working with staff on better communication with the residents. Going forward the following weeks menus will be posted by the end of each week. The form was signed by the dietary manager and the administrator. 2.) February 2025, Old Business: Menus being posted or handed out have had no improvement. 3.) March 2025, Old Business: Menu doesn't get posted and menu is not handed out. No improvement. Resident Council Departmental Response Form: The menu has not been posted consistently and residents have not been given a menu to choose from. Dietary director response: due to the Avian flu effecting the availability of eggs and a cooler being down, staff were unable to get all the products for the menu. As of 3/28/25 menus have been posted. The form was signed by dietary manager and administrator on 4/2/25. 4.) May 2025, no residents attended resident council. Interview on 6/12/25, at 1:41 p.m., with the activity director identified she organizes and attends and records minutes for the resident council. She confirmed the above findings and identified that in February of 2025, when residents reported there was no improvement with the posting of menus, she brought that information forward to the Quality Assurance and Performance Improvement (QAPI) committee and submitted a second department response form to the dietary manager. Review of March 2025 QAPI minutes identified resident council members stated the menu did not get posted and they would like it posted. The QAPI minutes made no mention of how the facility was going to ensure menus would be posted going forward. Observation on 6/12/25 at 12:00 p.m., of facility hallways, resident rooms, and entrance to dining room identified no upcoming menu posted. Interview on 6/12/25 at 12:23 p.m., with the dietary manager confirmed they have not been posting the weekly or monthly menus. He was notified that resident council had complained about upcoming menus not being posted. He attended a meeting and explained to the residents that kitchen has had some supply issues and a cooler that was temporarily down so he has had to adjust the menu on a daily basis. Going forward, he would print the weekly menu and leave them at the nurse's station for nursing assistants to pass out. He acknowledged he had not followed through or maintained the resolution and said he had the menus; however, he did not print them for residents or get them posted. Interview on 6/12/25 at 2:10 p.m., with the administrator identified he was aware there were concerns brought forward at resident council regarding the menus not being posted. He agreed there should be at least one week's menu posted in a resident area and reports he gave the dietary manager a copy of the policy to review and sign. He was not aware if the menus were currently being posted or not. He was unable to provide any documentation that he had completed any audits or follow up with residents to ensure the education provided was effective or to ensure the concern had been resolved. Review of the current, undated Facility Menus Policy identified menus would be written at least two weeks in advance and copies of the menus would be posted in at least two resident areas, in positions and in print large enough for residents to read them.

R27's 4/24/25, 14-day admission assessment, MDS identified her cognition was intact, and she required supervision to moderate assistance with activities of daily living, (ADLS). Her diagnosis list included ataxia, (impaired balanced or coordination), weakness, COPD, chronic back pain, and paranoid schizophrenia. R27's medical record identified MDS assessment: 1)4/8/25 entry tracking record 2) 4/13/25 discharge with return anticipated, with a 4/18/25 entry tracking record 3) 4/24/25 14-day admission assessment Review of R27's Hospital after visit summary identified she was hospitalized [DATE] through 4/18/25 with acute midline low back pain with right-sided sciatica, ((pain radiating along the sciatic nerve, which runs down one or both legs from the lower back). R27's 4/13/25 at 10:35 p.m. progress note identified she had called 911 from her room with complaints of back pain. The ambulance arrived and she was transferred North Memorial hospital and admitted to acute care. Review of the transfer and facility documentation failed to identify the Ombudsman had been notified of R27's discharge to acute care hospitalization. Interview on 6/11/25 at 4:45 p.m. with the director of nursing (DON) identified the Ombudsman had not been notified of R27's discharge to acute hospitalization on 4/14/25. Based on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 4 of 5 residents (R7, R18, R27, R35) reviewed for hospitalizations. Additionally, the facility failed to ensure the resident and/or legal representative had been informed of bed hold rights and ensure a written notice of transfer was provided for 1 of 5 resident (R18) reviewed for hospitalizations. Findings include: Ombudsman notices: R18's 4/9/25, quarterly Minimum Data Set (MDS) assessment identified R18's cognition was intact, R18 was dependent on staff for transfers and R18 attended dialysis. R18's 6/12/25, printed Medical Diagnosis list identified cystic fibrosis, immunodeficiency, lung transplant, dependence on renal dialysis, pulmonary nocardiosis (infection of lung), invasive pulmonary aspergillosis (a type of fungal infection of the lungs affects immunocomprised patients), diabetes, end stage renal disease, major depressive disorder. History of malignant neoplasm of thyroid, and attention-deficit hyperactivity disorder. R18's medical record identified the following MDS assessments: 1) 7/4/24 discharge with return anticipated, with a 7/12/24 entry tracking record 2) 7/15/24 discharge with return anticipated, with a 7/20/24 entry tracking record 3) 10/4/24 discharge with return anticipated, with a 10/11/24 entry tracking record 4) 10/12/24 discharge with return anticipated, with a 10/15/24 entry tracking record 5) 10/26/24 discharge with return anticipated, with a 11/1/24 entry tracking record 6) 1/2/25 discharge with return anticipated, with a 1/5/25 entry tracking record R35's 4/10/24, admission MDS assessment identified R35's cognition was moderately impaired. R35 wandered 1-3 days during assessment period, was independent with grooming with supervision. Attended speech, occupational, and physical therapy and planned to return to community. R35's 6/12/25, printed Medical Diagnosis list identified traumatic subdural hemorrhage without loss of consciousness, dementia, multiple fractures of ribs, weakness, hyponatremia, anemia, and hypertension. R35's medical record identified MDS assessment 4/18/24 discharge, return not anticipated. Review of the notices to the ombudsman that the facility provided identified: 1) 8/1/24 monthly notice for July 2024 discharges-R18 was not listed 2) 9/4/24 monthly notice for August 2024 discharges-R18 was not listed 3) 11/1/24 monthly notice for October 2024 discharges-R18 was not listed There were no other notices to the ombudsman provided by the end of the survey. Bed hold notice: R18's 4/9/25, quarterly Minimum Data Set (MDS) assessment identified R18's cognition was intact, R18 was dependent on staff for transfers and R18 attended dialysis. R18's 6/12/25, printed Medical Diagnosis list identified cystic fibrosis, immunodeficiency, lung transplant, dependence on renal dialysis, pulmonary nocardiosis (infection of lung), invasive pulmonary aspergillosis (a type of fungal infection of the lungs affects immunocomprised patients), diabetes, end stage renal disease, major depressive disorder. History of malignant neoplasm of thyroid, and attention-deficit hyperactivity disorder. R18's medical record identified the following MDS assessments; 1/2/25 discharge with return anticipated, with a 1/5/25 entry tracking record. The medical record had no documentation that a bed hold had been verbally or physically provided. A copy of the bed holds for hospital transfer on 1/2/25, was requested but not provided by end of survey. Review of 6/16/25, email from administrator identified that there was not a bed hold for R18 for 1/2/25. R7's 8/26/24, discharge return anticipated Minimum Data Set (MDS) assessment identified R7 had an unplanned discharge to an acute care hospital. R7's 2/4/25, discharge return anticipated Minimum Data Set (MDS) assessment identified R7 had an unplanned discharge to an acute care hospital. R7's 8/29/24, discharge summary identified he admitted to the hospital on 8 26/24 and returned to the facility on 8/29/24. R7's 2/5/25, discharge summary identified he admitted to the hospital on [DATE] and returned to the facility on 2/5/25. Review of a facility provided Action Summary report noted R7 had discharged on 8/26/24, to Park Nicollet Hospital, however, there was no confirmation the report had been provided to the Ombudsman. In addition, there was no information provided for the 2/4/25 discharge notification to the ombudsman.

Based on observation, interview, and document review, the facility failed to provide for Activities of Daily Living (ADL) related to assisting with toileting, turning and repositioning, queuing for food and hydration needs, and assisting with personal hygiene for 4 of 7 sampled dependent residents (R2, R7, R24, and R137). Findings include: R24 R24's 4/14/25 Significant Change Minimum Data Set (MDS) assessment identified she had severe cognitive impairment, required extensive to total assistance with ADLs including toileting and personal hygiene. She was incontinent of both bowel and bladder and wore a disposable brief. R24 had diagnoses of a cerebral vascular accident (CVA-stroke), Post Traumatic Stress Disorder (PTSD), seasonal affective disorder, skin cancer oh her left thigh, hemiplegia of right dominant side (paralysis of one side of the body), depression, and aphasia (inability to speak), and malnutrition and had been admitted to hospice due to rapid decline. R24 required supervision for eating or touching assistant and staff needed to provide verbal queues as R24 completed the task. R24's current undated care plan identified she was admitted to hospice on 4/8/25 for weight loss, poor food and fluid intake was noted to be expected and unavoidable related to her disease progression. Staff were to encourage food and fluids for pleasure as accepted by R24. Staff were to monitor and report to the physician concerns of choking, swallowing, holding food in her mouth as she makes several attempts at swallowing and has a known history of refusing to eat. Staff were also to monitor her malnutrition and report a significant weight loss and offer meals at later times if needed if the resident was asleep. The facility was to maintain communication with hospice and keep them informed of R24's condition and monitor R24 for non-verbal signs and symptoms of discomfort. Dietary supplements were also ordered and R24 was to be encouraged by staff to take them. Staff were also to assist R24 with personal hygiene, dressing and bathing. Random observations on 6/9/25 of R24 in her room identified at: 1) 1:00 p.m., R24 was lying in bed yelling out and crying. Staff entered the room and attempted to comfort R24. 1) 1:15 p.m. of she laid on her back in bed asleep and her eyes were closed and her knees were bent with her feet resting against the bed. Her noon meal tray sat on the bedside table uncovered and untouched. She had a water pitcher beside her tray that was partially filled and warm to the touch. An unidentified staff member entered R24's room, picked up the tray, without offering any food or drink and carried it to the cart to be returned to the kitchen. 2) 3:00 p.m. R24 was noted to remain in the same position in bed, crying and rubbing her knees. Her lips appeared dry. R24 made no attempt to reach for her water pitcher which remained in the same spot as previously noted and did not appear to have been refreshed. Staff persons were observed in the hall, but no one entered R24's room to attempt to queue her, assist her, or offer her a drink. 3) 5:45 p.m. R24 remained on her back in bed, with head slightly elevated and knees bent with feet resting on bed. Her supper tray was on the bedside table beside her bed, uncovered and untouched. The water pitcher remained in the same location, and did not appear to have been refreshed. 4) 6:15 p.m. R24's tray had been placed on the cart to be returned to the kitchen and appeared untouched. R24 remained in the same positioned on her back and appeared to be sleeping at the time of observation. R24's physician progress notes identified on: 1) 11/27/24, R24's physician (MD) noted she had an 11-pound weight loss. The MD noted it was difficult to ascertain exactly what was causing her decreased appetite, although likely depression related to her significant CVA. 2) 1/28/25, during their visit, R24 was sobbing. She was unable to tell them what was wrong, stated she was having pain, but was unable to say where and continued to sob through the visit. Psychiatry was ordered with the addition of topical pain medication. 3) 2/21/25, R24's MD noted she was sobbing again. Staff reported she does that most mornings. She denies pain but was noted to be clearly distressed. R24 was on anti-depressants for mood. 4) 2/27/25, R24's MD note was noted to be alert, present, and lying comfortably in bed. She had not interacted meaningfully during her MD visit due to her stroke. 5) 3/28/25, R24 was referred to hospice related to her stroke, weight loss, and cognitive deficit. 6) 4/2/25, R24 was noted to have weight loss from poor oral intake with refusals of food or drink. Staff were to encourage food and fluid intake. Dietary supplements were being provided. A conversation was had with the nurse manager, administrator, and family about R24's hospice referral. R24 was noted to be in significant pain and was unwilling to let staff turn and reposition her. 7) 4/4/25, R24 was noted to remain intermittently tearful and had ongoing weight loss. R24's dietary note identified on 4/14/25, R24's weight status was reviewed. Her weight was noted to be quickly trending down which was reported to be expected related to (r/t) hospice care. R24 was noted to be often refusing meals. R24's weight loss and poor oral intake was noted to be expected and may be unavoidable r/t hospice and her disease progression. Staff were to encourage food and fluid intake for pleasure and as accepted by resident. R24's 4/27/25 Nursing behavior note identified R24 was refusing medications and eating. She was also crying. Her pain and anxiety medication was given and R24 was encouraged to drink fluids. Observation and interview on 6/10/25 at 7:51 p.m., of R24 in her room identified R24 was noted to be crying and lying in bed. Registered nurse (RN)-A was observed to enter the room and attempted to comfort R24. R24 continued to cry, so RN-A advised the nursing administering medication to administer pain medication to R24. R24 last received pain medicating at 5:12 a.m. Interview on 6/10/25 at 8:25 a.m., with registered nurse (RN)-A identified R24 was not able to speak and had issues with anxiety and crying frequently and would touch and rub her knees due to pain. R24 remained in bed due to her leg contractures and discomfort, and would refuse repositioning and personal cares. RN-A reported she had orders for both scheduled and as needed (PRN) pain medications and PRN antianxiety medications. R24 had been admitted to hospice services the first part of April 2025 due to her CVA and decline in condition. RN-A identified PRN medication was given when a resident requested it and stated since R24 was not able to speak, staff would need to assess her for non-verbal indications for pain/anxiety. Interview on 6/10/25 at 11:24 a.m. with hospice nursing aide (HNA)-E as she prepared to perform personal cares for R24 identified when she came to visit, she frequently discovered R24 with a wet and/or soiled brief. Her top was often soiled, as was her bedding. NA-E had last visited R24 on 6/3/25. At that time she had noticed some redness alone her spine and coccyx area. Her feet were against the bed, but there were no open areas she noted. NA-E had updated both the case manager at the facility and the hospice nurse of her findings and documented it. R24 was often seen crying, moaning, and rubbing her knees and she would ask the facility nurse to see if she could assess R24 to see if pain or anxiety medication would need to be administered before she provided her cares. Review of the hospice nurse aide notes identified on: 1) 4/9/25, the NA initial visit was performed. The NA only noted she assisted with a transfer. No concerns noted at that time. 2) 4/16/25, R24 was given a bed bath and personal hygiene was performed. No concerns were noted on in the documentation. 3) 4/22/25, R24 was lying in bed and was very emotional. Staff noted they had to cut the back of her hair due to matting and washed it afterwards. Family was present. 3) 4/24/25, R24 was noted to have a big smile when the NA arrived. R24 was seen wearing the same shirt since her last visit on 4/22/25. 4) 4/29/25, R24's bath was completed, her hair washed, lotion applied, her brief changed. Redness was noted on her bottom and staff refilled her water glass. No concerns were noted on in the documentation and there was no documentation to support the hospice NA made the facility aware of the redness. 4) 5/1/25, hospice assisted with lunch and refilled her water. No concerns were noted on in the documentation. 5) 5/6/25, The NA completed a bath and washed her hair. [R24] didn't eat lunch. 6) 5/8/25, R24 was lying in bed, woke to the NA's voice. R24 was noted to be soiled in her brief and on her sheets. Her shirt, brief, and sheets were changed. No mention she performed any bathing. 7) 5/13/25, R24's bath was completed, hair was washed, and her brief changed. 8) 5/27/25, R24 was noted to be very emotional and cried the entire visit. Staff completed her bath and washed her hair. etc. Interview on 6/10/25 at 12:30 p.m. with the hospice RN-B reported she was notified of R24 having areas of bruising on her coccyx and heels on Sunday 6/8/25, and had visited R24 on Monday 6/9/25, but had not assessed the areas due to R24 sleeping. As a precaution, she had ordered cushioned blue boots (Prevalon boots) and an air mattress on 6/9/25. RN-B expressed concern for the lack of communication between facility staff and Hospice. RN-B verbalized her concern with personal care provided to residents at the facility and explained R24 had been admitted to Hospice on 4/8/25, and at that time, the room smelled strongly of urine and feces. In addition, during one of nursing assistant (NA)-F's first visits, not only did R24's room smell of urine and feces, she was wearing soiled clothing, and her incontinent brief and bedding was soiled with urine and feces, necessitating a complete bed bath and full bedding change. The HNA contacted her to report R24's hair was so dirty and matted, it would need to be cut as there was no way it could be washed and combed. Family members (FM)-A and FM-B were in attendance at that time and in agreement with cutting the matted hair which was so thick it appeared as dreadlocks (a hairstyle purposefully made of rope-like strands of matted hair). Review of R24's hospice nursing notes identified on: 1) 4/11/25, R24 was noted to be up in bed resting comfortably watching TV. R24 had normal vitals. 2) 4/22/25, 4/25/25, 4/29/25, and 5/2/25, hospice noted they were providing routing visits. R24's skin was intact, and they had no concerns at any of those times. 3) 5/13/25, R24 was noted to be tearful on their arrival. Hospice repositioned R24 and comforted her and assisted her with breakfast. Facility staff administered pain and anxiety medication during the visit. Upon hospice leaving, R24 was noted to be calm and speaking with family. No concerns were noted at that time and they would continue to monitor her appetite, weight and mood. 4) 5/16/25, Hospice noted R24 was resting comfortably. The facility was noted to be utilizing the as needed (PRN) pain and anti-anxiety medication more frequently to avoid tearful episodes. No concerns were noted. 5) 5/20/25 and 5/27/25, hospice noted No concerns at that time. 6) 6/9/25, hospice noted the facility had updated them on 6/8/25 at 7:00 p.m., that R24 had 3 new pressure ulcers. The hospice nurse noted they came to the facility on 6/9/25, however, she did not assess R24's pressure ulcers as she was asleep and resting comfortably and had not wished to disturb her due to significant pain when moving and repositioning. 7) 6/10/25, hospice did attempt to observe her heels somewhat but R24 started to yell out in pain and swatted the hospice nurse away. Hospice called the family, and per their wishes, no wound care was to be provided as it is painful and distressing to R24. Hospice supported the decision, and the focus would be to keep R24 as comfortable as possible. Hospice ordered an air mattress. R24 was noted to be in her final moments and had daily hospice and nurse aide visits. Hospice would continue to monitor and assess R24's rapid decline and comfort level. Continued interview 6/10/25 at 12:30 p.m. with RN-B identified there were 2 additional residents she had heard about whose hair had to be cut due to reported lack of care. RN-B further reported R24 frequently did not have fresh water. If her meal tray was in the room, it was often untouched. R24 was known to eat minimal bites of food but drank thirstily when liquids were offered. The hospice NA reported to her R24 was frequently wearing a soiled brief and needed a full bed bath in addition to her clothing and bedding changed when the NA would arrive for their visits. Telephone interview on 6/10/25 at 2:11 p.m., with hospice NA-F identified on 4/22/25, R24's FM-A and FM-B were in attendance and observed R24's hair extremely dirty and matted. She was not able to detangle it with a comb or brush due to the thickness of the matting, described it as appearing like dreadlocks. Both FM-A and FM-B had agreed with NA-F there was no other option except to cut her hair to remove the matting. She voiced their concern over the lack of care. NA-F contacted RN-B to obtain permission to cut R24's hair. FM-A and FM-B stated they had not reported their concerns about lack of care to the facility. NA-F further stated when she arrived for scheduled visits, she frequently noted R24's room smelled of urine and her clothing, bedding and brief were wet and required changing in addition to needing to provide a full bed bath. She identified she had reported this to the facility nurse manger, who responded, thank you for doing that, but nothing appeared to have changed. Review of a photograph of R24's cut hair from 4/22/25, provided by anonymous (A)-A identified a large amount of heavily matted, tangled, hair that had to be cut off R24 as it could not be combed through. Dense knots could be seen throughout the tightly-woven hair ball cluster. Interview on 6/10/25 at 1:30 p.m. with the DON reported she was aware of R24's hair having to be cut due to it being heavily matted. She expected staff to wash residents hair during bathing and combing and/or brushing was to be done with morning and evening cares each day. She agreed care had not been adequately provided to R24 related to ADL's, and staff should be offering liquids and/or food with interactions with R24. Interview on 6/10/25 at 4:28 p.m. FM-A identified they were concerned about R24's lack of care cares and stated they visit daily if possible. FM-A had been out of state intermittently from January 2025 through March of 2025, but returned during at times to visit and were shocked at R24's decline in condition. As a result of the decline, they made the decision to start Hospice services on 4/8/25 with the intent to keep R24 comfortable. FM-A stated R24's clothing was often soiled and not changed for days at a time. R24's room often smelled of urine and feces (BM). Her water pitcher was often empty. Both FM-A and FM-B had been in attendance when NA-F had to cut R24's hair due to the condition it was in. When they visited, her hair was always messy. They hadn't really visualized the back of her head prior to that day on 4/22/25, due to R24's positioning and being painful with repositioning, so they not certain how long it was in that condition. Interview on 6/10/25 at 5:23 p.m., with FM-B identified she voiced concerns about care provided for R24, and when she arrived her clothing was often soiled. She had waited 3 days once to see if her clothing was changed, and on the third day, she had to ask staff to please change R24's shirt. Continuous observations and interview on 6/11/25 of R24 in her room identified at: 1) 7:15 a.m., R24 was seen lying on her back in bed, eyes open and breathing through her mouth. She exhibited no crying or moaning at that time. Her room door was partially closed. Multiple staff passed by out in hall, but none entered the room. R24 had a water pitcher on her bedside stand that was partially filled, and warm to the touch, and her lips appeared dry and flaky. 1) 8:11 a.m., a breakfast tray was delivered to R24's room by NA-A and placed on the bedside table. No attempt was made by NA-A to queue R24 to drink or eat or offer their assistance. 2) 8:32 a.m., several unidentified direct care staff were seen walking passed R24's room. None of those staff checked on R24 or attempting to assist her to eat or drink. 3) 8:43 a.m., no staff had yet entered her room to offer food, fluids, or repositioning. 4) 8:52 a.m., R24 remained lying on her back. R24 made no attempts to eat or dink. No staff have entered her room to provide queuing. 5) 9:05 a.m. NA-C walked down hall and looked in as he passed the room, but did not enter. R24's breakfast tray remained covered on the bedside table. 6) 9:15 a.m. NA-C entered R24's room, picked up her tray placed it on cart to return to the kitchen. NA-C was interviewed at the time of the observation. He confirmed the tray was untouched, and reported the staff who had delivered the tray should have returned to assist the resident with her meal. Upon this surveyors request, NA-C offered R24 a drink to identify if R24 would respond to queuing. R24 then drank some of her milk. NA-C stated he would go and check to see if staff had attempted to feed R24. 7) 9:20 a.m., NA-C reported NA-A had gotten busy and had forgotten to return. NA-C stated he would leave to go and warm the food on R24's tray and return with attempt to feed R24. 7) 9:30 a.m. NA-C returned and offered R24 fluids. R24 took a few sips when queued. NA-C offered bites of oatmeal. R24 accepted a couple of bites before turning her head away. NA-C stated R24 had not been eating much but was normally offered food and fluids. Interview on 6/11/25 at 3:30 p.m., with the nurse practioner who made rounds at the facility reported R24 had cognitive and emotional issues related to Pseudobulbar affect (a medical condition that causes crying and/or laughing that is sudden, frequent, uncontrollable, and exaggerated and exaggerated or doesn't match how a person feels). She was not aware of R24 routinely refusing cares. She reported she had not been informed of the concern of matted hair. She would have expected to be notified of the incident where her hair was so matted it had to be cut, and for administration to address the issue with staff. She was however, aware of a different resident who also had to have their hair cut due to excessive matting. The NP reported not only could the matting have caused skin breakdown but could have been painful for the resident. The NP voiced her concern that there had been a breakdown in communication between the facility and her office over the last 6 months and she was not certain why this had occurred. Interview and document review on 6/11/25 at 4:31 p.m. with the administrator, DON, nursing consultant identified they were made aware concerns regarding lack of staff offering food to R24. All had voiced agreement of their expectation for staff to offer and/or provide personal care, food, and fluids. When interviewed regarding R24's hair being matted and requiring cutting, the DON replied hair care was part of personal care, and should be washed with bathing, and combed or brushed with daily care. She agreed staff had not been performing personal care as they should have been. She had not completed audits or observations to ensure appropriate personal care was provided to all residents. The administrator reported known concerns with resident care or needs was discussed at daily interdisciplinary meetings, but documentation was not routinely kept. His expectation for personal cares identified hair care was to be provided to residents daily and as needed. Attempts to contact the medical director twice on via telephone on 6/12/25 at 4:00 p.m. with a message and return number left, and again on 6/16/25 at 11:30 a.m. with a message left requesting a return call. No call back was provided. R7 Review of the 10/29/24, facility reported State Agency (SA) report identified R7 had complaints of being left in a wet brief for extended lengths of time. R7's 3/26/25, quarterly Minimum Data Set (MDS) identified his cognition was intact, he felt down and depressed 2-6 days weekly, and had no behaviors. R7 required the use of a wheelchair, he was frequently incontinent of urine and occasionally incontinent of BM. He had diagnoses of heart failure, seizures, anxiety, depression, compression fracture, asthma, weakness, and was unsteady on his feet. R7 was at risk for pressure ulcers and took pain medications on a routine basis. R7's current care plan identified he had an alteration in elimination with a goal to be continent during waking hours. The care plan identified direct care staff would assist R7 with toileting but did not identify how often. Staff would provide assistance with peri cares every a.m. and h.s. and as needed. The care plan identified a toileting plan of a.m./h.s. cares, before/after meals, and PRN during the night. Interview on 6/9/25 at 1:57 p.m., during resident screening R7 identified it took a long time for staff to answer call lights and the facility was understaffed and over worked. He reports he has been incontinent from waiting to long to have his light answered, he stated it makes me feel pretty bad however, had no report it affected him physically or emotionally. He just said it makes him feel bad?. He identified he was not normally incontinent but he thinks the facility encourage incontinence when residents first come in. He has reported it to management but they just write it down and nothing changes. He was told by a nurses aid that the rule of thumb is 2 visits by staff per day and that it was a law but reported he knew that was not true. Follow up interview on 6/12/25 at 9:27 a.m., with R7 identified he could not recall this exact incident but reports the same situation has happened multiple times since he had been at the facility. He reported about 6 months ago he had been changed at 6:30 a.m., and did not get changed again until 6:30 a.m. the next morning, he said his whole bed was wet and covered in urine. It took staff about an hour to answer his call light. When they get him up in the morning, they only wash his face, and they gave him a bath once a week. He reports staff have never offered to wash more than just his face in the morning and says he did not know they were supposed to do any more than that. He reports staff have never offered to take him to the toilet, they only come change his brief when he requests it. He says it makes him feel terrible that he must go to the bathroom in his pants and it makes him angry that someone doesn't care enough to help him to the bathroom or answer his call light timely. R7 identified there were times when staff arrive in 5 minutes but that is unusual. He recalled another time when his son was visiting, and they had plans to go on an outing. He had put on his call light for assistance with changing and getting ready to leave, he reported they waited about an hour then his son finally went down to the nurse's station and complained. The staff did eventually come and assist him. Interview on 6/12/25 at 3:02 p.m., with family member (FM)-I identified he had been to the facility for a visit to take his dad on an outing, his dad put the call light on, and they waited for an hour, he went down to the nurse's station and complained. He could not recall who he spoke to but said it was one of the nurses. He reported it still took another 20 minutes for staff to come and assist his dad. He reports his dad has called him on other occasions and complained that it takes a long time for staff to come assist him when he puts his call light on. Interview on 6/11/25, at 2:30 p.m., with the director of nursing identified she did not have any documented audits completed to ensure staff were providing complete and thorough cares. Interview on 6/16/25 at 11:41 a.m., with registered nurse (RN)-A identified she does the care plans. She reports her expectation is when she notes on the care plan that staff should assist with hygiene they should be washing face, underarms, peri-care, oral cares, hair care. She would expect staff to answer call lights timely. R137 Review of State Agency (SA), complaint on 10/28/24 at 3:40 p.m., on 1/27/25, R137 was transferred to a local senior living community. Upon arrival, facility staff nurse identified R137 was found with dried poop on her back, feet was dirty and dry, hair appeared matted, and had a body odor. R137 had informed the staff nurse that R137 had not had a shower in three months. R137's current, undated diagnosis sheet identified R137 had a diagnosis of a diagnosis of paraplegia (inability to control or move lower half of the body) and myelitis (inflammation of the spinal cord). R137's 1/27/25, discharge Minimum Data Set (MDS) identified R137 was cognitively intact and had R137 had little interest or pleasure in doing things, felt down, depressed or hopeless never to 1 day. R137 was dependent on staff with activities of daily living (ADL's). R137 was 5 feet (ft) and 3 inches (in). R137 no pressure ulcers. Interview on 06/10/25 at 8:31 a.m., with clinical coordinator (CC)-A, was informed by a staff nurse that R137 was found with matted hair on the back of her head and was unable to comb it. CC-A identified that R137's skin appeared dry and dirty. R137 was given a bath and her hair was cut. CC-A was concerned about the lack of cleanliness of R137's hair and skin and filed a report on R137's behalf. Interview on 6/10/25 at 2:23 p.m., with registered nurse (RN)-A identified R137 refused cares from facility staff during her stay and had a personal caregiver come in to assist R137 with her activities of daily living (ADL's). Before R137's was discharged , RN-A had completed a physical assessment of R137 who appeared clean and had no matted hair. R137's 1/27/25, discharge instructions and summary progress note identified R137 had bowel and bladder incontinence, had adequate hearing and vision and performed activities of daily living (ADL's) as tolerated. The medical record lacked evidence that a physical assessment had been completed. Interview on 6/11/25 at 2:04 p.m., with personal care assistant (PCA)-A visit R137 in the mornings at the nursing home, approximately between 8:30 a.m. to 9:30 a.m., for about one hour to accompany R137 at the bedside. PCA-A would assist R137 with meals and basic grooming task. On several occasions, during her visit, PCA identified R137's hair appeared matted when R137 was in bed and would comb it out. R137 had complained to the PCA-A that staff would not change her. R137's concern was brought to the nurse manager and was not addressed. During PCA-A's visit, R137 would press the call light for assistance, nursing staff would enter and ask the PCA-A to assist them with R137. PCA-A informed nursing staff that she could not help them. Staff replied to PCA-A that that they would need 2 people to assist R137. R137 had waited 45 minutes for staff assistance and yelled in pain when moved. PCA-A identified R137 appeared frustrated at the nursing staff. Interview on 6/12/25 at 11:23 a.m., with R137's family member (FM)-O was aware that R137 had worn long hair down her back. When R137 arrived to her new facility, FM-O identified R137's hair was not brushed and appeared messy. FM-O stated, if someone had tried to comb it, R137 would be in pain. R2 R2's 3/27/25, quarterly Minimum Data Set (MDS) assessment identified R2 had severe cognitive deficit. R2 had other behaviors 1-3 days. R2 was able to eat after set-up assistance but was dependent on staff for all other cares. R2 received a scheduled pain medication, an antipsychotic, anticoagulant, anticonvulsant, and diuretic. R2 had the diagnoses of cancer, hypertension, arthritis, stroke affecting the left side, dementia, depression and one-sided weakness. R2's 9/5/24, care plan identified alteration in mobility related to cognitive impairment, limitation movement, and muscle weakness. R2 required assist of 2 staff with all transfer. Staff were to provide routine skin care in morning and evening. Weekly skin audits would be completed with bath or shower. R2 relied on extensive assist of 1-2 staff with her grooming and staff were to encourage her to participate as able. Interview on 6/9/25 at 3:21 p.m., with family member (FM)-K identified she did not want shaving done on R2's chin hairs but rather wanted staff to pluck the chin hairs. FM-K had a concern that cares were not being completed daily. Staff were not charting in the book that family had requested them to chart in each time care had been completed. FM-K reported that R2 had been admitted to hospice that morning and she had reported her concerns about good cares to the hospice nurse. Observation on 6/9/25 at 4:24 p.m., of R2 laying in her bed sleeping, whiskers are visible on chin, there are multiple whiskers that are approximately 1/8 inch long. Observation on 6/10/25 at 8:51 a.m., of licensed practical nurse (LPN)-A in R2's room talking to her, R2 does not open her eyes but responds to LPN-A. R2 has multiple visible chin whiskers observed. Observation on 6/10/25 at 9:58 a.m., of nursing assistant (NA)-B, NA-C, and NA-D who entered R2's room to provide morning cares. NA-D reported that it was easier to complete cares with 3 staff, but it could be done with 2 staff. The staff proceeded to provide a bed bath to R2. Staff did not wash R2's hair, nor did they shave R2's multiple long chin whiskers prior to exiting R2's room. Observation on 6/10/25 at 12:11 p.m., R2 was sleeping in her bed, multiple long chin whiskers are visible from the doorway. Interview on 6/10/25 at 12:30 p.m., with hospice nurse identified R2 had been admitted to hospice the day prior and that family was concerned with how cares had been done. FM-K reported to hospice that personal was a priority for the family and wanted to make sure that R2 received good thorough cares. Observation on 6/11/25 at 10:20 a.m., R2 in her bed looking at Bible, she has no visible chin hairs on her face. She is wide awake with the TV on. Interview on 6/11/25 at 1:51 p.m., with NA-C identified he had never shaved R2 or any female in the facility. NA-C reported there was a family member down the other hallway that shaved one of the ladies. NA-C revealed that the staff do not shave R2's whiskers and he was unsure if R2's family ever shaved her chin hairs. Interview on 6/11/25 at 1:54 p.m., with NA-B identified she shaved lady's whiskers but had not shave R2's chin hairs. She reported hospice had shaved R2's chin whisker earlier today. NA-B then said she did good care; we all do good care. Interview on 6/11/25 at 3:57 p.m., with nurse consultant identified resident cares including facial hair should be addressed how the resident or family wished. Staff should be providing all aspects of care including addressing facial hair on both male and female residents. Review of the 3/31/23, Activities of Daily Living (ADL)/Maintain Abilities policy identified following the resident's comprehensive assessment and choices. The facility will ensure that the residents ADL's do not diminish unless unavoidable due to clinical condition. The facility will ensure appropriate services are provided to maintain or improved the resident's ADL function. The facility will provide care and services to resident's including hygiene, bathing, grooming, dressing, and oral care. For resident's unable to carry out ADL's the staff will provide the necessary services to maintain good grooming, nutrition, and oral hygiene.

Based on observation, interview, and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 when the facility failed to separate COVID positive residents from COVID negative residents resulting in an immediate jeopardy (IJ) due to the increased risk for transmission of COVID-19 for 2 of 2 residents (R1, R2) reviewed for infection control practices. The deficiency was identified as past noncompliance and issued at Immediate Jeopardy. The past noncompliance IJ began on 11/22/20, was removed and the deficient practice was corrected by 11/30/20, after the facility implemented corrective action to prevent reoccurrence. The administrator and director of nursing (DON) were notified of the IJ past noncompliance on 12/8/20, at 3:28 p.m., as a result of the corrective action taken by the facility. Findings include: Current CDC guidance last updated 11/20/20, indicated nursing home residents are at high risk of being affected by respiratory pathogens like COVID-19 due to older age and underlying chronic medical conditions. Residents with known or suspected COVID-19 should be placed in a private room with their own bathroom. Residents with COVID-19 should be cared for in a dedicated unit or section of the facility with dedicated staff. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had [DIAGNOSES REDACTED]. R1's COVID-19 polymerase chain reaction (PCR) test result dated 11/17/20, indicated R1 was positive for COVID-19. R2's admission MDS dated [DATE], indicated R2 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 (which indicated intact cognition), had [DIAGNOSES REDACTED]. R2's COVID-19 PCR test result dated 11/17/20, indicated R2 was negative for COVID-19. These comorbidities placed R2 at significant risk for complications if R2 were to contract COVID-19. During interview on 12/08/20, at 10:35 a.m. registered nurse (RN)-A stated she cared for R1 and R2. R1 tested positive for the [MEDICAL CONDITION] on 11/17/20. R2 tested negative for the [MEDICAL CONDITION] on 11/17/20. R1 was symptomatic and lethargic. RN-A stated that because R1 and R2 were roommates when COVID testing took place, they continued to reside in the same room. R1 and R2 shared commode in their room. R1 needed complete physical care and did not use a commode. During observation on 12/08/20, at 9:55 a.m. surveyor entered R1 and R2's room. R1's bed was against the wall that faced the window. There was a space of about 6 feet between R1's bed and the door that led to the bathroom. The bathroom door was closed. R2's bed was against the wall that faced the door. The head of the bed was toward the door. During interview with R2 on 12/08/20, at 10:01 a.m. R2 stated that she was unhappy to be in the room. She did not like to use the same commode with R1 and did not know why she had to stay with R1 when she was COVID-19 positive. R2 stated that she asked to be moved to different room but none had responded to her request. During interview with R1 on 12/08/20, at 10:05 a.m. R1 stated that she was tested COVID-19 positive and had headache, coughing. R1 confirmed she and R2 stayed together in the same room the whole time she was sick. During interview on 12/08/20, at 10:42 a.m. DON stated as far as she knew, R1 and R2 would continue to be roommates since R1 was no longer in quarantine period even though R1 was COVID-19 positive and R2 was COVID-19 negative. During interview on 12/08/20, at 10:57 a.m. the DON and administrator stated they just overlooked R2. They did not realized she was COVID-19 negative and her roommate was COVID-19 positive. During interview on 12/08/20, at 10:57 a.m. the administrator confirmed the COVID-19 policy indicated COVID-19 positive residents ideally would be moved to a private room with a private bathroom. However, she admitted that they overlooked and missed R1 and R2's situation. The administrator confirmed at the time of the onsite visit (12/8/20) there were no COVID positive residents. The CDC People with Certain Medical Conditions, revised November 2, 2020, identified adults with certain underlying medical conditions such as kidney disease, diabetes, or lung disease, are at increased risk from [MEDICAL CONDITION] that causes COVID-19. Severe illness from COVID-19 is defined as hospitalization , admission to the ICU, intubation or mechanical ventilation, or death. The immediate jeopardy (IJ) that began on 11/22/20, was removed on 11/30/20, when the facility took steps to remove the IJ and correct the deficient practice. The policy entitled Coronavirus COVID-19 updated 11/24/20, was revised to include if a resident was COVID positive, they would be moved to a private room with a private bathroom. On 11/30/20, a quality assurance performance improvement committee (QAPI) met and put a plan of correction in place. Those in attendance of the QAPI meeting included; DON, activity director, social services director, administrator, recreation services director, maintenance director and business office manager. The plan identified if a resident was diagnosed with [REDACTED]. The plan also identified before new residents were admitted , the facility would reserve 2 empty rooms for new positive residents. The staff who attended the QAPI meeting (administrator, DON, social services, director, activity director, director of maintenance and business office manager) were interviewed on 12/8/20, and all verified they developed a plan and audit tools and identified positive residents should not cohort together and a positive resident should be in private room. Licensed practical nurse (LPN)-B, who works evenings and weekends, was interviewed on 12/8/20, at 1:06 p.m. and verified residents who were COVID positive should not share and room and should be in a private room with a private bathroom. Review of the audit tool identified the date a resident were diagnosed as COVID positive and if they were in a private room or not. Review of all resident's polymerase chain reaction (PCR) tests also identified there were no COVID positive residents with COVID negative residents in the same room.