Every finding on record at The Gardens at Foley LLC

Based on interview and document review the facility failed to perform a thorough elopement assessment upon admission for 1 of 1 resident (R4) resulting in R4 leaving the facility without staff knowledge.Findings include:R4's admission Record indicated she admitted to the facility 7/14/26. R1's diagnoses included dementia with moderate agitation, depression and transient ischemic attack (a temporary blockage of blood flow to part of the brain that causes stroke-like symptoms without leaving permanent damage).R4's Elopement Risk Evaluation dated 7/14/26, indicated she was not at risk for elopement.R4's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated wandering behaviors occurred one to three days during the assessment period. The MDS indicated R4 transferred and ambulated independently.R4's 48 Hour Care Plan indicated alteration in psychosocial well-being and directed staff to monitor safety concerns as needed, i.e.: elopement.R4's care plan dated 7/14/26, identified an alteration in cognition and an alteration in mood and behavior. The care plan goal indicated R1 would respond to interventions by staff to calm and redirect her. Updated 7/23/26, R4 exhibited wandering behavior related to cognitive impairment that placed her at risk for injury, disorientation and entering unsafe areas.R4's Progress Notes indicated the following:7/15/26- Provider encounter note: Diagnosis included Dementia, severe with agitation. R4 admitted from another long-term care facility where the goal was to regain functional independence. The recommendation upon discharge from the facility was long-term memory care with 24/7 supervision. Brief interview for mental status score was 6/15, which indicated severe cognitive impairment.7/19/26- R4 was wandering around the unit asking what she was doing there and stated she would like to go home. Staff offered activity, snacks and re-direction, which was not effective. Family members called and spent time with R4. R4 in bed at time of note.7/20/26- 7:53 p.m., R4's family member was alerted R4 left the building to go for a walk without informing staff. R4 had not signed out and was educated on the importance of signing out when leaving. R4 was located by the apartment building across the street from the facility. Police were contacted and assisted. R4 stated she wanted to walk to her farm. Wander guard was placed at that time.Untitled facility document dated 7/20/26, indicated staff member last saw R4 at approximately 6:00 p.m. R4 had been in the day room and asked who was in charge so she could talk to them. R4 was re-directed to a recliner to sit. Staff left the area. When staff returned, R4 was up and looking upset. Staff went to assist another resident and upon return was unable to find R4. R4 was located in less than 30 minutes.Untitled facility document dated 7/20/26, indicated staff reported R4 went out the front door because she wanted to go home. Earlier staff had been trying to re-direct R4 due to exit seeking. R4 was located across the street. When asked, R4 said she wanted to go home but someone was chasing her so she hid in the bushes.R4's Community Mobility Assessment Form dated 7/21/26, indicated R4 had increased difficulty with shortness of breath and decreased balance. R4 did not have access to a phone or emergency call when outdoors. R4 was unable to orient to place or location outdoors, lacked capacity or insight into risk factors outdoors, did not find way back to staff and was unable to remember directions when navigating an unfamiliar area. R4 did not identify safety hazards when crossing the street. R4 was not safe to independently ambulate outdoors.During interview on 8/21/26 at 11:15 a.m., registered nurse (RN)-A stated the facility knew very little about R4 prior to admission. When [R4] arrived at the facility she did not have orders. No report was given to us from the nurse at the previous facility. RN-A stated assessments were completed upon admission. Within two days an initial (48 hour) care plan was developed. RN-A said R4 was not at risk for elopement when she admitted . The concern for elopement was identified on the day she eloped. RN-A said she had not been aware R4 had asked to go home on 7/19/26 and said that was a Sunday so I didn't know about that. RN-A said she reviewed progress notes on Monday, no new interventions were implemented for R4 in response to her request to go home or change in behavior over the weekend. RN-A said she had never asked about elopement attempts at the previous facility and did not call for a nurse to nurse report, it slipped through the cracks. RN-A stated she had not been aware of the recommendations for 24/7 supervision and memory care. When R4 left, RN-a had only heard that staff had to call the police and R4 was found in the bushes across the street.During interview on 8/21/26 at 11:33 a.m., the director of nursing (DON) stated she would have expected staff to gather information to complete an accurate elopement risk assessment. Typically, upon admission the nurses got a report from the nurse at the prior facility. That should have happened prior to completion of R4's assessments. The DON indicated she had been out during the time of R4's elopement and not part of the admission or assessments.During interview on 8/21/26 at 11:52 a.m., the assistant DON (ADON) stated she was not part of R4's admission but said she remembered they wanted to place her in the secured unit from the start. ADON stated she read R4 was agitated in her previous facility and wanted to go home. The ADON said the secured unit was been full when R4 admitted . The ADON stated the facility could have placed a wander guard on R4 when she admitted .During interview on 8/21/26 at 11:59 a.m., RN-C stated the evening R4 eloped, she received a phone call from staff around 6:30 p.m., so RN-C went to the facility. RN-C said she had stopped a few places on the way to look for R4 and when she pulled into the parking lot the police and a nursing assistant were walking with R4 into the building. RN-C said a wander guard was placed on R4 after she returned to the facility.Facility Elopement Policy dated 11/2025, indicated upon admission, each resident is assessed to establish elopement risk. The family may be interviewed for resident's previous history of elopement and responses recorded in the medical record.

Based on observation, interview and document review the facility failed to ensure they maintained sufficient numbers of staff to assist 5 of 5 residents (R5, R6, R7, R8 and R9) in a timely manner. This had the potential to affect all residents residing on the 300, 400 and 500 units of the facility.Findings include: R5R5's admission Record indicated she admitted to the facility 3/22/21. R5's diagnoses included chronic kidney disease, obesity and dysphagia.R5's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she was dependent on staff to complete toileting. The MDS indicated R5 was frequently incontinent of bowel and bladder and required assistance to transfer.During continuous observation on 6/23/26 at 1:05 p.m. through 2:25 p.m., R5 was seated in her room in a wheelchair in the dark. Nursing assistant (NA)-A approached R5 who told NA-A she needed to be changed. NA-A told R5 she would need to get the lift. NA-A left the room and did not return. At 2:05 p.m., R5 remained seated in her wheelchair with her head down and remained there until 2:25 p.m.During interview on 6/23/26 at 2:26 p.m., nursing assistant (NA)-A stated she should have gone back to assist R5, but she had gotten busy.At 2:33 p.m., staff had still not assisted R5.During interview on 6/23/26 at 3:02 p.m., NA-B stated the day shift had passed on to the evening staff that R5 needed to be changed and said they had not assisted R5 yet.During observation on 6/23/26 at 3:05 p.m., NA-B and NA-C prepared to assist R5 with toileting. R5's room had a strong urine odor. When R5's brief was removed it was saturated with urine and feces. NA-B confirmed R5's pants were soaked with urine.R6R6's admission record printed 6/30/26, indicated he admitted to the facility 2/26/25.R6's quarterly MDS dated [DATE], indicated R6's cognition was intact. R6 was independent with toilet transfers and toilet hygiene but required setup or clean-up assistance for personal hygiene. R6 was occasionally incontinent bowel and bladder.R6's care plan dated 5/21/25, identified an alteration in elimination related to decreased mobility. The care plan directed staff to assist with peri-cares, to provide incontinent products and assist to change as needed (PRN).During observation on 6/24/26 at 8:39a.m., R6 propelled himself from his room and told registered nurse (RN)-A he needed to go to the bathroom. RN-A told R6, I will find the girls.During interview on 6/24/26 at 3:02 p.m., R6 stated his call light had been on for over an hour that morning. R6 said it happened about once per week. R6 stated he had times when he had not made it to the bathroom on time because the call light was not answered and said it bothered him.R7 R7's admission Record printed 6/30/26, indicated he admitted to the facility 2/13/26.R7's quarterly MDS dated [DATE], indicated R7's cognition was intact. R7 required partial/moderate assistance from staff for transfers, dressing/undressing, toileting transfers and hygiene. R7 was occasionally incontinent of bladder and frequently incontinent of bowel.R7's care plan dated 4/27/26, identified and alteration in elimination and alteration in mobility. The care plan directed staff to assist with toileting and assist with movement in and out of bed.R8 R8's admission Record printed 6/30/26, indicated he admitted to the facility 2/6/24.R8's significant change MDS dated [DATE], indicated R8's cognition was intact. R8 required partial/moderate assistance for dressing/undressing and was independent with transfers and ambulation.R8's care plan dated 10/15/24, identified a self-care deficit and directed staff to assist with grooming, bathing and personal hygiene.During interview on 6/24/26 at 3:11 p.m., R8 said we can't get any help. R8 said today was so long he turned on his light because R7's light was not answered for so long. He [R7] told me this morning, he waited a long time to get help to get up and get ready for breakfast. R9R9's admission Record indicated she admitted to the facility 6/5/26.R9's admission MDS dated [DATE], indicated R9's cognition was moderately impaired. R9 required partial/moderate assistance with dressing/undressing, supervision or touching assistance with transfers and toileting hygiene. R9 was frequently incontinent of bowel.R9's care plan dated 6/5/26, identified an alteration in mobility and directed staff to assist with ambulation, movement in and out of bed and transfers.During interview on 6/24/26 at 3:15 p.m., R9 stated the call light was on a long time and said it was not the staffs' fault, they are busy. R9 said she had a bowel movement and had been waiting to get help to get cleaned up.Call light logs were reviewed for the following rooms for 6/24/26 from 7:00 a.m. - 11:00 a.m.room [ROOM NUMBER]B (R6), call light was cleared at 8:56 a.m. The call light had been on for 48 minutes and 17 secondsroom [ROOM NUMBER]B (R7), call light was cleared at 9:19 a.m. The call light had been on for 76 minutes and 30 seconds.room [ROOM NUMBER]A (R8), call light was cleared at 8:37 a.m. The call light had been on for 55 minutes and 43 seconds.room [ROOM NUMBER]B(R9), call light was cleared at 7:28 a.m. The call light had been on for 57 minutes and 37 seconds.Resident Council Meeting Minutes reviewed for 1/2026 through 6/2026 revealed the following:1/13/26, long call light wait times. One resident indicated they waited so long they had sores on their bottom. A Resident Council Response Form dated 1/22/26, reviewed call light logs for trends and patterns, education completed related to ensuring timely responses to the best of ability for shifts with trends noted.2/17/26, ongoing concerns about long call light wait times. Resident Council Response Form dated 3/15/26, indicated several new staff, management team was working with current and new team members to promote teamwork and division of tasks for efficiency.3/10/26, long call light times while on toilet, not getting washed up on evening shift. Resident Council Response Form dated 3/11/26, indicated residents complained of not getting washed up in the a.m. or p.m., several stated on p.m. they almost never got washed up. Reported by five residents. Resident Council Response Form dated 3/12/26, indicated care management to address residents not getting washed up at huddle. A second Resident Council Response Form dated 3/12/26, indicated residents being left on toilet, long call light wait times leading to sore bottoms and self-transferring of residents. The response indicated all staff education completed related to teamwork and collaboration to ensure task completion implemented at huddle. A third Resident Council Response Form dated 3/12/26, indicated residents stated they had not been getting showers. One family member had to call so the residents could get a shower, had been two weeks. Resident had been told staff did not have time. The form indicated, would review at huddle, care managers had been implementing a check in process with the NA's and if showers had been completed.4/14/26, 300, 400 and 500 units not receiving a.m. or p.m. cares, not getting washed up. Residents wanted to see management on the floor. Resident Council Response Form dated 4/20/26, indicated residents on the 300, 400 and 500 units stated they could not remember the last time they had been washed up in the a.m. or p.m. shifts. The form indicated staff received education on proper hygiene for all residents and explained residents right to be properly cleaned before bed and when they got up. A second Resident Council Response Form dated 4/20/26, indicated residents would like to see management on the floor and wanted to know why they did not help out. The form indicated upper management to round prior to morning meeting and throughout the day to ensure residents could put a name and face with the management team. A third Resident Council Response Form dated 4/20/26, indicated residents wanted to know who filled in when staff were on break or if they were just left short staffed on the floor. This was causing long wait time for the bathroom. The form indicated residents were informed that floor staff were to inform each other when they went on break and to cover for each other. Staff were to ask management for assistance when they needed help. Another Resident Council Response Form dated 4/20/26, indicated residents wanted proof of follow through and felt they were being pushed off. Response indicated the administrator spoke with residents during several activities and explained they were not being pushed off and there were a lot of moving parts.5/19/26, residents not getting washed up on day and evening shift on the 500 unit and needing the bathroom while staff is still in the dining room. Resident Council Response Form dated 5/20/26, indicated management and office staff would be on the floor and designated float to tend to residents who were not in the dining room. A second Resident Council Response Form dated 5/20/26, indicated residents stated they are still not getting washed up in the a.m. or p.m. and only one certain NA who worked on the overnight shift would perform a.m. cares. The form indicated care managers had a meeting to ensure they were rounding and laying eyes on the staff to ensure residents were properly cleaned and had clean clothing.6/9/26, cares not getting done, residents sitting on toilet too long. Resident Council Response Forms had not been completed.During interview on 6/24/26 at 4:43 p.m., with the administrator and the director of nursing (DON), the administrator said a little over a month ago they realized they had some grievances related to call lights. The administrator said they formed a team meeting every Friday and went over call lights from the previous week. The DON said they identified a trend in the morning when everyone wanted to get up and were looking at adjusting staff. The DON said mealtimes were the biggest trend so they had looked at increasing management presence to round on the units, answer call lights and if able, complete the task. The administrator said when they pulled the call light logs that morning he was surprised and thought they had been doing pretty good. The administrator said staff was based on per patient days (PPD) but said he did not know the breakdown. The administrator said he felt they had enough staff.During interview on 6/25/26 at 9:16 a.m., NA-E stated the previous day she had been assigned on the 400 unit and worked for about an hour. NA-E said she was told they were overstaffed and she was sent home. NA-E said she was not able to complete all her work before being sent home.During interview on 6/25/26 at 9:41 a.m., NA-F stated she was not all her assigned work during her shift.NA-F said breakfast was 8:00 a.m. and said the NAs were still getting people up and dressed at that time. NA-F said two day shift staff had been sent home early the previous day [6/24/26].During interview on 6/25/26 at 9:11 a.m., licensed practical nurse (LPN)-A stated management told staff they could only have three NA's to cover the 300,400 and 500 units because of census. LPN-A stated she tried the best she could to help out and said it was hard because a lot of residents required assistance from two staff. LPN-A said the long call light wait times was definitely not uncommon.A policy related to sufficient staff was requested but not received.

Based on observation, interview and document review the facilities Quality Assurance and Performance Improvement (QAPI) committee failed to address resident concerns related to call light wait times which resulted in cares not being performed and toileting tasks not being completed in a timely manner. This had the potential to affect all residents in the facility who required assistance from staff to completed activities of daily living. Findings include: Refer to F725:Based on observation, interview and document review the facility failed to ensure they maintained sufficient numbers of staff to assist residents in a timely manner on the 300, 400 and 500 units of the facility.During document review and interview on 6/25/26 at 1:38 p.m., with the administrator, the 2026, QAPI notes related to staffing were reviewed. The administrator stated in January the notes identified concerns related to staffing as it related to new hires. The administrator said nothing was noted related to call lights for the month of February. In March, the administrator said the committee discussed call light times and training staff to leave lights on until cares were completed. The goal for responding to call lights was nine minutes. In April, long call light times were noted, and the nurse managers were expected to follow-up. The administrator stated in May, long call light times were again identified and said the follow-up was the same as the previous month. The administrator said in June, again long call light wait times were identified and the committee discussed pulling the call light reports each day. The administrator stated he had reviewed the call light reports, and the last few weeks had been really good. Long call light wait times were noted around mealtimes, the plan included to increase management staff on the floor to ensure call lights were being answered and assist with getting residents to and from meals. The administrator stated there had not been discussion related to increasing the amount of staff in the facility related to the concerns.Facility policy Quality Assurance and Performance Improvement dated 2/2025, indicated the facility will develop, implement and maintain a QAPI program that is effective, data driven, comprehensive and will focus on indicators of the outcomes of care and quality of life. The plan describes the process for identifying and correcting quality deficiencies and contains the necessary components such as:Tracking and measure performance; Establishing goals and thresholds for performance measurement; Identifying and prioritizing quality deficiencies; Systematically analyzing underlying causes of systemic quality deficiencies; Developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

Based on interview and document review the facility failed to accurately code a facility acquired pressure ulcer on the Minimum Data Set (MDS) for 1 of 3 residents (R4) reviewed for pressure ulcers.Findings include:R4's Transfer/Discharge Report printed 6/30/26, indicated she admitted to the facility 3/19/26. R4's diagnoses included vascular dementia, malnutrition and hemiplegia (paralysis or severe weakness affecting one side of the body) and hemiparesis (one-sided muscle weakness).R4's Wound Evaluation dated 5/28/26, identified a peri-anal posterior pressure ulcer, stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling).R4's care plan revised 6/21/26, indicated alteration in skin integrity related to overall decline in condition, current wound to coccyx. The care plan directed staff to document on skin condition and keep provider informed.R4's discharge MDS dated [DATE], indicated she did not have a pressure ulcer.Facility policy related to MDS coding was requested but none received. The administrator wrote in an e-mail on 6/30/26, the facility followed the Resident Assessment Instrument manual.

Based on observation, interview and document review the facility failed to ensure a dignified toileting experience for 2 of 3 residents (R5, R9) reviewed for incontinence care.Findings include:R5R5's admission Record indicated she admitted to the facility 3/22/21. R5's diagnoses included chronic kidney disease, obesity and dysphagia.R5's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she was dependent on staff to complete toileting. The MDS indicated R5 was frequently incontinent of bowel and bladder and required assistance to transfer.During continuous observation on 6/23/26 at 1:05 p.m. through 2:25 p.m., R5 was seated in her room in a wheelchair in the dark. Nursing assistant (NA)-A approached R5 who told NA-A she needed to be changed. NA-A told R5 she would need to get the lift. NA-A left the room and did not return. At 2:05 p.m., R5 remained seated in her wheelchair with her head down and remained there until 2:25 p.m.During interview on 6/23/26 at 2:26 p.m., nursing assistant (NA)-A stated she should have gone back to assist R5, but she had gotten busy.At 2:33 p.m., staff had still not assisted R5.During interview on 6/23/26 at 3:02 p.m., NA-B stated the day shift had passed on to the evening staff that R5 needed to be changed and said they had not assisted R5 yet.During observation on 6/23/26 at 3:05 p.m., NA-B and NA-C prepared to assist R5 with toileting. R5's room had a strong urine odor. When R5's brief was removed it was saturated with urine and feces. NA-B confirmed R5's pants were soaked with urine.R5's care plan dated 6/24/26, identified an alteration in elimination and directed staff to use a full body lift for transfers. The care plan indicated R5 required assistance with pericare, bed mobility and assistance with movement in and out of bed.During interview on 6/23/26 at 4:10 p.m., registered nurse (RN)-A stated R5's toileting schedule was changed recently following a knee injury. RN-A said when a resident asked to be changed, staff should assist the resident as soon as they could get to them, depending on call lights. RN-A said waiting over two hours was unacceptable. RN-A further acknowledged she had noticed the urine odor in R5's room. During interview on 6/23/26 at 4:17 p.m., the director of nursing (DON) stated she expected staff to assist a resident as soon as possible if the resident asked to be changed. When asked about a reasonable time frame, the DON repeated as soon as possible. The DON said she definitely would have expected the resident to be assisted in less that an hour and a half and said if staff needed assistance they should have asked the management team for help.R9R9's admission Record indicated she admitted to the facility on [DATE]. R9's diagnosis included malnutrition, bladder dysfunction, urine retention and mild dementia.R9's admission MDS dated [DATE], identified intact cognition and indicated she required supervision/touching assistance for toileting. The MDS indicated R9 was frequently incontinent of bowel.R9's care plan dated 6/5/26, identified an alteration in mobility and directed staff to assist with ambulation, movement in and out of bed and transfers.A Grievance Form-Nurse/NA Behavior dated 6/22/26, indicated R9 reported on 6/22/26 at 7:00 a.m., NA-D had ripped off her brief very violently, threw it in the garbage and said, you can do this on your own. R9 did not want NA-D back in her room. A correlating Resolution Report dated 6/22/26, indicated the DON spoke with R9 who denied care concerns that morning.During interview on 6/24/26 at 3:15 p.m., R9 stated she had learned how to take care of herself except when she needed help with her catheter bag. R9 said a lady (NA-D) had been banned from her room and said a few days prior, she had been trying to get her pants down and had pushed her button. R9 said I don't know what set her off, she ripped my brief off. I thought she [NA-D] was going to slam me into a wall. R9 said she was scared like this and demonstrated by shaking her hands. R9 said she filed a complaint but wasn't sure if it went anywhere.A Grievance Form- Care Concern dated 5/20/26, indicated an unidentified resident reported on 5/20/26 at 2:00 a.m., she pushed her call light to be taken to the bathroom and stated the NA (NA-D) said she was unable to take her to the bathroom because she was the only NA on the floor. NA-D told the resident she could put on a brief and go to the bathroom in it. The resident went the whole shift without using the toilet. A correlating Resolution Report dated 5/22/26, indicated the DON interviewed NA-D who said there had been a miscommunication and said she had been trying to offer the resident other options.Resident Council Meeting Minutes for May 2026, indicated NA-D- very rude.During interview on 6/24/26 at 4:43 p.m., with the administrator and the DON, the administrator stated he needed to look more into how the facility addressed concerns related to NA-D and would get back to this surveyor. No follow up was received.Facility policy was requested but not received.

Based on observation, interview and document review the facility failed to investigate the cause of an injury that resulted in pain and a change in transfer status for 1 of 1 resident (R5) reviewed with an injury which occurred during a transfer. Findings include:R5's admission Record indicated she admitted to the facility 3/22/21. R5's diagnosis included chronic kidney disease, obesity and dysphagia.R5's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she was dependent on staff to complete toileting. The MDS indicated R5 was frequently incontinent of bowel and bladder and required partial to moderate assistance to transfer.R5's care plan dated 10/1/24, identified a self-care deficit and an alteration in elimination and indicated she required assistance from one staff for bed mobility and toileting. The care plan was revised 6/24/26, and directed staff to transfer using a full body mechanical lift and two staff.R5's Progress Notes identified the following:6/16/26, R5 reported the p.m. staff had been very rude and said while transferring, the staff did not listen to her. R5 reported the staff moved too quickly resulting in pain to R5's left knee.6/16/26, Nurse practitioner visited for acute onset of left knee pain. Chart review indicated the pain started following a transfer the previous night. R5 was unable to specify exact mechanism of injury but stated the aide was not gentle. The pain involved the entire left leg but was most severe in the knee and slightly below. The left knee was swollen and painful with movement. R5 expressed concern regarding the aide who assisted her during the incident.6/19/26, Nurse practitioner (NP) visit note, indicated R5 endorsed that three days prior a staff member attempted to get her out of bed and ended up twisting her knee. Since then had been progressively worse. Staff reported R5 had been refusing to get out of bed due to pain. R5 reported staff had been attempting to help her out of bed and she twisted her knee. The pain had been getting progressively worse and she was unable to get out of bed due to the pain. Orders included limit weight bearing for two weeks and a knee immobilizer or brace. Findings suggested a ligament injury.During observation on 6/23/26 at 3:05 p.m., nursing assistant (NA)-B and NA-C prepared to transfer R4 using a mechanical lift. NA-B stated something happened when R5 had been transferred before she needed the lift and her knee twisted. R4 was saying ouch when staff touched her knee. During the transfer, R4 said, ouch, please. When staff rolled R4 in the bed, R4 said oh, it hurts so and continued vocalize pain throughout being rolled and changed in the bed.During interview on 6/23/26 at 4:10 p.m., registered nurse (RN)-A stated the previous week, R5 was being transferred and she kind of tweeked her knee. RN-A said the next morning R5 complained of knee pain and did not want to get out of bed. RN-A said R5 told her the transfer the evening before, Had not gone well.During interview on 6/23/26 at 4:17 p.m., the director of nursing (DON) stated R5 had reported knee pain and said they investigated the source of the pain. The DON said staff had gone in to transfer R5 and she had struggled to stand so the staff got help from another staff person and eventually used a mechanical lift. The DON said she interviewed R5 about the staff being rude during the transfer and said R5 liked things done a certain way and felt it was rude that staff had not followed her routine. The DON provided statements from a nursing assistant who had not cared for R5 that night and said R5 had first reported the concern to a nurse but she did not have a statement from that nurse. The DON said the other statements were in e-mails and she would look for them.During interview on 6/24/26 at approximately 8:00 a.m., the DON provided copies of handwritten papers, in her own handwriting, and said they were the statements from the other parties involved. The DON said because there was information in the e-mails that pertained to other things not involved in the investigation, she could not provide them.During interview on 6/24/26 at 12:10 p.m., with the administrator and DON, the administrator stated he would have to talk to corporate leadership about the e-mails and said it was not their policy to give out internal communication. The administrator returned a few minutes later and said there was nothing in the e-mails and said the DON had found the papers in a different file. The DON was asked why she told the surveyor the interviews were in an e-mail and the DON stated, I don't know why I told you that.During interview on 6/25/26 at 10:28 a.m., R5 stated since her knee injury, when the staff rolled her it hurt and said she couldn't get into the bathroom. When asked how her knee was injured, R5 stated the NA, Did not want to be told nothing, so the whole routine was wrong. R5 said the NA couldn't get her in bed and R5 told her she needed to get some help but the NA did not listen. R5 said NA eventually did get help. One NA was in front of her and the other NA was behind her and they were squeezing her around the arms. R5 said, she [NA] was very rude, and said, that's when the bad thing came. R5 said her knee had not hurt prior to that incident. R5 said, I didn't want to write her up, and said she was told they got rid of the NA. R5 said, I don't want to have her again.Facility policy Abuse Prohibition/Vulnerable Adult Policy indicated the facility investigation team will review all incident reports including those that indicate and injury of unknown origin and determine if further investigation is needed. The facility will provide proper follow up communication related to the incident across all shifts.

Based on observation, interview, and document review, the facility failed to provide toileting assistance in a timely manner for 1 of 1 resident (R4), reviewed for dignity. Findings include: R4's face sheet printed 3/19/26, indicated admitted to the facility on [DATE], and had the following diagnoses: unspecified focal traumatic brain injury (localized brain damage from a specific impact to the brain), seizures, major depressive disorder, and morbid obesity. During interview on 3/18/26 at 1:16 p.m., R4 stated he was aware when he needed to have a bowel movement and he notified staff by a push button call light system. R4 stated when he felt the urge to have a bowel movement, he was supposed to be transferred to the toilet or a commode to complete. R4 stated at times he waited an hour or more for staff to answer his call light and this resulted in incontinence. R4 stated this made him upset and frustrated. He felt 'like a little kid' and 'it's embarrassing to me'. Review of R4's call light log from 12/26/25 through 12/28/25, and 3/11/26 through 3/18/26 revealed the following: 12/25/25 at 1:58 p.m. R4's call light was unanswered for 42 minutes and 42 seconds12/26/25 at 7:13 p.m. R4's call light was unanswered for 57 minutes and 59 seconds12/26/25 at 2:02 p.m. R4's call light was unanswered for 60 minutes and 22 seconds3/13/26 at 7:47 p.m. R4's call light was unanswered for 32 minutes and 5 secondsDuring interview on 3/18/26 at 4:22 p.m., Director of Nursing (DON) stated staff were encouraged to answer call lights as quickly as possible. DON stated call light times could be longer based on the time of day or how many staff were working. DON reviewed call light times for R4 and stated the facility was aware call light times had been increasing and they were working towards a resolution as a facility to reduce the amount of time residents had to wait. DON stated extended call lights that resulted in incontinence could negatively affect residents and result in a dignity issue. DON stated she expected staff to answer the call lights as quickly as they were able and to communicate with residents if they had to wait longer than anticipated. DON stated it was important to answer call lights timely to promote quality of life and support the residents' rights. During interview on 3/18/26 at 4:50 p.m., Administrator (Admin) stated he believed an acceptable amount of time for staff to respond to a call light was 6-8 minutes, but that time could increase or decrease based on resident needs and how many staff were available. Admin stated 45 minutes, 60 minutes or longer was an unreasonable wait time. Admin stated he was aware call light times were long as the facility had received resident/family grievances related to long call light wait times. Admin reviewed facility provided call light logs and acknowledged multiple response times in excess of 30 minutes. Admin stated this could have a negative effect on residents' quality of life and dignity. The Combined Federal and State [NAME] of Rights for residents in nursing care facilities states the following: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoters maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Facility provided policy titled Resident Rights Policy with last revision date of 11/2025

Based on interview and document review, the facility failed to adequately assess, document, and provide appropriate staff and provider updates for treatment orders for 1 of 3 residents (R1), when R1 was found to have buttock redness during an initial skin assessment that did not dissipate with pressure reduction, or when an open area was observed by staff to R1's buttocks the following day. R1 admitted to the facility on [DATE] and discharged on 10/16/25.Findings include: A 10/8/25 hospital Oncology Note identified R1 had pain related to concurrent chemoradiation therapy and radiation dermatitis (Grade 1) to the inguinal (groin) area. R1's hospital Discharge summary, dated [DATE], identified R1's primary problem was vaginal pain. R1 was diagnosed with vulvar cancer and underwent chemotherapy, and radiation that started on 10/8/25. She was provided discharge orders for perineal care related to dryness, to help wick moisture away, and for discomfort to the groin/vulva area [related to effects of radiation]. Additionally, R1 was previously discharged from the hospital on [DATE] with a commuted fracture of the left humerus (shoulder) that brought about issues of self-care due to cast use. A review of R1's hospital notes lacked evidence to support buttock/coccyx skin impairments (i.e., redness/wounds/pressure ulcer(s) were identified during her hospital stay. R1's Admission/Initial Data Collection form, dated 10/10/25, completed by registered nurse (RN)-A, identified a Skin section that housed a subsection to document Incisions, Discoloration, Bruises.Decubitus, Open areas, Skin tear. This area lacked evidence of any skin impairments. An additional subsection labeled If alteration in skin noted was treatment or monitoring setup? was checked as Not Applicable; however, the next subsection related to Skin Comments identified Redness on the buttocks. This data collection form lacked any additional details related to the redness or further actions taken in response to the redness identification, nor did it identify the groin radiation dermatitis identified on 10/8/25. R1's 48 Hour [Baseline] Care Plan, dated 10/10/25, completed by RN-B, identified R1 had alterations in her skin integrity related to perineal and buttock wounds. The goal was to have this resolved by next review with the following triggered interventions: dietary interventions, including encourage supplements as ordered, weekly skin measurements and assessment of wound, monitor for skin breakdown for signs/symptoms of infection with reports to provider, document on skin condition and keep provider updated on any changes, wound care follow, treatment to open areas per order, turn and reposition or reminders to offload every two to three hours and as needed, pressure redistribution mattress to bed, and pressure redistribution cushion to wheelchair and chair. R1's Admission/Initial Data Collection form, completed on 10/10/25, lacked information related to perineal and buttock wounds: only buttock redness. R1's October 2025 Treatment Administration Record (TAR), directed a weekly skin inspection due on 10/11/25, and a skin assessment form to be completed by a licensed nurse. The task was signed off by RN-C; however, there was no skin assessment form in R1's medical record. A Task report identified R1 refused her 10/11/25 shower/bath. R1's 10/11/25 progress note, completed by RN-C, identified wound care was provided; however, the note lacked any additional information on which wound(s) and/or the wound(s) status. In addition, the note lacked information related to the Weekly Skin Assessment process. A progress note, dated 10/12/25, indicated RN-D questioned a nursing assistant about R1's bathing since admission. This interaction identified R1 received a shower on 10/10/25 with no skin concerns identified at that time, [despite the 10/10/25 skin assessment and baseline care plan that identified skin impairments were present that day]. R1's Braden Evaluation (scale for predicting pressure ulcer risk), dated 10/12/25, indicated the following:-Sensory Perception: No impairment.-Moisture: Rarely Moist.-Activity: Walks occasionally-Mobility: Slightly Limited. Makes frequent though slight changes in body or extremity position independently.-Nutrition: Adequate.-Friction and Shear: Potential problem. This scoring identified a score of 19 which equated to a lower risk. A progress note, dated 10/13/25, identified R1 was assessed by nurse practitioner (NP)-A and found to have peri area (layer of skin between genitals and anus) erythematous (abnormal redness or inflamed skin), which R1 identified was baseline secondary to radiation. There were no changes in the plan of care. The note lacked information related to the 10/10/25 buttock redness/wounds and/or that the buttock area was assessed and found free of concerns. R1's Clinical Nutrition Assessment, dated 10/14/25, identified the dietitian suggested a house supplement every day related to malnutrition. It was estimated that R1 met greater than sixty percent of her estimated needs through oral intake; however, the focus was to stay with good oral intakes and remain hydrated. The assessment indicated No additional nutrition concern at this time. The assessment lacked information related to R1's skin alterations. R1's progress notes, dated 10/15/25, and 10/16/25, indicated R1's skin was free of concerns. R1's 5-Day Minimum Data Set (MDS), dated [DATE], identified R1 admitted on [DATE]. R1 was cognitively intact and without communication concerns. She was diagnosed with malignant neoplasm of the vulva as a primary medical condition with subsequent diagnoses of anemia, malnutrition, anxiety disorder, radiodermatitis (radiation skin damage), fibromyalgia (long-term condition that causes widespread pain and fatigue), pancytopenia (low blood levels of red and white blood cells, along with platelets with increased infection risk), and agranulocytosis (low neutrophil levels causing impairment of the body to fight infections) secondary to cancer chemotherapy. R1 required substantial/maximal physical assistance with toileting, upper and lower body dressing, bed mobility, and transfers, R1 utilized a Foley catheter for [urine management/skin impairment prevention] and was frequently incontinence of stool. R1 was free of pressure ulcers; however, she was at risk. An Office Visit - Palliative Care progress note, dated 10/16/25, at 10:58 a.m., identified R1 informed NP-B that the facility staff informed her there was a white area on her buttocks that is new. R1 further identified she experienced excessive sweating upon waking, and her appetite was decreased, and she was not eating well. Upon NB's assessment, R1 was identified to have a stage 2 (partial-thickness loss of dermis - middle layer of skin) pressure ulcer to her right buttock, along with sloughing to her bilateral buttocks. Along with this, the periarea radiation dermatitis continued. An attached picture, taken at the appointment, identified R1's bilateral buttocks. Peeling, reddened skin was present on each buttock that was overall centralized medially. The right buttock skin peeled more and was redder than the left. In the lower left corner of the right buttock peeling was an open oval/circular area with a whitish base, due to this, the depth/stage would have been unable to be determined. Periwound skin was slightly redder than the redness noted on the buttock. The progress note lacked measurements for the impairments. A progress note, dated 10/16/25, at 11:39 p.m., identified the St. Cloud Hospital called the facility and requested information on R1 as she was admitted for pain. The Emergency Department Note, dated 10/16/25, identified R1 reported to the provider pain started in her right buttock after she moved into the care center and that her pajama shorts adhered to the sore, thus causing increased discomfort. The provider's assessment identified R1's vulva and pubic symphysis areas displayed erythema secondary to radiation and a stage 2 wound to the right buttock with surrounding erythema to the right and left buttocks that was warm to touch. Due to the redness and warmth, the provider was concerned for possible cellulitis (bacterial skin infection) concerns. The note lacked any additional ulcer details. A hospital progress note, dated 10/17/25, completed by medical provider (MP)-A, identified R1 reported she developed a pressure ulcer on her right buttock due to lack of cares at the care facility. She indicated not being provided basic hygiene cares, difficulty with repositioning, and there was no care for gradually worsening pain in her right buttock. The note identified R1 reported mild pain localized to the right buttock which was observed an approximately 2 cm (centimeter) pressure ulcer with mild periwound erythema and no evidence of infection. This area was considered unstageable (full-thickness ulcer that cannot be accurately assessed due to the presence of necrotic tissue/eschar (dead tissue) covering the wound bed). R1's hospital records lacked additional details related to the ulcer. A facility Skin Evaluation and Skin Risk Factors form, dated 10/17/25 (the day after R1 was admitted to the hospital), and completed by the director of nursing (DON) identified R1 had Redness to the Left buttock and the Right buttock. A Summary section identified R1 noted to have redness to bilateral areas of the coccyx (tailbone region). [R1] continues with turning and repositioning schedule along with toileting plan. [R1] primary continent and one noted bowel incontinence episode. The form allowed for areas to insert additional details related to the skin alterations (length, width, depth, stage) and a description area; however, these areas remained blank. This form identified R1 was at risk for skin alterations related to medications which included psychotropic(s), pain, urinary/fecal incontinence, chronic end stage disease or cancer. Options for malnutrition, medical device (cast and catheter which was relevant to R1), and immunosuppression, were unchecked. A review of R1's facility medical record identified the medical record lacked the following information related to the buttock redness identified on admission, and the perineal and buttock wounds identified during the baseline care plan process:-treatment and monitoring of the buttock redness or buttock wound(s). (Treatment was directed for perineal area).-measurements and comprehensive redness/wound assessments.-care management update(s) on the redness by the admission nurse when initial buttock redness was observed.-medical provider update and consultation related to the buttock redness/wounds. -wound care provider involvement.-therapy involvement for appropriate bed mattress, or wheelchair and chair cushions.-dietary update and consultation related to skin status. When interviewed on 10/27/25, at 1:21 p.m., MP-A stated R1's ulcer presentation concerned him that R1 lacked appropriate hygiene cares and positioning while at the care center. MP-A, after review of R1's hospital records, verbalized the following assessment based on his 10/17/25 visit with R1 and the wound care nurse: right medial buttock pressure ulcer unstageable. Red/yellow wound bed - full thickness. Minimal serious drainage. Periwound skin sloughing epidermis with blanchable erythema. No s/s of infection. Estimated at 2.5 cm x 1 cm. During an interview on 10/27/25, at 2:00 p.m., the DON stated when a skin impairment, such as redness or an open area, was identified, she expected staff to update the nurse and then the nurse to complete an initial assessment and document the findings in the medical record after completion which included details such as measurements and specific location(s). Next the provider, as soon as recognized, along with herself or the care manager, and the wound care provider (after care manager review), were to be updated for further assessment processes, collaboration, and interventions. Interventions included such things as a bed air mattress and cushion on wheelchair/chair with therapy involvement to help determine the most appropriate pressure reduction devices based on resident needs. Additional interventions were to be resident specific, again based on needs, along with resident input. These interventions were then to be adjusted based on any changes in skin impairment(s) or resident status. Representative involvement would be initiated depending on the situation. In addition, dietary was to be consulted depending on the situation. Skin impairment monitoring was to be initiated where staff usually will put something on the TAR. usually by the MDS assessment reference date (ARD), which was typically by the seventh day of stay. By the ARD, she expected all forms and comprehensive skin assessments to be completed. If a skin impairment was noted on admission, she ultimately wanted the initial comprehensive assessment completed sooner than later but this also depended on what [was] going on with the facility in terms of the MDS process and/or other staff tasks. Overall, a holistic approach was to be utilized to look at what was going on when a skin impairment was identified. When interviewed on 10/27/25, at 3:20 p.m., RN-B explained her processes as the nursing manager which included steps to review the admission information and the admission skin check on the resident's second day of admission, and if any concerns identified, she started wound rounds and then completed a comprehensive skin assessment by the MDS ARD. By the ARD, she was expected to have all the necessary skin alteration steps in place (i.e., assessment, monitoring setup and interventions, along with provider and/or any other appropriate ancillary staff updates and collaboration.) RN-B stated during the comprehensive skin assessment process, she only put eyes on the resident's skin when staff indicated concerns and something warrants it. RN-B stated R1 was admitted with concerns for vulva cancer and that R1 went to radiation appointments most days and was out for extended periods of time with her leaving in the morning and returning in the afternoon. RN-B recalled R1 was ordered treatments to help wick away moisture but did not recall any skin issues. She denied she assessed R1's skin during her stay as R1 discharged prior to the MDS ARD. After review of R1's record, she indicated R1's day two process occurred during a weekend and thus care manager RN-D completed it, and she again lacked remembrance of any redness or open areas. During an interview on 10/28/25, at 11:13 a.m., RN-D stated she did not review the admission assessment information on the second day of a resident's stay; she just ensured the Day 2 checklist was completed. She indicated it was expected she reviewed the admission information in the first week, and completed the comprehensive skin assessment by the MDS ARD; however, she typically only visualized the skin for this process if redness, or other skin impairments, were reported to her upon admission or identified during the assessment reviews. RN-D indicated she really did not remember R1; however, she identified she spoke to nursing assistants about R1's admission bath, as R1 refused the bath on 10/11/25 and there was not a weekly skin assessment identified for 10/11/25. Those conversations were free of noted concerns; however, RN-D stated she did not talk with RN-A. When interviewed on 10/27/25, at 3:41 p.m., RN-C stated if she were updated on, or observed, redness or other skin impairments, she was to complete an assessment, ensure all documentation was completed within the medical record, put interventions in place, and update the care manager. RN-C explained she was unable to recall R1 or any care provided to R1; however, any care or concerns would be reflected in R1's medical record if she had identified any, or if any were brought to her attention. When interviewed on 10/28/25, at 10:29 a.m., NP-B stated R1 informed her she had been through hell at the care facility and staff were not applying her creams as ordered. Further, she told NP-B staff informed her she had a white spot on her butt but did nothing about it. NP-B indicated R1 saw her to help manage the radiation pain. On the 10/16/25 visit, R1 displayed redness and skin peeling on bilateral buttocks and an area that resembled an unstageable pressure ulcer on her right buttock. NP-B did not expect such a presentation to be from radiation. R1 did display such radiation concerns along the front periarea regions, and this did not present a similar presentation. During an interview on 10/28/25, at 12:16 p.m., nursing assistant (NA)-A stated she assisted R1 on 10/11/25 with bowel incontinence care and noted R1 had radiation marks on her butt. NA-A described these areas as itty bity dots that were circular in nature and about the size of a pen cap. There were quite a few in number and there was a big red area surrounding them. The areas were mainly centered more medial to the inner buttock line then the outer buttock area. These areas did not bleed despite the first layer of skin being off. NA-A indicated it was painful for [R1]. R1 informed her the areas were from the radiation treatments. NA-A updated the unit nurse [RN-C] on the identified concerns, and let the nurse know that family wanted cream on twice a day. This family member was also overhead by NA-A talking to the same nurse and letting her know of the buttock issues and the need for cream. That same day, R1 declined her shower for NA-A as she had one the evening before. NA-A lacked remembrance of staff talking to her about R1's skin after that. When the DON was again interviewed on 10/28/25, at 12:41 p.m., she identified the 10/17/25 comprehensive skin assessment was completed after R1 had discharged and was completed for the MDS ARD process. She completed this assessment based on information obtained from R1's medical record, especially the initial admission assessment, and had not physically examined R1's skin for the comprehensive assessment process. When interviewed on 10/29/25, at 8:43 a.m., RN-A stated when a skin impairment was observed, which included redness: Anything is key, he was to assess the area, initiate interventions, place the information on the 24-hour board, along with monitoring on the TAR, update the provider for wound care orders, and let the care manager know so that they could follow-up on the area and adjust the care plan if needed. If impairments were found in the evening, the nurse manager then followed -up the next day; however, he identified if there was something concerning found, there was an on-call nurse. If redness was observed, he was expected to document details such as size, location, and if the area was blanchable (skin quickly returned to normal color once pressure removed) or non-blanchable (persistent redness to skin once pressure is removed). RN-A vaguely remembered R1 and the admission buttock redness. He stated he did not think it was significant as it was blanchable; however, the redness did not go away on his shift. He explained he passed this on in report as it needed follow up and monitoring. He did not recall doing any other processes for this redness. He did not remember any skin concerns related to open areas or the effects of radiation. RN-A identified his typical practice was to immediately follow-up on expected processes but there were times, due to the unit's fast pace and periods of interruptions, where he had to go back and complete or document things later in the shift. Due to this, there was potential for steps and documentation to be missed. During an interview on 10/29/25, at 10:17 a.m., NP-A stated if redness was noted on admission, they have a protocol on what to do, and she expected them to follow it. Further, she expected to see documentation of observed redness in the medical record such as size, location, blanching status, etc., along with care manager being updated and interventions put into place no matter how busy staff were, If the redness changed, she then expected to be updated. NP-A explained R1 underwent radiation to the vaginal area with noted redness to that area. R1 had informed her during the visit this was normal for her. She did not think she examined R1's buttocks. NP-A stated not having overall concerns for R1's pressure ulcer risk and questioned during the interview this being unavoidable versus avoidable, especially in the setting of radiation and having to lay without pressure reduction for those treatments. One of her biggest questions related to where the radiation was aimed and if this caused the potential open area. NP-A reviewed R1's chart and stated there were no notes to indicate staff updated her about any identified skin concerns. During an interview on 10/29/25, at 11:33 a.m., R1 stated she was free of open areas on admission, or prior pressure ulcers before admission. She did not think the admission nurse informed her of the observed redness to her buttocks; however, shortly after admission, she brought concerns to staffs' attention, especially the increased pain she had to her buttock area, especially when the sheet would stick to it or she laid on it. She stated staff looked at her buttocks on a few occasions when she questioned them, but staff denied concerns. She indicated this went on for a few days. It was not until 10/16/25 when she was made aware of an actual open area. She was unsure what the etiology was but her being out at appointments and extended time in the wheelchair may have played a factor. She identified she utilized a cushion in her wheelchair which she brought to the facility on admission and denied the facility provided her a different one. R1 stated, when staff first saw the buttock redness, she expected they would have updated to the doctor to put something on it. She feels it would not have gotten worse. She did not know if the area were avoidable but there was a chance it would not have gotten so bad. When interviewed on 10/29/25, at 11:47 a.m., for additional follow-up, the DON stated she expected R1 would have had interventions developed specific for R1 and any skin impairments identified during admission, and/or after. As the redness did not go away during her first day, she expected R1's provider would have been updated before the end of that shift for appropriate treatment. Therapy would have been involved to ensure the appropriate pressure reduction surfaces and thorough documentation would have been embedded within R1's medical record by the end of each shift where concerns were identified, especially open areas as identified by staff interview. R1 then would have been expected to be added to wound care rounds to ensure appropriate monitoring and treatment. The DON stated R1 had a very good gamut of interventions applied in the beginning. She was unable to speculate on any outcomes for R1 if staff on admission followed her expectations; however, commented that education was clearly needed, along with a review of the processes. During an interview on 10/29/25 at 12:00 p.m., RN-E, the regional consultant, stated they identified areas for improvement and had already started on a plan to fix process concerns related to assessments, updating appropriate people, and documentation processes. During an interview on 10/29/25 at 12:44 p.m., the medical director expected the appropriate staff to be updated, and protocols followed when skin impairments were identified. This included care manager visual assessment of the area, adequate and timely documentation, provider updates, individualized intervention implementation, and monitoring. When it came to provider update for redness, she stated she would expect this more so if the area deteriorated. The medical director was unable to speculate answers surrounding radiation questions or what may have occurred if staff on admission followed expectations; however, commented that R1's situation appeared like an error of omission. A Skin Assessment & Wound Management policy, last revised February 2025, directed the following when a New Skin Problem was identified: notify the nurse, provider, the resident's representative, and the nurse manager/wound nurse; complete education with resident/resident representative which included risks and benefits; initiate a Skin and Wound Evaluation; referrals to dietary and therapy if appropriate; review and update the plan of care which included interventions, along with skin breakdown identified risks, and to update the resident care lists.

Based on record review and interview, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) reassessment was conducted, documented, and retained to ensure mental health needs were appropriately addressed or provided for 1 of 3 residents (R53) reviewed for PASARR. Findings include: R53's quarterly Minimum Data Set (MDS), dated [DATE], identified R53 had intact cognition and required assistance with activities of daily living (ADLs). R53's diagnoses included schizoaffective disorder - bipolar type, hypertension, ulcerative colitis, diabetes mellitus, anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia and post traumatic stress disorder (PTSD). R53's pre-admission screening (PAS), dated 3/30/21, indicated R53 required a Level II assessment for mental illness to be done before admission to a nursing home. PAS further indicated R53 was in assisted living with an admission to the nursing home on 4/2/21 with an anticipated length of stay listed, Less than 30 Days. R53 was also noted to have a diagnosis of schizoaffective disorder, depressive episode and anxiety disorder. R53's Level II Preadmission Screening for Persons with Mental Illness Determination for Nursing Facility Admission, completed on 3/31/21, indicated admission is approved for post-hospital rehabilitative services for 30 days. This person may have a mental illness and may need specialized services, by [but] meets the requirements for post hospital rehabilitation. Further assessment and service plan changes must be documented upon a change in the resident's condition or when the nursing facility (NF) stay is anticipated to exceed 30 days. The NF is responsible for alerting LMHA to such changes. During interview on 9/17/25 at 9:47 a.m., social services director (SSD) stated being unaware of R53's Level II assessment being limited to a 30-day admission. SSD reviewed R53's Level II assessment and confirmed it was limited to a 30-day admission. SSD stated Senior LinkAge Line should have been contacted when R53 stayed in the nursing home past 30 days. A facility policy was requested but was not received.

Based on observation, interview and document review, the facility failed to consistently track and monitor fluid intake for 1 of 1 residents (R54) on fluid restrictions reviewed for dialysis. In addition, the facility failed to ensure communication forms were consistently filled out with updates or reviewed following dialysis for 1 of 1 residents (R54) reviewed for dialysis.R54's admission Minimum Data Set (MDS) dated [DATE], indicated R54 was cognitively intact, required extensive assistance with activities of daily living (ADLs). R54 had diagnoses which included end stage renal disease, vascular prosthetic device, anemia, cardiomegaly and hypertension. R54's order summary printed 9/17/25, indicated R54 had an order dated 8/28/25 for weight gain - call your provider if you gain 3 pounds or more overnight, or gain 5 pounds in a week. In addition, the order summary indicated an order for fluid restriction 32 ounces (oz) (960 milliliters) daily dated 8/27/25. On 9/16/2025 at 12:41p.m., R54 was observed in the dining room for lunch with an 8 ounce cup of coffee and an 8 ounce glass of water. Progress note dated 9/7/2025 at 1:31a.m., indicated R54 complained of shortness of breath and difficulty falling asleep. R54 was placed on oxygen.Progress note dated 9/8/25 at 6:41 a.m., indicated R54 complained of shortness of breath and requested oxygen. When interviewed on 9/16/2025 at 1:55 p.m., licensed practical nurse (LPN)-A stated R54 complained of a hard time breathing which started the day before going to dialysis. LPN-A was not sure R54 had parameters regarding weight gain. LPN-A stated dialysis nor the provider had been updated regarding R54 having complained of having a hard time breathing or weight gains. LPN-A stated dialysis would have been updated by documenting the weight gain on the communication form that was sent with R54 to dialysis. When interviewed on 9/16/2025 at 3:08 p.m., registered nurse (RN)-B stated R54 occasionally went over her fluid restriction, communication with dialysis center was done using the communication form that was sent with R54 to dialysis. When asked regarding location of where communication forms were placed in R54's medical record RN-B went to R54's room and returned with several envelopes with communication forms inside. RN-B stated the forms were to be reviewed by the nurse for concerns or communication from dialysis center then placed in a dialysis binder for R54 but was unable to locate a binder for R54, RN-B then stated the forms would get scanned into the resident electronic medical record (EMR). When communication forms were reviewed there was no indication dialysis was updated regarding weight gains or complaints of shortness of breath between dialysis days. On 9/17/2025 at 8:15 a.m., reviewed R54's fluid intake recorded in electronic medical record (EMR), there was no order located on R54's treatment sheets to record fluid intake for the month of August 2025. In September 2025 treatment sheet indicated nursing staff started recording fluid intake on 9/3/25. Order indicated fluid restriction 32 ounces.Day shift 9/4/25 - 9/16/25:9/4/25: 240 milliliters (ml)9/5/25: 240 ml9/6/25: 360 ml9/7/25: 240 ml9/8/25: 240 ml9/9/24:120 ml9/10/25: 240 ml 9/11/25: 360 ml9/12/25: 32oz9/13/25: 360 ml9/14/25: 360 ml9//15/25: 300mlEvening shift 9/3/25-9/16/25:9/3/25: .240 ml9/4/25: 220 ml9/5/25: 4oz9/6/25: 32 oz9/7/25: 120ml9/8/25: 240 m,9/9/25: 120ml9/10/25: 240 ml9/11/25: 240 ml9/12/25: 32 oz9/13/25: 240ml9/14/25: 360 ml9/15/25: 300 ml9/16/25: 240 mlNight shift 9/3/25-9/16/25:9/3/25: 2 oz9/4/25: 0 oz9/5/25: 3 oz9/6/25:120 ml9/7/25:100 ml9/8/25: 240 ml9/9/25: 120 ml9/10/25: 2 oz9/11/25: 0 oz9/12/25: 0 oz9/13/25: 60 ml9/14/25: 300 ml9/15/25: 0 oz9/16/25: 0 oz. Review of R54's meal fluid intake was reviewed 9/2/25 through 9/16/25, dietary fluid intakes were recorded by total for the day which included all three meals, intakes were recorded as:9/2/25: 1100 ml9/3/25: 360 ml9/4/25: 360 ml9/5/25: 540 l9/6/25: 1000 ml9/7/25: 540 ml9/8/25: 440 ml9/9/25: 320 ml9/10/25: 440 ml9/11/25: 600 ml9/12/25: 440 ml9/13/25: 790 ml9/14/25: 640 ml9/15/25 400 ml9/16/25: 700 ml.There was no order or indication of facility staff totaling the amount of fluid intake between what nursing staff were providing to R54 and the amount R54 was consuming at meals to ensure R54 was following fluid restrictions. Reviewed R54's EMR, two dialysis communication forms were located in R54's EMR. No other communication forms were located in R54's EMR. In addition, the care plan and face sheet in the EMR failed to indicate the location and contact information for R54's dialysis. When interviewed on 9/17/2025 at 9:37 a.m., licensed practical nurse (LPN)-A stated what was recorded on the treatment sheets was fluids nursing personally gave R54 with medications and occasionally what was noticed R54 consumed outside of meals. Dietary staff recorded what was provided from the kitchen staff during mealtime. When interviewed on 9/17/2025 at 1:15 p.m., registered dietician (RD) from dialysis center stated they spoke with facility dietician on 9/8/25 regarding 1R54's fluid restriction, received a supplement that needed to be counted towards the 1000 ml. RD was concerned R54's weight was low but her gains have been quite large. The weight gains were difficult to safely remove during dialysis, the fluid overload between runs could be related to her complaints of shortness of breath. During interview on 9/17/2025 at 1:31 p.m., culinary services director (CSD) stated they recently talked with RD at dialysis center regarding the supplement needed to be counted toward the fluid restriction. CSD just discussed with R54 what fluids were wanted at each meal and needed to figure out what nursing staff needed to use for medication passes as this also needed to count towards the fluid restriction. CSD stated after discussion with RD that the supplement was not included in the fluid restriction realized that R54's meal ticket did not specify how much fluid R54 was to have for each meal, they just updated R54's meal ticket to reflect what fluids with specific ounces were to be given to R54 at each meal. CSD stated the dietary aides were responsible to record fluid intake consumed during each meal. When interviewed on 9/17/2025 at 2:00 p.m., registered nurse (RN)-A stated R54 had a really low fluid restriction, nursing staff should combine all fluid intake for their shift in the EMR. RN-A stated working with CSD to adjust the fluid allowance between dietary and nursing, they just updated her meal tickets and nursing was reminded to only provide four ounces (120ml) at each medication pass. RN-A stated they completed a resident/family education form with R54 to discuss the fluid restriction. RN-A stated dialysis communication forms should be completed with morning weight, vital signs and any information that dialysis should be made aware of including but not limited to weight gains, complaints regarding shortness of breath, fluid restriction concerns. Communication forms may contain communication from dialysis to the facility, expectation was for the nurse to review the forms for any communication from dialysis and scan them into R54s EMR with twenty-four hours. Resident Family Education assessment dated [DATE], indicated discussed fluid restriction with R54. Education was provided on fluid restriction orders and concerns for kidney inability to process fluid and effect on dialysis. RD reviewing with resident, worked with dietary to manage fluid restriction between medication pass and meals. When interviewed on 9/17/2025 at 2:35 p.m., director of nursing (DON) stated fluid intake in the EMR should contain what nursing staff provided, what dietary provided and anything staff had observed R54 take it upon herself to consume. DON stated facility did not complete risks versus benefits with residents, rather facility completed a resident/family education assessment. Correct fluid intake documentation was important to help monitor resident intake when on fluid restriction. DON stated communication forms were to be completed with vital signs, weights and any other information dialysis needed to be made aware of. When resident returned from dialysis forms were expected to be reviewed, any information relayed by dialysis acted upon in needed, then scanned into the EMR. Any change in resident status for example, weight increase and shortness of breath was expected to be provided to the provider via phone call or fax to ensure consistent coordinated care to the resident. Facility Dialysis policy dated 11/22/19, indicated the facility staff and the dialysis center would have ongoing communication and collaboration regarding dialysis care and services. Communication shared between facility and dialysis center could include but not limited to, residents response to dialysis, medications administered, labs drawn, and changes in condition or mood. In addition, the policy indicated Documentation should include fluid innate amounts for each shift with a 24 hour total if a fluid restriction was in place.

Based on interview and document review, the facility failed to update the provider as ordered when resident gained weight for 1 of 1 resident (R54) reviewed for dialysis. R54's admission Minimum Data Set (MDS) dated [DATE], indicated R54 was cognitively intact, required extensive assistance with activities of daily living (ADLs). R54 had diagnoses which included end stage renal disease, vascular prosthetic device, anemia, cardiomegaly and hypertension. R54's order summary printed 9/17/25, indicated R54 had an order dated 8/28/25, for weight gain - call your provider if you gain 3 pounds or more overnight, or gain 5 pounds in a week. A review of R54's weight record identified on 8/31/2025, R54 weight was 95.4 pounds (lbs.). When weighed on 9/1/2025, R54 was 103.6 lbs. - a 7.2-pound weight gain overnight. On 9/2/2025 R54's weight was 100.0 lbs. then on 9/3/2025, R54's weight was 105.0 lbs. - a five-pound weight gain overnight. On 9/4/2025, R54's weight was 99.6 lbs., then on 9/5/2025, R54's weight was 102.6 lbs. - a three-pound weight gain overnight. On 9/11/2025, R54's weight was 99.0 lbs., then on 9/12/2025, R54's weight was 106.6 lbs. - a weight gain of 6.6 pounds overnight. On 9/14/2025, R54's weight was 104.0 lbs., then on 9/15/2025, R54's weight was 107.2 lbs. - a weight gain of three pounds overnight. R54's medical record was reviewed and lacked any evidence the facility had contacted R54's physician to inform them of R54's weight gains. Progress note dated 9/7/2025 at 1:31a.m., indicated R54 complained of shortness of breath and difficulty falling asleep. R54 was placed on oxygen.Progress note dated 9/8/25 at 6:41 a.m., indicated R54 complained of shortness of breath and requested oxygen. When interviewed on 9/16/2025 at 1:55 p.m., licensed practical nurse (LPN)-A stated R54 complained of a hard time breathing which started the day before going to dialysis. LPN-A was not sure if R54 had parameters regarding weight gain. LPN-A stated dialysis nor the provider had been updated regarding R54 having complained of having a hard time breathing or weight gains. When interviewed on 9/16/2025 at 3:08 p.m., registered nurse (RN)-B stated when R54 went two days between dialysis runs her weight increased and R54 complained of shortness of breath. RN-B did not believe R54 had weight parameters, RN-B reviewed R54's medical record, verified R54 had an order to update provider with weight gain of three or more pounds overnight or five pounds in a week. When interviewed on 9/17/2025 at 1:15 p.m., registered dietician (RD) from dialysis center stated R54 has had weight gains that were large, the weight gains were difficult to safely remove during dialysis, the fluid overload between runs could be related to her complaints of shortness of breath. When interviewed on 9/17/2025 at 2:00 p.m., RN-A stated the expectation was to update the provider and/or dialysis when R54 had a weight gain of three pounds overnight or five pounds in a week. RN-A stated a respiratory assessment for R54 had not been completed, RN-A had not heard about R54 having complained of shortness of breath/difficulty breathing between dialysis days. Facility policy regarding change in condition/provider updates was requested, however, none was provided.

Based on observation, interview and document review, the facility failed to ensure the resident minimum data set assessments (MDS) were accurately documented for 1 of 3 residents (R4) in the sample who were reviewed for weight loss. Findings include: R4's Diagnosis Report (print date of 9/17/25) documented the following diagnoses: type 2 diabetes and morbid (severe) obesity due to excess calories. R4's quarterly Minimum Data Set (MDS) dated [DATE], R4 was documented as moderately cognitively impaired and was dependent on staff with dressing, bathing, bed mobility and transfers. R4's MDS further indicated in Section K Swallowing / Nutritional Status, resident had experienced a significant weight loss, recording the weight of 356 pound (lbs). In review of the facility's Resident Matrix (a document created from resident MDS data collected) also indicated R4 had a significant weight loss. During initial screening and interview on 9/14/25 at 1:09 p.m., R4 sat in a room recliner watching TV. R4 appeared to be significantly overweight. R4 stated he did not feel he received adequate amounts of food at meals, being his main concern. In review of R4's Clinical Nutritional Evaluation (dated 8/26/25) documented the following:[R4] has been doing fairly well in the facility over past quarter. Remains on 2 [gram] [sodium] diet order, regular textures, thin liquids, which provides [approximately] 2000 [kilocalories], 90 [grams] protein. Intakes have been great, averaging [approximately] 76-100%. [Weight] has a trigger for 5% loss. Loss is a healthy one due to current weight and [BMI - body mass index]. Current [weight] 356 [lbs], 30 [days]: 377 [lbs], 180 [days] 357 [lbs], [height]: 72 inches, BMI: 48.3, indicating obesity. Anticipated weight fluctuation with use of diuretic. No additional nutritional concerns at this time. RD to review / follow up as needed. In review of R4's Vitals section in Point Click Care (PCC - electronic medical record), the facility had recorded the following weights in the look back period, used to assess R4's nutritional concerns for the 9/05/25 quarterly MDS: 9/9/2025 13:55 365.4 lbs 8/26/2025 13:39 357.4 lbs 8/24/2025 12:57 356.0 lbs 8/22/2025 11:21 364.4 lbs 8/19/2025 13:59 366.2 lbs In an interview on 9/17/25 at 10:40 a.m., the MDS coordinator (MDSC) stated nursing does not assess or fill out Section K of the MDS, but rather the culinary services director (CSD). During interview on 9/17/25 at 10:59 a.m., the CSD, after reviewing R4's MDS in PCC, verified CSD used R4's 8/24/25 weight of 356 lbs and had triggered, after assessing, a significant weight loss. CSD then looked at R4's Vitals section in PCC and noted after CSD had completed Section K for R4's quarterly MDS, the registered dietitian (RD) had since reviewed the weights recorded and Struck Through the weights from 8/24/25 and 8/26/25 documenting them as inaccurate. CSD stated at the time of the quarterly MDS, the weight of 356 lbs had not been struck through and assumed it was an accurate recording. CSD stated the facility holds weekly Weight Loss Meetings, and at that time, he was not aware that R4's weight was inaccurate. In review of a progress note for R4, dated 9/17/25 at 11:50 a.m. documented the following: Nutrition communication: RD met with [interdisciplinary team] [related to] weights (9/15). Weights struck out from (8/24-8/26) [related to] 8 [lb] discrepancy. Resident weight is stable from 7/25-8/22. RD suggests inaccurate weights [related to] stability of weights, and with new obtained weight (9/16) showing continuing of stability of weights. No additional nutrition concern at this time. RD to review / follow up as needed. In review of the facility policy, entitled: Weight Policy (revised 5/1/24), documented the following:10. The registered dietitian (RD) and/or registered dietic technician (DTR) shall review residents who trigger for significant weight gain or loss. Significant is defined as a person with 5% weight change over 30 days, 7.5% weight change over 90 days, or 10% weight change over 180 days.AND11. The interdisciplinary team and/or facility designee shall review weights for significant weight changes and will be discussed to determine individualized care plan interventions and documented in the electronic medical record.

Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning to promote healing of pressure ulcer for 1 of 1 resident (R1) in accordance with the individualized care plan.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R1's diagnoses included pneumonitis (an inflammation of the lungs) due to inhalation of food and vomit, atrial fibrillation (heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), diabetes mellitus (chronic metabolic disorder characterized by high blood sugar (glucose) levels that persist over time), thyroid disorder (condition where the thyroid gland produces an abnormal amount of thyroid hormones), seizure disorder (sudden burst of electrical activity in the brain), anxiety disorder, chronic obstructive pulmonary disorder [COPD] (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breathe), hypoxemia (condition where there is an abnormally low level of oxygen in the blood), dysphagia (difficulty or pain when swallowing food or liquids, leading to symptoms like coughing, choking, and a sensation of food being stuck) and unspecified intellectual disabilities. MDS indicated R1 was at risk for the development of pressure ulcers. R1's care plan, undated, identified R1 had a pressure ulcer to coccyx (small triangular bone at the base of the spinal column) and left medial gluteus (left buttock) and was at a risk for altered skin integrity and pressure injuries and directed staff to turn and reposition R1 every two to three hours and as needed while in bed and/or wheelchair. During continuous observation on 9/16/25 from 12:31 p.m. to 4:09 p.m. R1 was observed to be seated in a Broda (reclining wheelchair with bilateral supportive cushions) chair. At 12:31 p.m., R1 was sitting in the living room area with other residents. At 12:36 p.m., unidentified staff assisted R1 to the dining room to eat. At 12:39 p.m., R1 was sitting in dining room eating with staff assistance. At 1:00 p.m., R1 was assisted back to living room area. At 1:22 p.m., R1 continued to sit in the living room area. At 1:25 p.m., staff assisted R1 back to her room. At 1:58 p.m., R1 was sitting in her Broda chair, in her room, in the same position. At 2:09 p.m., R1 remained in room watching television. At 2:21 p.m. R1 remained in room watching television. At 2:52 p.m., hospice chaplain entered R1's room and sat next to R1 and was talking and singing with R1. Hospice chaplain did not touch or reposition R1 during interaction. At 3:03 p.m., hospice chaplain left room. At 3:19 p.m., R1 remained in room watching television. At 3:41 p.m., R1 remained in room watching television. At 3:47 p.m., activity aide entered R1's room and asked if R1 would like to attend activities, with R1 grunting and activity aide left room. At 3:52 p.m., R1 remained in room watching television. At 4:09 p.m., registered nurse (RN)-C went with surveyor into R1's room to lay her in bed and access her skin. During interview on 9/16/25 at 3:52 p.m., licensed practical nurse (LPN)-A stated R1 was unable to reposition herself in her broda chair and needed staff to assist with repositioning. LPN-A stated R1 was to receive assistance with repositioning every two hours due to significant pressure ulcers. LPN-A was not sure the last time R1 was repositioned During observation and interview on 9/16/25 at 4:09 p.m., RN-C assisted nursing assistant (NA)-A with lying R1 down in bed. R1 had reddened creases approximately one-half to one inch above pressure ulcer that was located on R1's spine. RN-C stated it appeared the indentations were from where R1's shirt and sling were sitting when she was in broda chair. Area around pressure ulcers were reddened but were blanchable. Pressure ulcer on R1's coccyx was reddened and had no bandage or dressing present. During interview on 9/16/25 at 4:20 p.m., nursing assistant (NA)-A stated R1 was unable to reposition herself in her broda chair and needed staff to assist with repositioning. NA-A stated R1 was to receive assistance with repositioning every two hours due to her sores. During interview on 9/17/25 at 2:52 p.m., director of nursing (DON) stated she expected staff to turn and reposition residents as indicated in the resident's care plan. DON stated the time between repositioning is determined per resident and resident specific concerns. DON stated it was important to ensure the resident is receiving the appropriate care for healing of pressure ulcers. The facility Care Planning Policy, dated 11/24, indicated the facility would have a person-centered care plan developed by the interdisciplinary team for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs. The care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purpose 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. A policy regarding re-positioning was requested but was not received.

Based on observation, interview, and record review, the facility failed to ensure that respiratory care and services were provided in accordance with professional standards of practice for 1 of 3 resident (R1) reviewed for oxygen therapy. Specifically, the facility administered oxygen without a physician's order specifying the liter-flow rate and failed to ensure the resident's portable oxygen tank was filled and available for use. These deficient practices created the potential for improper oxygen delivery, respiratory compromise, and delayed access to oxygen during mobility or emergencies.Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R1's diagnoses included pneumonitis due to inhalation of food and vomit (inflammation of the lungs caused by accidental aspiration of food or gastric contents), atrial fibrillation (an irregular heart rhythm affecting blood flow), diabetes mellitus (a chronic disorder causing elevated blood sugar), thyroid disorder (a condition affecting thyroid hormone production and metabolism), seizure disorder (a neurological condition causing recurrent seizures), anxiety disorder (a mental health condition causing excessive worry or fear), COPD (chronic obstructive pulmonary disease, a progressive lung disease causing airflow limitation), hypoxemia (low oxygen levels in the blood), dysphagia (difficulty swallowing, increasing aspiration risk), and unspecified intellectual disabilities (significant limitations in intellectual functioning and adaptive behaviors).Record review on 9/16/25, revealed R1 had a physician's order dated 7/6/25, for oxygen continuous via nasal cannula wean as able every shift. The order lacked required specifications for liter-flow rate, usage parameters, or maximum dosage. No additional clarifying orders were found in the medical record.During observation on 9/14/25 at 10:41 a.m., R1 was seated in a Broda chair receiving oxygen via nasal cannula. The oxygen concentrator was running at two liters per minute (2L/min). There was no physician order directing staff to administer oxygen at 2 L/min, and there was no documentation indicating who determined or adjusted the flow rate.During observation on 9/15/25 at 5:25 p.m., R1 was seated in a Broda chair in the dining room receiving oxygen via nasal cannula connected to a portable oxygen tank. The portable tank was running at three liters per minute (3L/min). There was no physician order directing staff to administer oxygen at 3L/min, and there was no documentation indicating who determined or adjusted the flow rate.During observation on 9/16/25 at 10:16 a.m., R1 was lying in bed receiving oxygen via nasal cannula. The oxygen concentrator was running at 2.5 liters per minute (2.5L/min). There was no physician order directing staff to administer oxygen at 2.5L/min, and there was no documentation indicating who determined or adjusted the flow rate.During observation on 9/16/25 at 12:31 p.m., R1 was seated in a Broda chair in the living room receiving oxygen via nasal cannula connected to a portable oxygen tank. The portable tank was running at 3L/min. Again, there was no physician order directing staff to administer oxygen at 3L/min, and there was no documentation indicating who determined or adjusted the flow rate.During a separate observation on 9/16/25 at 12:39 p.m., R1 was seated in a Broda chair with a portable oxygen tank hanging on the back of the chair. The tank gauge showed the tank was almost empty. At 1:00 p.m., R1 was assisted to the living room area. Staff had not identified or replaced the nearly empty tank, leaving R1 without access to portable oxygen during transport, movement away from the concentrator, or in the event of an emergency requiring immediate oxygen support. At 1:22 p.m., R1 remained seated in the living room and appeared to be short of breath. At 1:25 p.m., the surveyor informed licensed practical nurse (LPN)-C of R1's status, and LPN-C confirmed the portable tank was empty. LPN-C checked R1's oxygen saturation, which was 90% on room air. LPN-C assisted R1 back to her room and connected her to the in-room oxygen concentrator at 3L/min.During an interview on 9/16/25 at 3:52 p.m., LPN-D stated R1's oxygen flow rate fluctuated, and she was unsure what the correct flow rate should be. LPN-D stated R1's flow had previously been set at 1.5 to 2L/min before LPN-D left for vacation. LPN-D went to R1's room and observed the concentrator was set at 3L/min. LPN-D confirmed there were no specific liter-flow instructions in the physician order and stated staff use their judgment in determining the rate.During an interview on 9/16/25 at 4:56 p.m., the assistant director of nursing (ADON) stated oxygen was administered to R1 daily and acknowledged staff typically left the flow rate set by the previous shift. The ADON confirmed there was no written guidance directing staff on adjusting oxygen flow. The ADON stated R1's oxygen order indicated continuous use, but staff were not able to determine what liter flow should be used and needed a specific physician order.During an interview on 9/17/25 at 2:52 p.m., the Director of Nursing (DON) stated all oxygen orders must include the liter-flow rate and confirmed R1's order was incomplete. The DON stated staff should not administer or adjust oxygen without a complete order. The DON further stated portable oxygen tanks should never be empty, must be checked each shift, and must be replaced before becoming depleted.A policy regarding oxygen administration was requested but was not received.

Based on observation and interview, the facility failed to ensure medications were stored and handled in accordance with professional standards of practice and facility policy. Specifically, staff pre-set multiple residents' medications into medication cups and stored them in the top drawer of the medication cart, creating a risk for medication errors, contamination, and administration of the wrong medication to residents. This deficient practice had the potential to affect 3 of 3 residents whose medications were observed in the cart.Findings include:During observation of the medication cart and interview with licensed practical nurse (LPN)-B on 9/15/25 at 3:48 p.m., the surveyor opened the top drawer of the cart and observed five plastic medication cups, each containing various crushed medications. The medication cups had resident initials and medication times written on them. The medications were sitting loosely in the drawer without protection from contamination or temperature control. LPN-B stated she had pre-set medications for several residents and placed the cups in the drawer to save time. LPN-B stated the cups were prepared approximately 30 minutes earlier and acknowledged they were not individually secured. LPN-B stated she had some extra time and was not familiar with this particular unit, so she pre-set all the scheduled medications beforehand. LPN-B stated she should not have pre-set medications, as doing so could lead to medication errors and administering medications to the wrong resident.During an interview on 9/16/25 at 12:36 p.m., LPN-C stated staff were not permitted to pre-set medications ahead of scheduled administration times and confirmed all medications must remain in their original, labeled packaging until they are administered directly to the resident. LPN-C stated that storing pre-set medications in the cart drawer was not acceptable practice and against policy.During an interview on 9/17/25 at 1:01 p.m., the assistant director of nursing (ADON) stated the facility's expectation medications must remain secured in their original pharmacy-labeled containers until administration. The ADON verified pre-setting medications and storing them in the cart drawer created an opportunity for medication errors and cross-contamination.During an interview with the director of nursing (DON) on 9/17/25 at 2:35 p.m., the DON stated medications should not be pre-set and doing so was against facility policy. The DON stated pre-setting medications could cause medication errors because staff would be unable to verify the residents' medications against the medication administration record and the physician orders.A medication storage policy was requested but was not received.

Based on interview and document review, the facility failed to ensure antibiotic was administered per physician orders for 1 of 1 resident (R1) reviewed for medication administration. Findings include: R1's Admission Record dated 10/24/24, indicated R1's primary diagnosis was Osteomyelitis. The Admission Record further indicated R1 had methicillin susceptible staphylococcus aureus infections (a type of staph that can be resistant to several antibiotics) as the cause of the diseases as his secondary diagnosis. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE] and had orthopedic condition, no memory loss or behaviors. The MDS further indicated R1 needed assistance with ADL's, had lower extremity weakness and used a wheelchair for mobility. R1 further received intravenous antibiotics. R1's Care Plan dated 10/26/24, indicated R1 had a peripherally inserted central catheter (PICC) line and was at risk for infections, had self care deficit related to infection and had risk for skin integrity. R1's Hospital Discharge Orders dated 10/24/24, indicated R1 was to receive sodium chloride 0.9% 250 milliliters (ml) with oxacillin (antibiotic) 2 gram 24 hour continuous. R1's Hospital Medication Administration Report dated 10/24/24, indicated while at the hospital the medication was started at 7:04 a.m. on 10/24/24, (the next dose would need to be started at 7:04 a.m. on 10/25/24). R1's Medication Administration Record (MAR) at the facility indicated on 10/25/24, R1 received his next IV sodium Chloride 0.9% 250 ml 2 gram 24 hour continuous at 12:19 p.m. (over 5 hours late). Review of R1's Progress Notes (PN) indicated on 10/26/24, at 4:26 p.m. writer entered room where family stated resident appeared to be increasingly confused. Writer completed assessment noted congestion to upper lungs and nonproductive cough. BP 157/75, pulse 121, respiratory rate 121, pulse 20, temperature 102.9. The indicated family wanted R1 sent in and primary care provider updated and orders received to send to hospital. A hospital History and Physical dated 10/26/24, indicated R1 was admitted with a fever. The H&P indicated R1 was previously hospitalized [DATE] to 10/24/24, secondary to persistent right hip tenderness, and right iliac bone Osteomyelitis and infections myositis (a disease that makes your immune system attack your muscles) and was discharged on oxacillin continuous infusion. The H&P indicated R1 was started on broad-spectrum antibiotics and was discharged back to the facility on [DATE]. A Medication Error Dispensing Error And Treatment Error Report indicated on 11/05/24, R1 was supposed to receive oxacillin 24 hour continuous and registered nurse (RN)-B (agency nurse) signed as given on 11/05/24. The report indicated the night shift nurse found at 3:00 a.m. on 11/06/24, the oxacillin had not been started on 11/05/24 and the antibiotic was missed for 12 hours. The report indicated the primary care provider was notified and the nurse was placed on due not return due to concerns with the medication error to follow up with further education. A facility PN dated 11/06/24, at 3:13 p.m. indicated it was reported by the night nurse that resident did not get his antibiotic noted at 3:00 a.m. due to have been changed at 3:00 p.m. last evening. The PN indicated the night nurse restarted the antibiotic and at 8:30 a.m. his legs were at least 3 plus pitting edema and that the left lower leg was and red and had some water blister on the lower leg, the skin was also very shinny. Resident did not complain of pain and the area was not warm to touch. Physician was called and stated to have the resident go to the emergency room to eval and treat. During interview on 11/13/24, at 2:20 p.m. director of nursing (DON) stated she was unaware R1 received his antibiotic 5 hours late on 10/26/24 and the nurses were supposed to look at the hospital MAR to see when the antibiotics were started at the hospital. The DON stated RN-B signed out she gave R1 his antibiotic on 11/05/24, at 3:00 p.m. and it was discovered on 11/06/24, at 3:00 a.m. the medication was not started. The DON stated RN-B was agency nurse and her first day at the facility, after they discovered her medication error they immediately called the agency and put her on a do not return and informed the agency she needs further training. The DON further stated it is the facility's expectation the nurses from the agency are competent with administering IV medications and if they are not they should inform the facility, in addition the DON stated that evening there was another nurse from their facility who was certified in administering IV medications if she had questions. The DON stated the medical director felt the medication error did not cause harm and did not feel it was the cause for R1's hospitalization s. In addition the DON stated R1 did not hold his bed so they were unable to find out any information from his hospitalization on [DATE]. When requested RN-B's phone number the DON stated since they placed her on due not return they would not be able to receive her phone number. Facility Policy Medication Procedure reviewed 1/2020, indicated for determining significance of a medication error: The relative significance of medication errors is a matter of professional judgment. Follow three general guidelines in determining whether a medication error is significant or not: Resident Condition - The resident ' s condition is an important factor to take into consideration. If the resident ' s condition requires rigid control, a single missed or wrong dose can be highly significant. Drug Category - If the medication is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This is especially important with a medication that has a Narrow Therapeutic Index (NTI). Frequency of Error - If an error is occurring repeatedly, there may be more reason to classify the error as significant. For example, if a resident ' s medication was omitted several times, it may be appropriate, depending on consideration of resident condition and medication category.

Based on observation and interview the facility failed to follow the Centers for Disease Control (CDC), Infection Control Guidance: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 19) dated 6/24/24, which directed the facility to implement source control measures to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. On 8/28/24 at 9:50 a.m. a sign on the front door of the facility indicated the facility had a current COVID outbreak. On 8/28/24 at 9:55 a.m., the director of nursing (DON) The DON stated the census of the building was 68 and confirmed there was a current COVID outbreak in the facility. On 8/28/24 at 3:11 p.m., therapeutic recreation aide ([NAME])-A was observed in the dining room in close proximity to three residents while they were all seated at a table, approximately 2 feet apart. [NAME]-A's mask was positioned under his chin, not covering his mouth or nose. On 8/28/24 at 3:13 p.m., registered nurse (RN)-A was observed standing at the medication cart in the hall of the 400 unit, with his surgical mask under his chin. The mask was not covering his mouth or nose. RN-A was observed pulling the mask up to the correct position to cover his mouth and nose. On 8/28/24 at 3:16 p.m., RN-A was observed with his mask under his chin, speaking to a resident who was within approximately three feet of RN-A at the medication cart on the 400 unit. The resident was also not wearing a mask. On 8/28/24 at 3:18 p.m., RN-A stated the goal of wearing the mask was to minimize spreading COVID. RN-A stated wearing the mask under his chin was not the appropriate method to prevent the spread of infection. On 8/28/24 at 3:20 p.m., [NAME]-A stated he was aware the proper way to wear a mask way above the nose and over the mouth. On 8/28/24 at 3:38 p.m., the DON stated indicated 7 residents in the building currently had COVID. She stated the residents with COVID were on the 200, 400, and 500 units. The DON stated staff education was conduction through daily huddles at shift changes, on facility bulletin boards, and on residents' doors. The DON stated the expectation was that staff were to wear surgical masks at all times in common areas of the buildings. The DON stated it was unacceptable to wear the surgical masks under the chin. On 8/29/24 at 8:51 a.m., the infection prevention nurse (IPN) stated staff are expected to wear a mask in common areas while the facility is in outbreak status and staff are expected to wear masks properly, covering mouth and nose. On 8/29/24 at 1:57 p.m., the medical director stated surgical masks must be worn in common areas of the facility and worn properly to prevent the spread of COVID. The medical director stated the masks must be worn covering the mouth and nose. A facility document, COVID Policy, dated 3/7/24 directed this facility follows recommended standard and transmission-based precautions, environmental cleaning, to prevent the transmission of COVID-19 within the facility. This policy is based on current CDC recommendations for infection prevention and control practices for COVID-19. While in the building, personnel are required to adhere to established infection prevention and control policies, including: appropriate use of PPE. Centers for Disease Control (CDC), Infection Control Guidance: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 19), dated 6/24/24, directed the facility to implement source control measures to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.

Based on interview and documentation review, the facility failed to complete post-fall vital signs and neurological assessments for 3 of 3 (R1, R2, R3) residents reviewed for post-fall assessment and monitoring. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had diagnoses of dementia and heart failure. R1's MDS assessment indicated he had moderate cognitive impairment, and required assistance with transfers and personal cares. R1's care plan dated 5/13/24 indicated he was at risk for falls. On 8/11/24 at 2:40 p.m., a progress note indicated R1 was found on the floor by the nursing assistant. R1 was holding his head, and his oxygen saturation rate was initially low at 64%, but then rose to 84% (normal is 90% andabove). The note indicated a skin assessment was conducted, the provider was contacted, family was present and R1 was sent to the emergency department (ED). On 8/13/24 at 9:23 a.m. a progress note written by registered nurse (RN)-C summarized the incident. R1 was noted to be minimally responsive with sternal rub. Vital signs were taken and were within normal limits with the exception of oxygen saturation, which was in the lower 80's. R1 was sent to the ED to be evaluated and returned without any concerns. R1 had a skin tear and a large bruise, and denied pain. The incident was reviewed with the interdisciplinary team (IDT). On 8/13/24 at 9:23 a.m. a progress note referenced the risk management report, indicating R1 was found on the floor on his right lateral side, and was holding his head off the floor. The nurse provided a pillow to R1. Initial oxygen saturation reading was 64%, followed by an 84% reading, with the rest of the vitals within normal range. Ten minutes later, R1's family members were present. Provider and on-call physician were notified of the fall. R1 refused to go to the ED for further evaluation, but his pain increased to 8 out of 10, and R1 agreed to go to the ED after a few hours. R1's medical record lacked frequent post-fall neurological assessments from the time of the fall at on 8/11/24 at 2:40 p.m. to the time R1 was sent to the hospital. An emergency department note indicated R1 arrived at the hospital at 5:18 p.m. on 8/11/24. On 8/28/24 at 11:48 a.m., the assistant director of nursing (ADON) stated post-fall neurological assessments were a part of the facility's protocol when a resident fell and hit their head, or had an unwitnessed fall. On 8/28/24 at 1:57 p.m. RN-D stated the nurse should complete post-fall neurological assessments after a fall with a head strike or an unwitnessed fall. On 8/28/24 at 2:28 p.m., registered nurse (RN)-B stated she was working when R1 fell . She did an initial set of vital signs. She did not have the form to complete frequent neurological assessments available. She checked on R1 every 15 minutes for the first hour, but did not document it. R2's admission MDS dated [DATE] indicated R2 had diagnoses of unsteadiness of his feet and pain. R2's MDS indicated R2 had a history of falls. R2's care plan dated 8/6/24 indicated R2 was at risk for falls. On 8/20/24 at 4:42 p.m. a progress note indicated per risk management note: R2 was found on the floor in his room at 2:00 p.m. by nursing assistant (NA) with his forehead on the floor, with minor bleeding. Vital signs noted. R2 refused to go to the hospital for evaluation. R2's family member came around midnight. Shortly after the family member left, R2's condition changed. Confusion and an elevation blood pressure were noted and R2 was sent to the ED. On 8/20/24 at 4:55 p.m., a progress note indicated R2 reported he was in his wheelchair and had dropped an item on the floor, and was attempting to reach the item when he fell . While in the ED, he was diagnosed with COVID. R2's chart lacked frequent post-fall neurological assessments for the 12 hours prior to going to the emergency room for evaluation. R2 fell at 2:00 p.m on 8/20/24 and 911 was called at 2:30 a.m. on 8/21/24 due to his change of condition. On 8/29/24 at 10:05 a.m., RN-C stated the nurse should have completed frequent post-fall neurological assessments per facility protocol. On 8/29/24 at 10:45 a.m., RN-E stated nurses should follow the facility fall protocol, treating any unwitnessed fall as a head strike, and complete neurological assessments. If the neurological assessment form were missing from the packet, the nurse should ask the nurse manger on-call where to find the form. On 8/29/24 at 11:33 a.m., RN-B state she was working when R2 fell . R2 was found with some minor bleeding to his head. She had been taking his vitals consistently, but did verbally because she could not locate the neurological assessment form. RN-B stated she did not document her assessments for R2, but had frequent interactions with him. R3's annual MDS dated [DATE], indicated R3 had diagnoses of dementia and history of falls. R3's MDS indicated he had severe cognitive impairment and required supervision with all personal cares and transfers. R3's care plan dated 7/12/23 indicated R3 was a fall risk. On 8/28/24 at 7:55 a.m., a progress note indicated R3 was found on the floor, unable to recall how fall occurred, but thought to be self-transferring. Neuros were started and were within normal limits. On 8/28/24 at 2:58 p.m., a progress note indicated R3 was being monitored for behaviors. Note lacked post fall assessment details. An Incident Review form dated 8/28/24 at 11:00 a.m., indicated R3 was found on the floor. The note indicated neuros were started, and family and physician were notified. An x-ray was ordered. On 8/29/24 at 12:21 p.m., licensed practical nurse (LPN)-A stated she was working when R3 fell on [DATE]. She had completed his post fall assessments, from the time of R3's fall at 7:55 a.m. through 1:45 p.m on 8/28/24, per the protocol on the designated facility form, but she was unable to locate the form in R3's medical record. On 8/29/24 at 12:21 p.m., LPN-A stated she was working with R3 immediately after his fall. She completed his initial frequent vital signs and neurological assessments, but the form was missing. If she could not locate a document, she would ask a clinical manager where to find one and still complete the necessary actions. LPN-A stated she would just write them on a sheet of paper if the form were missing. A facility document Neurological Procedure, dated 6/21 directed neurological assessments are indicated: a. Upon physician order. b. Following an unwitnessed fall. c. Following a fall or other accident/injury involving head trauma; or d. When indicated by resident's by resident's condition. When assessing neurological status, always include frequent vital signs. Particular attention should by paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be indicative of increasing intracranial pressure (ICP). e. Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately. Check vital signs and do neuro checks immediately and with the following frequency: Every 15 minutes x 4, Every 30 minutes, x 2, Every 1 hours, x 4, then every 4 hours for a total of 24 hours. Documentation: The following information should be recorded on the neurological flow sheet and placed in the resident's medical record:

Based on observations, interview and document review the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, during 1 of 1 quarters (Quarter 2: January 1 - March 31, 2024), reviewed for payroll based journal (PBJ) for excessively low weekend staffing. Findings include: Review of the staffing schedules and timecard verifications with the facility for Quarter 2 identified the facility had licensed nursing staff, 24 hours per day 7 days per week, and 8 consecutive hours per 24 hours of registered nurse (RN) coverage documented. Observations during the facility's recertification survey (8/5/24 through 8/8/24) quality of care was observed. Residents were all dressed and groom well, call lights were answered within acceptable time frames. In further review of the facility's weekend schedules, during the quarter triggered by the facility's PBJ report, it was noted that several of the weekends had two extra staff scheduled, even though there were floats scheduled to assist staffing levels normally scheduled. The extra staff scheduled were not listed as being in training, as noted on other schedules reviewed. Schedules during the same quarter indicated, weekdays matched the weekends where the extra staff were not scheduled. During interview on 8/8/24 at 9:30 a.m., the director of nursing (DON), corporate registered nurse (CRN), corporate nurse lead (prior DON - CNL), the administrator in training (AT) and human relations (HR) were present. CRN stated that HR works with corporate in gathering the the facility's staffing information for submission in the PBJ report. HR stated the only information HR was responsible to gather is that of agency staff and contractual staff. HR stated corporate utilized the payroll system for gathering facility staff hours. HR only submited non-facility staff to corporate for inclusion for the PBJ. CNL, who had been the director of nursing during the quarter in question, stated the scheduler at that time, had over scheduled on some weekends. CNL stated the scheduler, when there were open shifts, would first schedule agency staff. When staff would then volunteer, many times, scheduler would forget to cancel the agency staff. This may have been why some weekends appeared more heavily scheduled. In review of the facility's policy, entitled: Payroll Based Journal Policy (undated) documented the following: Payroll Based Journal Staffing Data Submissions are to be completed by all of Monarch Healthcare Management's Long-Term Care Facilities. Monarch follows the Federal Policy Manual created by the Centers for Medicare & Medicaid Services in regards to Electronic Staffing Data Submission Payroll-Based Journal. Monarch's Staffing data is generated and exported from out SmartLinx Scheduling Software and the imported into CMS according to the Submission guidelines provided by CMS. Submissions are to be completed by the Due data for the correct Fiscal Quarter according to the deadlines provided from the Centers for Medicare & Medicaid Services.

Based on observation, interview and document review, the facility failed to ensure appropriate wheel chair (WC) positioning was maintained for 1 of 2 residents (R45) in the sample reviewed for positioning. Findings include: R45's most current quarterly minimum data set (MDS), dated [DATE], documented R45 was severely cognitively impaired and was dependent with most of his activities of daily living. R45's Medical Diagnosis sheet printed 8/7/24, indicated diagnoses of morbid (severe) obesity due to excess calories, chronic obstructive pulmonary disease, and dementia with other behavioral disturbances. During observation on 08/05/24 at 2:28 p.m., R45 was observed in his WC. near the central dayroom. R45 was a sleep, leaning back in his WC. The vinyl back of the WC lined up with R45's mid-back, which when sleeping, caused R45 to be arched over the back of the WC. When R45 leaned back, the vinyl back was pushed down approximately two inches. During breakfast observation on 8/6/24 at 8:57 p.m., R45 was finishing his breakfast, as he was leaning back in his WC. R45 stated he was sore today. He had pain in his back. During observation on 8/07/24 at 7:45 a.m., R45 was again observed sitting at a dining room table sleeping, leaning back in his WC. R45 was leaning so much, he was facing the ceiling and snoring. The vinyl back appeared to be pressed down approximately two inches down mid-back. R45 was in such a reclined position, resident's shoulders and head were over the back support of his WC. R45's medical records indicated R45 was last seen by occupational therapy in September 2023. An evaluation (screened) for needs was completed, however it was decided R45 did not require any treatment or interventions at that time. During observation and interview on 8/8/24 at 9:58 a.m., R45 was sitting in his WC next the the family room on the unit, sleeping and leaning back. The contracted occupational therapist (OTR) performed a brief visual screen of R45. OTR stated, although R45's WC was wide enough in the seat, the back was too narrow and too short, which was not providing sufficient support for R45. OTR stated she had only been at the facility for a couple of months, and had never worked with R45, nor was informed of any WC issues with R45. A review of the facility's policy, entitled: Activities of daily Living (ADLs) / Maintain Abilities Policy (last updated 5/9/24) documented the following: 1. Based on a comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living to not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable. 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.

Based on interview and document review, the facility failed to follow a care planned intervention to reduce the risk of falls for 1 of 4 residents (R4) reviewed for falls. This resulted in actual harm for R4 when he fell and sustained a thoracic fracture. R4 required subsequent hospitalization , where he expired. The facility implemented corrective action so the deficient practice was issued at past non-compliance. The past non-compliance began on [DATE], when R4 fell and sustained a fracture after staff failed to follow a care planned intervention. The facility implemented corrective action on [DATE], prior to the start of the abbreviated survey, and was issued as past non-compliance. Findings include: A Facility Reported Incident (FRI) report, submitted to the State Agency (SA) on [DATE] at 1:33 a.m., identified R4 fell at 3:25 p.m. after he self-transferred. R4 stated he gathered items in preparation for a shower, and when he went to grab the door handle, he missed and fell to the floor. He initially denied pain and requested the shower; however, subsequently reported increased lower back pain and was transported to the emergency department (ED). ED assessments and testing identified R4 sustained a T11 (thoracic 11th vertebrae) endplate fracture with some dorsal displacement of the dominant fracture fragment. In addition, R4 required supplemental oxygen and was found to have elevated complete blood count (CBC) reading(s). The report identified R4's careplan directed staff to offer assist with setting out clothing for his evening shower. Nursing assistant (NA)-A was placed on administrative leave pending the investigation. R4's annual Minimum Data Set (MDS), dated [DATE], identified R4 was cognitively intact. He was diagnosed with debility, cardiorespiratory conditions, heart failure, anemia, and arthritis. R4 was free of falls over the prior three months. R4's Risk for falls care plan, revised on [DATE], identified R4 demonstrated Gait/balance problems, weakness, refusal to wait for assistance, self-transferring at times, refusal to lift PWC (power wheelchair) footrests prior to transfers for safety as directed by therapy. The goal was for R4 to be free of serious fall related injury. A fall intervention, dated [DATE], directed NA to offer R4 assistance with setting out his clothing in preparation for his shower. A PointClickCare (PCC) POC (point of care) triggered task report for R4 identified the task, Offer to assist me to set out my clothes for my shower (fall [DATE]), was triggered for the day NA to complete. The report indicated this task pushed to the Kardex's (NA care plan) safety category. A POC documentation report for R4 identified NA-A documented on [DATE], at 1:59 p.m., she offered R4 assistance to set out his cloths for his shower. A progress note, dated [DATE] at 4:06 p.m., identified a NA went into R4's room to update him on the timeframe for his shower and found him on the floor. Vitals were taken and he was assisted into his wheelchair with a mechanical lift. R4 reported he felt fine and denied pain. R4 was initially assessed, and during his shower, a reddened area was noted on his lower back which R4 felt was related to a new belt he wore when he fell . A subsequent progress note, dated [DATE] at 8:10 p.m., identified R4 complained of significant lower back pain and nausea after his HS (hour of sleep) medications were administered. His vitals were WNL (within normal limits), as was his ROM (range of motion). His pupils were PEARL (equal and reactive to light). He was unable to lay down due to the increased pain, which was an 8 to 9 on a 0 to 10 pain scale. The on-call medical doctor and registered nurse (RN) were updated and R4 was transported to the ED. A Facility Investigation, completed [DATE], identified with immediate assessment after the fall, R4 denied pain. He initially refused to be transported to the hospital and requested his shower as planned. During the shower skin assessment, a reddened area on his lower back was noted. [NA-A] was placed on administrative leave pending further investigation. The investigation described R4 as a strong-willed [AGE] year-old who frequently self-transferred without notifying staff and/or using his call light and was very particular about his day and the way things were completed, specifically related to his showers. R4 stated he attempted to independently find his own clothes to be dressed in after his shower. He grabbed for the door handle, missed, and fell to the floor. According to staff, he regularly obtained his clothing independently per his preference and failed to utilize his call light or obtain staff assist. In review of his care plan, the intervention to offer him assist to set up his clothing was identified. A review of the completed documented tasks identified [NA-A] completed this task on [DATE] at 1:59 p.m.; however, [NA-A's] interview indicated she did not assist R4 as documented. Additional staff interviews suggested R4 preferred to pick out his own clothing and did this for some time. Due to the investigation, the facility substantiated the fall likely led to the fracture with evidence that suggested staff had an opportunity to assist R4 with his cloths prior to the fall. In response, NA-A received corrective action and education and the remainder of the nursing staff were educated to ensure tasks assigned in PCC's POC were completed and that they referred to the plan of care or their supervisor for any resident specific questions. In addition, additional care plans for those who required assistance with clothing selection were reviewed and determined to in fact be completed. The facility determined there were no similar incidents in the past six months, or since the initial report was filed with the SA, and therefore, this incident was believed to be an isolated incident. R4's hospital Discharge Summary - Death report, dated [DATE], identified R4's discharge diagnoses included a closed superior endplate T11 compression fracture with ankylosing spondylitis (spine arthritis) reportedly due to mechanical fall and worsened acute hypoxic respiratory failure due to increased atelectasis and the need for an ART (respiratory trauma event team response). Neurosurgery was consulted; however, he was felt too high risk for surgery given his age, underlying comorbidities, and worsened respiratory failure, and thus he was transitioned to comfort cares. R4 progressively became very drowsy during the course of hospitalization and passed away on [DATE] at 12:40 a.m. During an interview on [DATE] at 1:54 p.m., NA-B stated he was expected to follow the plan of care and to ensure his documentation was accurate. He vaguely remembered R4; however, was typically not on R4's unit. He expressed R4 required setup assist and he preferred a particular aide to assist with showers. He indicated R4 fell and confirmed education that was provided to him shortly after was related to the fall and ensuring the care plan was followed. When interviewed on [DATE] at 2:09 p.m., NA-C stated she was expected to follow the plan of care and to ensure her documentation was accurate to ensure residents remained safe. She identified R4 required assist of one for cares; however, he was stubborn and tended to do things on his own as he did not like to ask for help. Due to this, he needed strong encouragement to ask for assistance. She explained education was provided after R4's fall to ensure tasks were followed and charting reflected the care provided. During an interview on [DATE] at 12:51 p.m., NA-A stated she was expected to follow the plan of care and to ensure her documentation was accurate to ensure residents remained free of harm, such as injuries or falls. She explained she was not on duty when R4 fell and identified she charted incorrectly as she documented a task she did not complete. NA-A identified she was educated in relation to the incorrect charting and charting expectations, along with the need to ensure she followed the plan of care. When interviewed on [DATE] at 1:23 p.m., the DON stated she expected care plans and NA group sheets to be followed and if information was found incorrect, the managers or herself was to be updated to decrease the risk of injury and/or death. She went over the investigation steps taken after R4's fall which included NA-A's disciplinary action and staff education. She identified due to the investigation; it was identified NA-A failed to follow the plan of care. She denied related concerns since. On [DATE], during the DON interview, R4's facility fall investigation file was reviewed and contained the following: -A comprehensive fall investigation with summary of events, interviews, resident assessment, description of immediate resident protections, notifications, causal and/or contributing factors, and an overall detailed summary. -multiple staff interviews. -Notice of Suspension Pending Investigation, dated [DATE], for NA-A. -a Record of Verbal Counseling, dated [DATE], for NA-A with expectations going forward related to tasks and documentation. -a Care Planning policy signed by NA-A. -a staff list that identified those educated on [DATE], along with additional staff signed Care Planning and Task Education. -emailed communications with the medical provider and medical director. The deficient practice was corrected on [DATE], after the facility implemented a plan that included the following actions: R4 was immediately assessed and fall protocols were followed. Upon R4's change in pain and mobility status, R4 was transferred to the ED. Facility investigation was coordinated with interviews of staff and R4, along with care plan review. NA-A was placed on administrative leave and provided verbal coaching and education after it was determined she failed to follow R4's plan of care. As of [DATE], most nursing staff were provided education related to the deficient practice and those who worked after were provided education upon their next shift. The facility was free of additional falls after [DATE] related to failure to follow plan of care. The corrective actions were verified through documentation review and staff interviews. A Care Planning policy, dated [DATE], identified each resident was to have a person-centered care plan to meet their individual medical, physical, psychosocial, and functional needs. The policy directed the care plan was to be utilized by staff for the purposes of providing care or services to the resident. The care plan was to be modified and updated as the condition and care needs of the resident changed.

Based on observation, interview and document review, the facility failed to ensure staff were competently trained to perform transfers using a mechanical (Hoyer) lift. This resulted in an immediate jeopardy (IJ) for R1 who fell from a Hoyer lift and sustained injuries during a transfer. This practice had the potential to affect all nine facility residents who used a mechanical lift for transfers. The IJ began on 9/19/21, when R1 fell out of a mechanical lift during transfer and the facility failed to provide education that included staff return demonstration of lift use competency and failed to train staff on manufacturer's recommendations for connecting the lift slings to the lift. The administrator and director of nursing (DON) were informed of the IJ on 9/22/21, at 6:16 p.m. The IJ was removed on 9/23/21, at 12:55 p.m. but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated he was severely cognitively impaired and required extensive assistance from two staff to transfer. R1's care plan dated 4/21/21, identified a self-care deficit related to [CONDITION(S)], contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and dementia. The care plan directed staff to transfer R1 with a full body lift and two staff. R1's facility Progress Note (PN) dated 9/19/21, indicated staff used a mechanical lift to transfer him from his chair to the bed. While R1 was suspended in the air with the lift, staff lifted R1's legs up to put them on the bed and R1 slipped out of the lift sling and landed on the floor. The note indicated R1 hit his buttocks, back and head and sustained a skin tear to his elbow and a small cut behind his left ear. A Fall Scene Investigation Form dated 9/19/21, indicated R1 fell . Factors at the time of the fall were identified as equipment malfunction. The form did not identify the equipment malfunction but indicated staff used the straps that made R1 sit too straight up causing him to slip out of the lift sheet. An untitled facility document dated 9/19/21, indicated staff education and training was provided on proper lift sheet use and how the straps used affected resident positioning. The document did not identify which staff received training. An e-mail dated 9/19/21, identified registered nurse (RN)-A updated the administrator R1 fell from a mechanical lift during a transfer in which he hit his elbow and head on a dresser. He sustained a skin tear to his elbow, a skin tear behind his left ear, and a hematoma to the back of his head. The nursing assistants (NA)s who transferred R1 at the time of the incident demonstrated how they used the lift and how the incident occurred. Per the demonstration, it appeared when R1's legs were moved and lifted, this caused him to lean in the sling. As a result, he slid out of the sling and landed on his buttocks. A Progress Note dated 9/20/21, indicated the lift chair was removed from use until maintenance could inspect, sling was removed and R1 was evaluated for sling fit. Interventions: agree with above. Facility protocol followed, management updated. Staff education and training on proper lift sheet use and strap use completed with staff in facility at time of incident. During observation on 9/22/21, at 2:36 p.m. RN-A was seated in an office chair with a mechanical lift sling underneath her. RN-A was demonstrating the use of the sling to a NA. A mechanical lift was not used for the demonstration, nor was the NA demonstrating use of the sling, only watching RN-A's demonstration. At 2:24 p.m. RN-A stated after R1 fell from the lift they started training staff on proper use and said it was a reiteration as staff training had been conducted a few weeks prior. RN-A stated she was in the building when R1 fell from the lift and said she thought the sling had been hooked up properly based on the training she received when the lifts were initially purchased. RN-A stated the day after the fall the team had a safe patient handling meeting and learned staff had not been hooking the slings to the lifts properly which could have resulted in R1 falling out of the sling. During interview on 9/22/21, at 2:48 p.m. with NA-A, NA-B and LPN-A, NA-A stated she had received training that day about how to hook up the straps correctly. NA-A stated prior to that day she had not received training in a while but said the facility had an annual skills training. NA-B stated she had received training about three weeks prior, after another resident had fallen out of a sling from the lift. Licensed practical nurse (LPN)-A stated prior to this week she had an update reviewing policies a few months ago but stated she had not received any recent training on lift or sling use. All three staff stated they were being taught something different than in the past related to positioning of the bottom straps when hooking the sling to the lift. On 9/22/21, at 3:25 p.m. the DON stated after speaking to the two NA's involved in R1's incident it was determined that the bottom straps on the sling were not crisscrossed under R1's legs as recommended by the manufacturer and when the NA's maneuvered R1's legs, along with moving the lift, it was enough force for him to come out of the sling. The DON stated they started education that day but stated since then, they had determined they needed to educate differently. The DON stated after watching a video they had learned that staff had been hooking up the slings incorrectly since the lifts had been purchased more than five years ago. The DON stated they had staff competencies but said the competency did not specify crossing the straps as part of the competency. The DON stated after another resident had fallen out of a lift last month, they had completed a mechanical lift competency with all staff but only used a toileting sling and did not train on the use of a full body sling. The DON stated after the last fall they did not review the instructional video because the previous fall involved an incorrect sling size. On 9/22/21 at 3:58 p.m. RN-B stated she received training that day about how to hook up a sling to make it more secure. RN-B stated about a month ago, a resident had fallen out of a sling and they had a training that consisted of a meeting and management demonstrating the sling and lift but staff did not actually demonstrate how to hook up the sling. RN-B further stated the earlier training did not include the proper way to hook up a full body sling. On 9/22/21, at 4:09 p.m. the DON stated the previous training had been a mixture, and said some of the training was a one to one and some were in large groups. The DON said some staff demonstrated use of the mechanical lift and some were just talked through how to hook the sling to the lift. On 9/22/21, at 4:15 p.m. the administrator stated all of the managers had been assisting on the floor regularly so there had been no reason to think staff were not using the slings correctly. The administrator stated when the previous resident fell from the lift it had been a separate issue, so they had not provided training on connecting the straps to the lift. The administrator stated they learned some staff had been connecting the straps of the sling to the Hoyer lift correctly and some staff had not since the lifts were purchased eight years prior. A facility policy Lifting Machine, Using A Mechanical dated July 2017, indicated the procedure was to establish the general principles of safe lifting using a mechanical lifting device. The policy directed staff to attach the sling straps according to the manufacturer's instructions. A document titled Hoyer Quickfit Deluxe Slings, undated directed the bottom straps be crossed under the resident prior to connecting them to the Hoyer lift. The IJ was removed on 9/23/21, at 12:55 p.m. when it was verified through observation and interview the facility had implemented a training program which included return demonstration of manufacturer's recommendations for connecting the straps of the Hoyer lift to the mechanical lift and all staff working had completed training or were scheduled to complete training prior to next scheduled shift.

Based on interview and document review the facility failed to provide the necessary care and services to attain or maintain the highest physical well being in accordance with the comprehensive assessment and care plan for 1 of 5 residents, Resident (R)-2, reviewed who experienced constipation, pain and abdominal distention without timely nursing intervention. Findings include: Medical record review revealed R-2 was admitted to the facility 10/10/2013 with [DIAGNOSES REDACTED]. R-2's nurse practitioner note dated 10/1/2013 was reviewed and revealed R-2 was taking [MEDICATION NAME]/[MEDICATION NAME] for pain control. R-2 was using mirilax as needed for constipation. R-2's careplan dated 10/29/2013 revealed R-2 required the assist of 1 to use the toilet, and required daily bowel medication to help manage his bowel regularity. R-2's bowel flow sheet revealed R-2 had a large formed stool on 10/19/13. R-2's bowel flow sheet revealed R-2 did not have any stools on 10/21/13, with no new intervention. R-2's bowel flow sheet revealed R-2 had a small stool on 10/22/13 with no new intervention. R-2's bowel flow sheet revealed R-2 had no stools on 10/23/13 with no new intervention. R-2's bowel flow sheet revealed R-2 had no stools on 10/24/13 with no new intervention. R-2's bowel flow sheet revealed R-2 had no stools on 10/25/13 with no new intervention. R-2's bowel flow sheet revealed R-2 had no stools on 10/26/13 with no new intervention. R-2's nursing notes were reviewed and revealed on 10/27/2013, 8 days after his last normal bowel movement, R-2 complained of constipation and was given [MEDICATION NAME], mirilax and milk of magnesia. R-2 was up and down to the toilet frequently with little results. R-2 had a small hard stool on 10/27/13 with milk of magnesia and enema attempted. R-2's nursing notes revealed on 10/28.2013 R-2 was given as needed Mirilax with little results. R-2's nursing notes revealed on 10/29/2013 R-2's wife expressed concerns with R-2's bowel status, R-2's abdomen was assessed and revealed a distended and painful abdomen with no bowel sounds heard. R-2 was experiencing increased confusion. R-2 was sent to the hospital on [DATE] related to the abdominal pain and distention and was seen in the emergency department. Hospital medical records dated 10/29/2013 - 11/7/2013 were reviewed and revealed R-2 was seen in the emergency department, diagnosed with [REDACTED]. R-2 was treated for [REDACTED]. Director of Nursing-(DON)-C was interviewed on 11/8/2013 at 12:00 p.m. and stated the nurses should review the bowel flow sheets and initiate intervention for constipation when the resident is on day 2 of no bowel movements. DON-C was again interviewed on 12/9/2013 at 2:00 p.m. and confirmed that from 10/19/2013 until 10/29/2013, a period of 10 days R-2 had no substantial bowel movements and nursing intervention for constipation did not take place until 10/27/2013. DON-C also confirmed that no physician or medical practitioner was made aware of R-2's constipation during that period. The facility policy titled standing orders dated 2/25/2013 was reviewed and revealed under Constipation: Milk of magnesia 30 cc daily as needed. [MEDICATION NAME] Suppository 1 rectally daily as needed. Fleet enema, 1 rectally daily as needed. A policy related to the facility's bowel program was requested and the standing orders were referred to as the bowel program.

Based on interview and record review that facility failed to ensure that the resident environment remained as free from accident hazards as is possible and to implement adequate interventions to reduce the risks of accident for 1 of 3 residents in the sample (Resident #1), who was at risk for a burn related to hot pack and biofreeze (a topical treatment that is not recommended to be used with hot packs) use. Although another resident experienced a possible burn related to hot pack use in combination with biofreeze, the facility did not investigate the incident or update their policies regarding their use together. 13 days later Resident #1 presented with a blistered area after combination hot pack and biofreeze use. Findings include: A review of the information sheet (undated) for Resident #1 revealed that she was admitted to the facility in May 2011 with [DIAGNOSES REDACTED]. Resident #1's physician order [REDACTED]. There was no order noted with regard to which should be used first, or how long to wait after hot packs before applying biofreeze. A review of an incident report dated 4/13/2011, (13 days after the suspected burn on another resident), indicated that Resident #1 was found to have a 2.5 by 1.5 inch dark pink area with small blisters on her lower back. Resident #1 reported that Employee (B)/LPN applied her biofreeze treatment to the area before the hot pack treatment during the last treatment on 4/12/2011. Nurse Practitioner (C) examined Resident #1 on 4/13/2011 and documented blistered red areas in a linear pattern across the back that measured 40x4cms in diameter. Nurse Practitioner's order dated 4/13/2011 revealed Resident #1 was treated with silvadene treatment to the blistered area. Resident #1's injury was observed on 4/27/2011 at 9:20 a.m. The area was noted to be 2 X 1 inches and reddened. The skin was noted to be intact. The silvadene treatment two times a day was continuing through 4/27/2011, the day of the observation. A review of the manufacturers instructions for biofreeze dated 4/27/2011 revealed that "Biofreeze should not be bandaged or used with external heating pads as it may cause blistering." Employee (A)/RN/DON was interviewed on 4/27/2011 at 1:00 p.m. and stated that the facility did not have any policies in place regarding hot pack and biofreeze use together. Employee (A) stated that the nursing staff would need to refer to the manufacturers instructions to determine how long to wait after the hot packs before applying the biofreeze when both are ordered. Although the facility had noted an injury to another resident using biofreeze and hot packs together 13 days before resident #1's injury, Employee (A) stated that no policies had been changed as a result of the first incident. A review of the facility information sheet, undated, for Resident #2 revealed that he was admitted to the facility in November 2007 with [DIAGNOSES REDACTED]. A review of nursing notes dated 3/30/3011 at 6:30 a.m. revealed that Resident #2 was noted to have a reddened left knee following a hot pack and biofreeze treatment the evening before, that "appeared to be a burn." Employee (D)/LPN was noted to be the staff person who performed that treatment to Resident #2. A review of Resident #2's physician orders [REDACTED]. During an interview with Employee (B)/Social Worker on 4/27/2011 he stated that the reddened knee was discussed during the interdisciplinary team meeting on 3/31/2011 and the determination was made that an internal investigation into the cause of the incident should be initiated. Employee (B) stated that he thought Employee (E)/RN was responsible for the internal investigation. Employee (E) was interviewed on 5/10/2011 at 3:10 p.m. and stated that she did not perform an internal investigation into the incident. Employee (E) stated that she did provide retraining to Employee (D) regarding biofreeze treatment with hotpacks. Employee (E) stated that Employee (D) stated she followed the physician's orders [REDACTED].