Every finding on record at The Villas at Richfield

Based on observation, interview, and document review the facility failed to provide a dignified dining experience for 1 of 1 resident (R87).Findings include: R87's significant change Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of liver cell carcinoma (cancer of the liver) and severe protein-calorie malnutrition. It further indicated R87 required substantial assistance with eating. R87's care plan dated 2/23/26, indicated self-care deficit related to liver cell carcinoma with an intervention of assist of 1 staff with eating. During observation on 5/18/26 at 12:09 p.m., R87 was sitting in his wheelchair in his room. The lights were off; his bedside table was in front of him and the MDS coordinator was standing up next to his wheelchair assisting him to eat. During interview on 5/19/26 at 7:05 a.m., nursing assistant (NA)-G was unable to determine whether they should be standing or sitting when assisting a resident to eat stating that's not something that has been generally trained, but the lights should be on, and I would sit down and have a conversation with them. I don't think it's trained that you're supposed to be standing over them. During interview on 5/19/26 at 7:20 a.m., the MDS coordinator stated they usually don't assist with feeding residents and was unable to determine whether they should be sitting or standing when assisting a resident to eat, stating I will have to check with the director of nursing (DON).During interview on 5/19/26 at 7:35 a.m., NA-L stated nursing staff should be sitting down next to the resident and having a conversation with them while assisting them to eat. NA-L further stated the lights should also be on because it provides a more dignified experience, instead of just shoving food in their mouth. During interview on 5/20/26 at 11:00 a.m., the DON stated the nursing staff (NA's and nurses) should be assisting residents to eat at the resident's eye level and the lights should be on unless the resident preferred to eat in the dark. The DON further stated R87's chair sit's up higher so that's why the MDS coordinator was assisting him to eat while standing up. If R87's chair wasn't elevated, staff would've been expected to sit next to the resident while assisting him to eat. A facility policy regarding dignity was requested but not received.

Based on observation, interview, and document review the facility failed to provide appropriate clothing (socks) to 1 of 1 resident (R96) who requested them. Findings include:R96's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of heart failure and type II diabetes.During observation and interview on 5/17/26 at 11:40 a.m., R87 was sitting in his wheelchair in his room. He was barefoot and stated he had asked staff (unknown) for socks several times and they won't give me any. During observation on 5/18/26 at 8:59 a.m., R96 was sitting in his wheelchair in his room, barefoot. Nursing Assistant (NA)-M stated he would have to wait to get socks until some came up from laundry and left the room. At 9:15 a.m., the physical therapist (PT)-A entered R96's room and R96 stood up so PT-A could put the gait belt on him. Then they proceeded to exit the room and walk down the hallway to the elevator. R87 was barefoot. At 9:43 a.m., PT-A and R96 came back to his room and as they passed by, licensed practical nurse (LPN)-B stated, They haven't found you any socks yet? and then LPN-B entered another resident's room, without getting him any socks. R96 went back to his room and PT-A left him sitting in his wheelchair, barefoot. During interview on 5/18/26 at 9:55 a.m., LPN-C verified R96 was walking in the hallway barefoot and shouldn't be, especially in the hallways and on the elevator stating they (facility) have plenty of socks, in all different sizes. During interview on 5/19/26 at 7:05 a.m. NA-G stated the residents should always be wearing socks, especially when walking in the hallways and on the elevator. There are always gripper socks available, if not in the linen closet, then in the storage closet. During interview on 5/19/26 at 7:35 a.m., NA-L stated if they saw a resident was walking around with bare feet and/or asked them for socks, they would get them for the resident. Residents shouldn't be walking around barefoot, especially in the hallways or on the elevator. NA-L stated gripper socks were always available but sometimes laundry had a hard time keeping up with washing them. During interview on 5/20/26 at 7:44 a.m., registered nurse (RN)-D stated all of the staff were responsible for ensuring the residents had socks and the residents shouldn't be walking in the hallways or going on the elevator barefoot. They have plenty of extra socks and are readily available. During interview on 5/20/26 at 9:12 a.m., physical therapist (PT)-A stated R96 had physical therapy 3-5 times per week. R96 often was not wearing socks (barefoot). PT-A was unable to determine the reason why. During interview on 5/20/26 at 11:00 a.m., the director of nursing (DON) stated her expectation was for residents to be wearing socks, especially when walking in the hallway or going on the elevator. This was important for infection control and also because R96 was diabetic and was more susceptible to getting wounds and skin alterations. The DON further stated, there are always gripper socks available and if for some reason they weren't, the nursing assistants were expected to let the nurse know, so they could get some more. A facility policy was requested; however the facility doesn't have a policy that addresses these concerns.

Based on observation, interview, and document review, the facility failed to ensure personal privacy during toileting for 1 of 1 residents (R71) reviewed for privacy.Findings include:R71's admission Minimum Data Set (MDS) dated [DATE], indicated R71's cognition was not assessed, required supervision or touching assistance for most activities of daily living (ADLs) including toilet hygiene and transfer, and was always continent of bowel and bladder. R71's diagnoses include hemiplegia and hemiparesis (weakness and paralysis affecting one side of the body), aphasia (condition affecting speech), and depression.R71's care plan dated 5/14/26, identified R71 was at risk for elopement due to cognitive impairment and previous attempt to leave the facility.R71's provider orders dated 5/17/26, indicated, Resident on 1:1 monitoring.During observation on 5/17/26 at 12:15 p.m., R71 was in his room with nursing assistant (NA)-F providing 1:1 supervision. NA-F assisted R71 into the bathroom and transferred to the toilet. The bathroom door was left open. R71's roommate (R13) had a visitor, who had direct line of sight to R71 on the toilet. R13 had a privacy curtain that could have been pulled to prevent visitor from observing R71, but was left open. During interview on 5/18/26 at 12:58 p.m., R71 stated he did not understand why he was receiving 1:1 supervision. R71 further stated it bothered him that a visitor could observe him while he was on the toilet and would prefer privacy.During interview on 5/18/26 at 1:03 p.m., NA-F stated residents should be provided privacy while in the bathroom. NA-F stated she did not want R71 to escape through the adjoining room so she left the bathroom door open to continue 1:1 supervision. NA-F stated she should have pulled the privacy curtain to protect R71's privacy.During interview on 5/19/26 at 11:11 a.m., licensed practical nurse (LPN)-B stated would expect all residents to be provided privacy as appropriate when in the bathroom and that the NA should have pulled the privacy curtain.During interview on 5/19/26 at 11:25 a.m., director of nursing (DON) stated expectation for resident's privacy to be respected and R71 should have been given privacy by shutting the door or using a privacy curtain.Facility policy on personal privacy was requested but not provided.

Based on observation, interview, and document review the facility failed to offer or provide individual or group activities for 1 of 2 residents (R62).Findings include:R62's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of vascular dementia, adult failure to thrive, and muscle weakness. It further indicated R62 required substantial assistance with bed mobility and was dependent on staff for transfers. R62's annual MDS dated [DATE], indicated listening to music was very important to her. It further indicated participating in her favorite activities, participating in group activities, participating in religious services, and going outside were somewhat important. R62's care plan dated 5/12/26, indicated R62 was dependent on staff for activities, cognitive stimulation, social interaction, and well-being related to cognitive deficits and immobility. It further indicated the following interventions: -Allow for periods of rest-Inform resident early of scheduled programs to allow resident time to digest and make choices-Thank resident for attendance at activity function.During observations made on 5/17/26 between 11:51 a.m. and 2:29 p.m., R62 was lying in bed with the lights on without any music, television, or interactions from staff aside from required care (medications, turning, and repositioning) services from staff. During observations made on 5/18/26 between 9:26 a.m. and 2:06 p.m., R62 was lying in bed with the lights on without any music, television, or interactions from staff aside from required care (medications, turning, and repositioning) services from staff. During observations made on 5/19/26 between 7:26 a.m. and 1:00 p.m., R62 was lying in bed with the lights on without any music, television, or interactions from staff aside from required care (medications, turning, and repositioning) services from staff. During observations made on 5/20/26 between 7:50 a.m. and 9:51 a.m., R62 was lying in bed with the lights on without any music, television, or interactions from staff aside from required care (medications, turning, repositioning, and wound care) services from staff. During interview on 5/19/26 at 7:05 a.m., nursing assistant (NA)-G stated R62 didn't get out of bed because she didn't want to. The only time she would get out of bed was on her shower days. NA-G further stated R62 did not attend group activities and didn't participate in individualized activities. During interview on 5/19/26 at 7:56 a.m. NA-L verified they don't turn on the television or radio in R62's room because it was too loud and they only get her out of bed for group activities if the nurse tells them to, which wasn't very often. During interview on 5/20/26 at 7:44 a.m., registered nurse (RN)-D stated therapeutic recreation, and social services were responsible for providing activities to residents whether it be in their room or bringing them to group activities. Nursing staff was not responsible for providing residents activities. During interview on 5/20/26 at approximately 10:00 a.m., therapeutic recreation (TR)-A stated one way the residents were made aware of group activities was by handing out a paper called the Daily Chronicle that listed the day's activities. They also have their main group of people that come regularly to the activities, and they will also go around and ask residents individually if they want to attend. The TR-A further stated for individual activities, they work together with the nursing staff to make sure their television, or radio is on or they're provided with other individual activities of their choice (books, newspaper, puzzles, etc.). If the resident was non-verbal or unable to express whether they would like to attend an activity or not, they will bring them to the activity for socialization and if it doesn't work or the resident appears to be overstimulated, they will bring them back to their room. TR-A stated R62 had a 1:1 visit every other day (for one hour) and there was a Tea Party every Tuesday they would usually bring her to. TR-A was unable to determine what individual activities were provided to R62 each day when she was in her room as they also work with nursing staff to provide those activities. During interview on 5/20/26 at 11:00 a.m., the director of nursing (DON) stated an assessment was completed with each resident regarding their activity preferences and their preferences should be added to the care plan. Staff (nursing and activity) were then expected to follow those preferences. The facility policy regarding activities was requested but not received.

Based on observation, interview and document review the facility failed to utilize available resources for 1 of 1 resident (R40) who requested eyeglasses.Findings include: The National Eye Institute website dated 9/11/25, identified the following resources to obtain eyeglasses, including but not limited to:VSP Eyes of Hope provided children and adults with no-cost eye care and eyeglasses. This program was for people with limited income who don't have health insurance. To apply for Eyes of Hope, you'll need help from a school nurse or a community partner organizationLions Clubs International offers help paying for eye care through its local clubs. Some clubs may also provide eyeglasses.New Eyes provides prescription eyeglasses to children and adults who can't afford them. A social worker or someone at a community health center may be able help you apply.R40's quarterly Minimum Data Set (MDS) dated [DATE], identified vision was adequate with no glasses or corrective lenses. R40 could understand, make herself understood, was independent with eating, and required set up for oral hygiene. Diagnoses included stroke, high blood pressure and hemiplegia (one-sided paralysis). R40's communication care plan dated 4/30/26, identified her primary language was Spanish and she was able to understand and speak in English. The goals included residents' needs will be anticipated and met by staff. There were no vision interventions. R40's Doctor of Optometry (DO) visit note dated 2/6/25, identified eyeglasses were requested. R40 was diagnosed with myopia (distant objects look blurry) and age-related cataracts (when the lens of your eye becomes cloudy, affecting your ability to see). R40's DO visit note dated 8/15/25, identified eyeglasses were requested again. R40's nurse practitioner visit note dated 4/8/26, identified R40 complained of her left eye vision worsening and requested to see the eye doctor, so an order was placed.R40's MHM Hearing/Vision Form dated 4/13/26, identified she could see in adequate light with glasses or other visual appliances, and no corrective lenses were in place, which conflicted with R40's recent statement to the NP on 4/8/26, about left eye vision worsening with a request to see the eye doctor. R40's order dated 4/15/26, identified ophthalmology apt (appointment) pt (patient) complains of vision changes in left eye. R40's progress notes and care conference notes dated 2/6/25 through 5/17/26, lacked notation that R40 was assisted with the eyeglasses request. During an interview on 5/18/26 at 2:52 p.m., R40 stated her left eye was getting worse, she would get a headache when reading and needed eyeglasses. During an interview on 5/18/26 at 3:03 p.m., the health information manager (HIM) stated she coordinated ancillary services. The HIM stated eyeglasses were not covered on R40's emergency medical assistance (EMA).During an interview on 5/18/26 at 3:18 p.m., the social services director (SS)-D stated he was not aware of resources for someone on EMA to obtain eyeglasses and he was not aware of a request of R40's for eyeglasses. During an interview on 5/20/26 at 12:44 p.m., the administrator stated social services could look into eyeglasses resources for residents on EMA, and he did not have any specific resources or policies.During a follow up interview on 5/20/26 at 12:56 p.m., the SS-D stated there was no specific policy for resources on the acquisition of eyeglasses for residents on EMA.

Based on observation, interview, and document review, the facility failed to ensure fall interventions were in place for 1 of 2 residents (R44) reviewed who were at risk for falls. Findings include:R44's quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 had moderate cognitive impairment, required setup/clean-up assistance with meals, and was dependent on staff for personal hygiene, dressing, and mobility. R44's diagnoses included spondylosis of the lumbar region (degeneration of spine which can cause pain and affect mobility), and syncope and collapse (temporary loss of consciousness and muscle control). R44's care plan dated 4/16/26, identified R44 was at risk for falls due to low back pain and weakness. R44's care plan instructed staff to keep call light within reach, bed low, and mat on floor next to bed while resident in bed. R44's Fall Review Evaluation dated 5/17/26, indicated R44 had 1-2 falls in the last six months, was oriented to person but not always oriented to place, and was unable to independently come to standing position. R44's post fall Incident Review and Analysis dated 1/26/26, indicated R44 was found on floor, and he could not explain what had happened. Intervention identified, Floor mat next to the bed while the resident is in bed. During observation and interview on 5/17/26 at 4:45 p.m., R44 was in bed lying on his right side with his back to the wall. The bed was against the wall, and the call light was under his bed with the cord stuck between the bed and the wall. R44 stated he could use the call light if he needed help but did not know where his call light was at that time. R44 stated he did not know what he would do if he needed assistance and could not reach the call light. During observation and interview on 5/17/26 at 5:36 p.m., nursing assistant (NA)-D stated R44 was able to use his call light and was regularly encouraged to do so. NA-D into R44's room to deliver dinner and confirmed call light was under R44's bed and out of his reach. During observation on 5/18/26 at 8:19 a.m., R44 was asleep in bed. R44's bed was not in the lowest position, and the floor mat was folded up and standing on edge next to the privacy curtain. During interview on 5/19/26 at 9:30 a.m., NA-E stated residents at risk for falls should have falls interventions in place at all times. NA-E stated R44 required his bed to be low, a mat on the floor next to the bed, and his call light within reach. During interview on 5/19/26 at 11:11 a.m., licensed practical nurse (LPN)-B stated would expect fall interventions to be in place such as call light in reach, bed low and mat on floor next to bed. During interview on 5/19/26 at 11:25 a.m., director of nursing (DON) expected fall interventions to be in place as indicated on the care plan. Facility policy Fall Prevention and Management dated 11/2025, Facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.

Based on observation, interview, and document review the facility failed to ensure nutritional supplements were provided as ordered for 1 of 1 resident (R74) reviewed who had nutritional supplements ordered. Findings include: R74's 5-day Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, no rejection of care and impairment on one side of upper and lower extremities. R74 was dependent on staff for eating and had diagnoses of encephalopathy (altered mental status), hemiplegia (one-sided paralysis) and malnutrition. R74's nutritional assessment dated [DATE], identified she was at risk for malnutrition. R74's admission weight on 4/25/26, was 138.2 pounds (lbs) and most recent weight on 5/11/26, was 135 lbs (a 3.2% loss). R74's order dated 5/14/26, identified provide 120 cc (cubic centimeters) Med Pass or Mighty Shake (nutritional supplement) after meals. R74's care plan dated 4/27/26, identified current nutritional status was less than 75%. R74 had swallowing issues and altered diet texture with goals to maintain adequate nutritional status. Interventions included provide nutritional supplement per MD (Medical Doctor) and record nutritional intakes per facility protocol. During an observation and interview on 5/17/26 at 11:22 a.m., R74 had two 120 cc warm unopened chocolate Mighty Shakes on the tables in her room. R74 stated she did not know how often she was supposed to have them, but staff did not open the shakes, otherwise she would have drank them. R74 stated she had paralysis on her left hand, had a splint on, and that was why she could not open the shakes. R74 thought she had some weight loss since she was admitted . During an observation and interview on 5/17/26 at 11:31 a.m., nursing assistant (NA)-A entered R74's room and observed the two unopened Mighty Shakes. NA-A stated they should probably be thrown away since they were warm. The labels printed on the shakes were dated 5/14/26 (3 days ago) and one from today 5/17/26. NA-A put the shakes in the garbage. During another observation on 5/18/26 at 10:49 a.m., R74 was in her room, and another unopened Mighty Shake was on the bedside table. During an observation and interview on 5/18/26 at 11:54 a.m., NA-B entered R74's room to bring her outside and did not address the unopened Mighty Shake. When surveyor asked R74 if she wanted her Mighty Shake, she replied please and with a straw and to let the nurse know. During an interview on 5/18/26 at 11:58 a.m., registered nurse (RN)-B stated nursing staff provided the Mighty Shakes to residents. RN-B accompanied surveyor to R74's room to observe the unopened Mighty Shake. RN-A followed us in. The Mighty Shake was observed to have the date 5/18/26 AM. RN-A stated staff should have opened R74's Mighty Shakes due to her limited use of both hands. During an interview on 5/18/26 at 12:22 p.m., the RD stated she expected staff to accurately document nutritional supplement so she could measure progress. The RD stated she could update the order to identify for nursing to open the shake or put it in a cup and measure the drink after R74 finished. During an interview on 05/20/26 at 12:21 p.m., the director of nursing (DON) stated she expected staff to assist residents as needed to ensure nutritional supplements were consumed as ordered. The facility's Nutritional Supplements policy dated 9/2012, identified nursing personnel deliver, serve and/or feed or assist the resident as needed and record intake of supplements. All supplements would be listed on the medication administration record and nursing would record in amounts the amount consumed by the resident on the medication treatment sheets.

Based on observation, interview, and document review, the facility failed to ensure staff followed proper infection control practices for hand hygiene for 1 of 2 residents (R4) observed for personal cares. Findings include:R4's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R4 was cognitively intact, had impairment of one side of upper body, and bilateral amputation of lower extremities. R4 was dependent on staff for total body care, bed mobility, and transfers. It also indicated R4 had a diagnosis of cerebral infarction.R4's physician orders dated 2/9/26, directed staff to follow enhanced barrier precautions (EBP) while providing wound cares and other high contact care activities.R2's care plan dated 4/28/26, directed staff follow EBP when providing high contact cares. Additionally, R4 was incontinent of bowel and bladder and needed to be checked and changed, provided incontinence cares as needed.During observation on 05/18/26 10:06 a.m., nursing assistant (NA)- K and licensed practical nurse (LPN)- B donned gown and gloves and entered R4's room. R4 was in bed and NA-K, and LPN-B explained cares. NA-K and LPN-B lowered pants checked pad and determined R4 had a bowel movement. NA-K cleaned front of peri area and turned R4. NA-K then wiped R4's bottom which had feces with wipes. Without changing gloves or completing hand hygiene, NA-K then applied cream to bottom and peri area, opened and applied a new brief. R4 was assisted onto her back and NA-K and LPN-B closed brief then pulled up pants. As R4 was repositioned for offloading, NA -K proceeded to touch pillow, blankets and tray table with the same contaminated gloves.During interview on 5/18/26 10:16 a.m., NA-K stated they did not change gloves between dirty and clean cares and should have. NA-K verified they wore one pair of gloves for all cares provided.During interview on 5/20/26 at 9:13 a.m., LPN-B stated the expectation was to remove dirty gloves, wash hands and put on a new clean pair of gloves. The importance of proper hand hygiene decreased the spread of infections.During interview on 5/20/26 at 11:00 a.m. director of nursing/infection preventionist (DON/IP) expected staff to perform hand washing before putting the gloves on, go from clean to dirty, after dirty or soiled cares were completed, staff should remove gloves and sanitize their hands. DON/IP further stated it was not acceptable to clean feces and then reposition resident and touch pillows, or any other items. A policy titled Handwashing dated 2/2004, directed staff to use proper hand-washing techniques should be used to protect the spread of infection. Hand washing shall be completed changing incontinent products or cleaning up after someone who has used the toilet. Additionally, when conducting a procedure requiring the use of gloves, proper hand washing shall be completed before donning gloves and after removing gloves.

Based on interview and document review, the facility failed to ensure a comprehensive community safety assessment was completed to determine whether a resident could safely attend outside appointments independently and failed to maintain an effective system to account for and respond when residents did not return from outside appointments as expected for 1 of 1 residents (R1) who was unaccounted for overnight and required emergency department evaluation. Findings include:R1's face sheet dated 5/14/26, identified diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) and alcohol use.R1's Quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no behaviors, used a wheelchair, needed supervision for chair/bed to chair transfer, and was independent in wheelchair mobility. R1's cognition was not listed on the MDS.R1's mobility focus care plan dated 1/22/26, identified R1 had an alteration in mobility related to hemiplegia and hemiparesis following cerebral infarction (stroke). Interventions as follows:-Independent with movement in bed and supervision in and out of bed.-Supervision with transfers.-Used a wheelchair independently for locomotion. R1's physician orders dated 1/26/26, identified R1 may go on leave of absence with medications. R1's Brief Interview for Mental Status (BIMS)(a test used to identify a resident cognition level) dated 1/21/26, identified R1 was cognitively intact. R1's occupational therapy note dated 3/29/26, identified decision making ability for routine activities that R1 was moderately impaired, and safety awareness was impaired. R1's Elopement Risk Evaluation dated 4/27/26, identified R1 was not at risk for elopement.R1's Brief Interview for Mental Status dated 4/30/26, identified R1 was cognitively intact. During an interview on 5/14/26 at 10:20 a.m., licensed practical nurse (LPN)-A stated was the nurse on 5/8/26 when R1 had an appointment scheduled with an outside laboratory. LPN-A explained R1was to be taken to his appointment by a transportation service, so she assisted R1 down to the first floor to wait for his ride. LPN-A had given R1 an envelope with the name and number of the transportation company and gave him instructions to call the transportation company when he was done with his appointment. R1 had his cell phone on his person when he left for the appointment and R1 was able to make phone calls on his phone. LPN-A stated on 5/8/26 at around 5:00 p.m., she identified that R1 had not returned from his appointment and instructed the other nurse to call the outside laboratory to see if R1 was still at the appointment, however, when they called the laboratory the clinic was already closed. LPN-A further explained that the other nurse had attempted to call R1 and R1's first contact and was unable to reach either of them. LPN-A then called the nurse manager and she was told the R1 was his own person and that he must have left the appointment without calling the transportation company for a ride back and gave her instruction to follow the facility's leave of absence policy and notify the police if he did not return after 24 hours. LPN-A stated when she returned to work the next day on 5/9/26, R1 was still not in the facility, so had called 911 and filed a missing person report with the police. R1's progress note dated 5/9/26 at 9:37 a.m., identified a state agency report was completed due to resident not returning from an appointment. Facility staff completed a missing person's report with the police department. R1's progress note dated 5/9/26 at 11:06 a.m., identified physician was notified of R1 not returning to the facility. R1's emergency department (ED) note dated 5/10/26 at 1:04 a.m., identified R1 was brought to the ED after he was found using his wheelchair in a crosswalk with difficulty prompting a bystander to call emergency management systems (EMS). R1 had a left knee wrapped and an abrasion to his left elbow. R1 had difficulty providing details of the event, but is alert and oriented to person, place, time, and event. R1's biggest concern was his left elbow pain and left hip pain. History was limited secondary to R1's intermittent altered mental status. R1 denied being in significant distress. R1 stated he had consumed alcohol. Alcohol level checked and was negative. R1 was admitted to the hospital due to fluctuating cognitive levels, an elevated white cell counts with an admitting diagnosis of adult failure to thrive. During an interview on 5/14/26 at 10:11 a.m., nursing assistant (NA)-A stated the facility had assigned staff to attend appointments with residents that are identified as needing an escort due to not being able to go independently and this is marked on the calendar each day on who would need an escort. NA-A stated R1 was alert and orientated and did not need an escort to appointments. During an interview with police department on 5/15/26 at 2:22 p.m., stated the facility had contacted the department on 5/9/26 to report a resident that had not returned from an appointment on 5/8/26. The department took the report and when the investigator contacted the facility to complete the report, R1 had already been found by that time. During an interview on 5/14/26 at 11:52 a.m., registered nurse/nurse manager (RN-NM) stated she decides if a resident needs to have an escort to any outside appointment and will ensure that a resident has staff accompany them if needed. RN-NM stated that the facility does not perform a formal community safety assessment to ensure they are safe to go independently and will use the elopement risk and the Brief Interview for Mental Status assessment to make the determination. RN-CM further explained R1 was independent in his decision making and they believed when he left for his appointment on 5/8/26, he chose to not call the transportation service and went on a leave of absence, however, R1 had not signed out or contacted the facility saying he was not returning per the facility policy. During an interview on 5/14/26 at 12:11 p.m., registered nurse (RN)-A stated R1 left for an appointment on 5/8/26 with a transportation service around 9:00 a.m., and when he did not return around 5:00p.m., the facility attempted to call the outside laboratory to see if R1 could be located, however, the lab was already closed for the day. RN-A stated she believed R1 was his own person and assumed he must have not contacted the transportation service and decided to go on a leave of absence (LOA), however, R1 had not signed himself out or called the facility to inform the facility he would not be returning. RN-A stated when a resident is admitted to the facility she will complete an elopement assessment and review the BIMS score to make a determination if a resident is safe to go to appointments alone, however, the facility does not perform a community assessment prior to making this determination. During an interview on 5/15/26 at 10:31 a.m., DON stated R1 had not had a community safety assessment completed to determine if he was safe to go out to an appointment independently and he should have had this completed. DON further explained the facility is going to change the process of determining if residents need to have a staff escort by having the interdisciplinary team (IDT) review a resident's diagnosis, cognition, and safety awareness to ensure the resident is safe to go out in the community for things like outside appointments. Currently the facility does not do community safety assessments on each resident going out in the community independently, however, will be doing this going forward. Review of the facility's Resident Leave of Absence Policy dated 11/25, identified the purpose of the policy was to establish guidelines and a procedure for appropriate communication and documenting leave of absence requirements. Prior to leaving the facility the resident or resident representative will be instructed to sign out prior to going out on LOA to include when they will be returning with approximate date and time. Request a policy for outside appointments but did not receive.

Based on observation, interview and document review, the facility failed to ensure care was provided in accordance with a resident's care plan for 1 of 3 residents (R18) reviewed for non-pressure related skin concerns.Findings include:R18's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R18 had short- and long-term memory problems, knew location of own room and staff names and faces, and had some difficulty in new situations regarding her cognitive skills for daily decision making. R18 did not have behaviors or rejection of cares. R18 required substantial/maximal to dependent assistance with most activities of daily living (ADLs). R18 was at risk for pressure ulcers.R18's care plan, indicated R18 was at risk for skin alteration related to incontinence, history of recurring redness/rash under breasts and skin folds, poor safety awareness, and history of walking towards doors and walls. The care plan interventions included barrier cream after each incontinent episode, encourage to allow cleansing and drying of skin folds in the morning and bedtime and reapproach if refuses, ensure socks removed carefully and does not stick, assist with nails and toenail care weekly and as needed, heel protectors on while in bed, place a pillow under resident's back when turned and repositioned, turn and reposition every two to three hours and as needed, monitor skin integrity daily during cares and weekly skin inspection by nurse, treat open areas per order, encourage adequate fluid intake, pressure redistribution cushion to wheelchair and chair, low air loss mattress and monitor function every shift, and follow dietary interventions which included supplements as ordered.R18's physician order dated 2/14/24, indicated geri-sleeves (protective sleves) or long sleeves on in the morning and off at bedtime every shift.During observation on 6/25/25 at 7:40 a.m., R18 sat in her wheelchair in the dining area and had short sleeves on and no geri-sleeves.During observation on 6/25/25 at 9:25 a.m., nursing assistant (NA)-A and C assisted R18 to bed and provided peri-cares. R18 had short sleeves on and new geri-sleeves. R18's heels were not floated off the bed with pillows or protective boots.During interview on 6/25/25 at 9:37 a.m., NA-A verified R18 did not have long-sleeves or geri-sleeves on. NA-A stated they were not sure if R18 needed her arms covered. NA-A verified R18's heels were not floated and did not know about protective boots for R18. NA-A stated R18's heels were not an issue and feet did not have skin breakdown.During observation and interview on 6/25/25 at 11:10 a.m., R18 was in bed and observed in short sleeves and no geri-sleeves, and R18's heels were not floated. Registered nurse (RN)-E stated R18 needed her heels floated and verified they were not floated. RN-E found heel protector boots in R18's closet and applied them to R18's feet.During interview on 6/26/25 at 10:37 a.m., the assistant director of nursing (ADON) stated R18 was at risk for pressure ulcers and floating R18's heels were important for pressure ulcer prevention. The ADON stated R18 needed geri-sleeves when she used to bump into doorways and got bruises related to poor safety awareness. During interview on 6/26/25 at 2:01 p.m., the director of nursing (DON) expected staff to follow the care plan. The DON stated geri-sleeves or long sleeves were used to prevent skin tears and bruises.The facility Care Planning policy dated 11/2024, directed staff to use resident's plan of care to provide 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 a resident's preferred activities for individual entertainment were available for 1 of 1 resident (R16) reviewed for activities.Finding include:R16's Minimum Data Set (MDS) assessment dated [DATE], identified R16 had cognitive impairment and displayed no delusional thinking, with some rejection of cares. R16 was dependent on facility staff for upper and lower body dressing, putting on and removing shoes, and transferring from bed to chair.R16's Evaluation and Social History dated 8/19/24, indicated R16 had no visual or auditory deficits that would impact activity participation, enjoys time with her children, music, and game shows. R16's specific preference to music is old rhythm and blues. Further, R16 was willing to try new activities, actively engages in structured activities of choice, and actively engages in independent activity of choice.R16's care plan dated 11/14/24, indicated R16 had generalized anxiety, major depressive disorder, and obsessive-compulsive disorder. The interventions the facility outlined in this document included:-administer medications as ordered-complete PHQ-9 (depression screening) per facility policy-encourage resident to take part in Music Therapy Group events (Bell Choir, Singing Groups, Music in Motion) to stimulate socialization.-Monitor/record/report to MD as needed any changes in mood patterns, signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocolsDuring interview on 6/23/25 at 3:38 p.m., R16 confirmed she likes to listen to music and would be interested in attending music activities or groups. Family stated the facility had not previously had any music-related activities for the resident to attend. Further, the facility staff do not ask the resident if she would like to join a group activity. The activity calendars dated, February 2025, March 2025, April 2025 , May 2025 and June 2025 did not contain any music-related activities or groups.During observation on 6/24/25 at 1:00 p.m., activity director (AD)-A was walking down the hall, gathering residents for a Tuesday Tea Party in the 3rd floor dining room. The AD-A did not enter R16's room to offer to take R16 to the Tea Party. During this observation no other facility staff went into R16's room to alert her to the activity nor offer to take her to the activity.During observation on 6/24/25 at 2:43 p.m., activity director (AD)-A was walking down the hall, gathering residents for Bingo in the 2nd floor dining room. The AD-A did not enter R16's room to offer to take R16 to Bingo. During this observation no other facility staff went into R16's room to alert her to the activity nor offer to take her to the activity.During observation on 6/25/25 at 10:23 a.m., activity director (AD)-A was walking down the hall, gathering residents for a Bible Study in the 2nd floor dining room. The AD-A did not enter R16's room to offer to take R16 to bible study. During this observation no other facility staff went into R16's room to alert her to the activity nor offer to take her to the activity.During observation on 6/25/25 at 12:31 p.m., activity director (AD)-A was walking down the hall, gathering residents for movie in the main activity hall. The AD-A did not enter R16's room to offer to take R16 to the movie. During this observation no other facility staff went into R16's room to alert her to the activity nor offer to take her to the activity.During interview on 6/25/25 at 10:35 a.m., certified nursing assistant (CNA)-C stated the resident was dependent on staff; if she would like to go to an activity, staff would have to assist her. Further, stated the resident should be notified before each activity because she has dementia and wouldn't be able to remember when or what the activity was before the activity.During interview on 6/25/25 at 10:47 a.m., assistant director of nursing (ADON) stated the resident does experience anxiety or depression at times. ADON stated the staff at the facility respond to this anxiety or depression by following the interventions outlined in the care plan. ADON could not list the specific patient-centered music-related intervention for R16.During interview on 6/26/25 at 8:06 a.m., AD-A could not state what R16's personal goals for activity and leisure were. AD-A stated she regularly does rounds on each floor to gather residents to go to activities. AD-A confirmed she did not ask R16 to attend activities on either 6/24/25 or 6/25/25. AD-A stated the facility does not offer music-based activities very often. AD-A stated she was aware R16 had a general anxiety disorder and depression; not knowing about the person-centered intervention to offer music therapy or music-related activities. A facility activity policy was asked for, and not received.

Based on observation, interview and document review the facility failed to ensure bruises were adequately assessed and monitored for 1 of 1 resident (R92), failed to ensure non-pressure wounds had timely assessment and documentation for 1 of 3 residents (R92), and furthermore failed to implement and/or clarify a wound order after a hospitalization for 1 of 3 residents (R2) reviewed for non-pressure related wounds.Findings include: R92's admission Minimum Data Set (MDS) assessment, dated 6/11/25, indicated intact cognition, did not have delusions or hallucinations, physical, verbal, or other behavioral symptoms, and did not reject care. Further, R92 was dependent on staff for toileting hygiene, lower body dressing, and required substantial to maximal assistance with upper body dressing, personal hygiene, and showering and bathing. R92's diagnoses included cancer, wound infection, diabetes, arthritis, was morbidly obese with a body mass index of 50.0 to 59.9. Furthermore, R92 was at risk for developing pressure injuries, had surgical wounds, and took an anticoagulant (blood thinner). During observation and interview on 6/23/25 between 2:14 p.m., and 2:17 p.m., R92 had bruises bilaterally to the back of her upper arms. R92's right arm had a bruise approximately the size of a grapefruit and the bruise located on R92's left arm went from R92's arm pit area to her elbow and was purple towards the elbow and a faded yellow color on the upper part of R92's left arm. R92 stated they were from her blood thinner shots. R92 stated her camisole stitching rubbed on her and rolled up on her due to her large abdomen and had a sore spot on her left arm pit area. R92's left posterior arm at armpit crease had a small nail head sized open area. An dressing (ABD) pad was tucked in next to the area, but did not cover the open area. R92 stated she didn't want to wear other shirts because she didn't want drainage staining them from her dressings. R92's Physician's Orders form, indicated the following orders: 6/13/25, surgical incision to the right axilla, right breast, cleanse with NS (normal saline) or WC (wound cleanser), pat dry. Cover with a non-adhesive dressing or ABD (dressing type) and secure with tape every day. Monitor for signs and symptoms of infection. 6/6/25, Complete Daily Skilled Note under forms in PCC (Point Click Care-facility electronic medical record). State why the resident is currently being covered for #6 skin issue, #7 infection, #9 diabetes, #13 anticoagulant. 6/8/25, Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle and joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, SOB [shortness of breath], nose bleeds. 0=No Symptoms, +=See NN (nurse note). 6/8/25, weekly skin inspection by the licensed nurse. Complete weekly skin inspection in PCC. 6/5/25, enoxaparin sodium (generic for Lovenox) injection solution prefilled syringe 40 milligrams (mg)/0.4 milliliters (ML) inject 0.4 ml subcutaneously every 12 hours for prevention of a blood clot. R92's lacked documentation or treatment instruction for an ABD pad related to the open area and a specific assessment or monitoring for the bruising to R92's upper arms. R92's medication administration record (MAR) and treatment administration record (TAR) dated June 2025, indicated R92 received enoxaparin twice daily at 9:00 a.m., and 9:00 p.m., R92's care plan dated 6/6/25, indicated R92 was diabetic and interventions indicated to check all of her body for breaks in skin per protocol and treat promptly as ordered by the physician. R92's care plan dated 6/12/25, indicated R92 had a potential for alteration in blood formation and coagulation due to use of an anticoagulant and interventions included to monitor and notify the physician for signs and symptoms of bleeding, to monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status, and or vital signs, SOB, and nose bleeds. R92's care plan dated 6/6/25, indicated R92 had an alteration in skin integrity related to recent surgery and had surgical wounds on the right breast and underarm. Interventions indicated to monitor skin integrity daily during cares and weekly skin inspections by the nurse, treatment to open areas per order, turn and reposition or reminders to offload every 2 to 3 hours and as needed, weekly measurements and assessment of wound. R92's care plan dated 6/6/25, indicated R92 had an alteration in mobility related to generalized weakness and interventions indicated R92 required assist of one with movement in bed and in and out of bed, assist of 2 staff with a Hoyer for all transfers, and R92 could not ambulate. R92's care plan dated 6/6/25, indicated R92 had a self-care deficit, and her sling was to be left under her due to risk of friction and shear. Additionally, R92 had interventions for assist of 1 with grooming, bathing, dressing, was able to dress upper body, and required set up assist with personal hygiene. R92's Skin Evaluation and Skin Risk Factors form dated 6/5/25 at 8:07 p.m., indicated R92 had the following skin conditions: a surgical incision to the right breast measured 3.7 centimeters (cm) long, by 0.3 cm wide, a surgical incision to the right armpit measured 4.2 cm long by 0.5 cm wide. Further, R92 had bruising to the right and left lateral upper arms. The form lacked information regarding and assessment of the coloring of the bruising, size of the bruising or how R92 obtained the bruising. Further the form indicated R92 had the following risk factors that included medications, obesity, and diabetes. R92's Weekly Skin Inspection form dated 6/8/25 at 10:45 p.m., indicated R92 had an open surgical wound on the right breast and all other skin was clear and intact. R92's Weekly Skin Inspection form dated 6/22/25 at 8:44 p.m., indicated it was the nurse's responsibility to evaluate the resident's skin at a minimum of once a week to ensure skin integrity and implement interventions as applicable. The form indicated R92 refused a bath and nail care, however, the form indicated R92 had an open surgical wound on the right breast and all other skin was clear and intact. R92's Skin and Wound Evaluation forms dated 6/24/25 , lacked information R92 had an open area to the left upper posterior arm. R92's Daily Skilled Note dated 6/5/25 at 10:09 p.m., The form lacked an assessment of R92's bruises, or R92 had a bruise. R92's Daily Skilled Note dated 6/6/25 at 1:01 p.m., The form lacked an assessment of R92's bruises or that R92 had a bruise. R92's Daily Skilled Notes dated 6/7/25 at 12:42 p.m., 6/8/25 at 1:03 p.m., 6/9/25 at 12:54 p.m., 6/9/25 at 9:45 p.m., 6/10/25 at 2:03 p.m., indicated R92 was alert and oriented to person, place, and time, did not have behaviors that included resisting care. The form indicated the same check box next to skin issues, and anticoagulant use. Further, the form indicated R92 was free from signs and symptoms of bleeding related to anticoagulant use, and the anticoagulant was administered as ordered. The forms lacked an assessment of R92's bruises or that R92 had a bruise, and further lacked information the bruises identified 6/6/25, had resolved. R92's Daily Skilled Notes dated 6/11/25 at 1:35 p.m., indicated R92 was alert and oriented to person, place, and time, did not have behaviors that included resisting care. The form indicated the same check box next to anticoagulant use. Further, the form indicated R92 was free from signs and symptoms of bleeding related to anticoagulant use, and the anticoagulant was administered as ordered. The form lacked an assessment of R92's bruises or that R92 had a bruise. Further, under a heading, Resident Response to Treatments & Additional Comments that indicated R92 did not have bruising or bleeding noted from anticoagulants. R92's MHM Daily Skilled Note dated 6/12/25 at 11:39 a.m., and 6/13/25 at 11:32 a.m., lacked an assessment of R92's bruises or that R92 had a bruise. R92's MHM Daily Skilled Notes dated 6/17/25 at 6:56 p.m., 6/18/25 at 10:23 a.m., 6/19/25 at 9:25 a.m., 6/20/25 at 1:29 p.m., 6/21/25 at 2:11 p.m., 6/23/25 at 11:37 a.m., and 6/24/25 at 1:06 p.m., lacked an assessment of R92's bruises or that R92 had a bruise, and further lacked information the bruises identified 6/6/25, had resolved. R92's Integrated Wound Care note dated 6/17/25, indicated R92 was seen for evaluation of wound sites to the front right axilla and the right breast. Further R92's surgical site on the right axilla was tender due to friction with the edge of the camisole and factors that affected R92's healing included diabetes, cancer, neuropathy, weakness, obesity, and reduced mobility. R92's Integrated Wound Care note dated 6/24/25, indicated R92 was seen for evaluation of the surgical wounds to the front right axilla and the right breast. The note lacked information R92 had a wound to the left upper posterior arm. R92's progress notes were reviewed from 6/5/25, to 6/24/25, and lacked documentation of bruising to arms or an open area assessment of the left upper posterior arm During interview on 6/25/25 at 9:27 a.m., to 9:44 a.m., registered nurse (RN)-B stated skin was assessed and documented weekly, and further stated skin was looked at daily. RN-B stated skin notes were in the Forms tab of their electronic medical record (EMR). RN-B stated they had to report bruising because you need to know how a resident obtained it and then management took pictures of skin issues. RN-B stated open areas had to be documented and if it was new, would utilize standing orders to clean and cover and further stated new bruises or new skin issues had to be assessed and the provider would place orders to either put pads on or keep skin clean and dry. RN-B stated bruises are monitored and when asked how RN-B knew if bruises were changing or getting worse, RN-B stated they would go by orders to monitor the bruise on the MAR or TAR every shift. RN-B stated R92 had wound pictures of R92's sore on her right side, but further stated she did not see any bruising documented and viewed orders and forms and stated there was no documentation of bruising. RN-B opened a Weekly Skin Assessment Form dated 6/8/25, and 6/22/25, and verified there was no documentation of bruising. Further RN-B viewed R92's Daily skin note dated 6/24/25 and verified it lacked information of R92 having a bruise and stated it would not be documented anywhere else. At 9:44 a.m., RN-B verified R92 had bilateral bruising to both arms along with the open area to R92's left arm near her arm pit and stated it had not been documented or measured and stated it should have been. R92 was wearing her tank/camisole again that was rolled up to under her breasts and her arms were exposed. During interview on 6/25/25 at 9:56 a.m., the director of nursing (DON) stated if a resident had a bruise an order needed to be placed to monitor the bruise, and the guardian and physician would be notified and they would complete a risk management form. The DON verified R92 did not have a risk management form. The DON stated a new bruise has color changes of dark red and purple and if a resident was alert and oriented would ask how they got it and would complete an incident analysis and would place a monitoring order and would resolve once the bruises were healed. The DON stated a fresh bruise was a dark purple. The DON stated she would have to review the policy in order to know how staff assessed residents to know whether bruising was getting worse. The DON further stated R92 had diabetes, breast cancer, was obese, and was on a blood thinner and stated the bruise was identified on admission and verified R92's medical record lacked information on the color, shape, or size of R92's bruise identified on 6/5/25. Further, the DON verified R92's chart lacked documentation R92 had an open area to her left arm and stated R92 refused her bath on 6/22/25, and stated there were no further assessments on R92's bruises. When asked about the lack of documentation of bruises in the Daily Skin Notes, the DON stated they would document new bruises. The DON stated she wondered if R92's open area on the left arm pit was from the day prior and verified there were no pictures of the wound on R92's left arm pit. Further, the DON could not explain how staff could identify whether a bruise documented from admission was the same bruise, or if a resident had a new bruise and could not explain how bruises were assessed or documented and stated she would have to check the policy. A late entry note created on 6/25/25 at 11:11 a.m., was entered into R92's progress notes for 6/24/25 at 8:09 a.m., that indicated, This writer and wound provider access resident armpits noted redness caused by the surgical garment. An additional progress note dated 6/25/25 at 11:44 a.m., was entered into R92's progress notes, Resident has bruises on her bilateral arms due to anticoagulant use. Redness noted under her right breast and Little open area on the left armpit. Provider updated. During interview on 6/25/25 at 12:18 p.m., nursing assistant (NA)-B stated R92 required a check and change and was alert. NA-B stated R92 could dress her top half after providing the top and further stated they completed skin checks when residents were changed. During interview on 6/26/25 at 11:49 a.m., the DON verified R92's Skin Evaluation and Skin Risk Factors form did not contain measurements for R92's bruises. A policy, Skin Assessment and Wound Management, dated 2/2025, indicated the purpose of the assessment was to provide guidelines for assessing and managing wounds. Further, prevention and identification included implementing preventative skin measures, a skin evaluation and skin risk factors form was completed before initial MDS, annually, and upon significant change. Further, staff would perform routine skin inspections with daily care and nurses were to be notified if skin changes were identified and a weekly skin inspection was completed by licensed staff. Further when a significant alteration in skin integrity is noted such as large or multiple bruising, or other non-pressure related wounds the following actions will be taken: notify the provider, treatment ordered, notify the representative, complete education with the resident including risks and benefits, initiate a skin and wound evaluation, notify the nurse manager, review and update the care plan including interventions. R2 R2's quarterly Minimum Data Set (MDS) assessment, dated 4/29/25, indicated R2 had severe cognitive impairment, no behaviors or rejections of care, and required substantial/maximal to dependent assistance with activities or daily living. R2's diagnoses included peripheral vascular disease, neurogenic bladder, diabetes mellitus, dementia, anxiety, and depression. R2 had an indwelling catheter, was always incontinent of bowel, and was at risk for pressure ulcers. R2's care plan, indicated R2 was at risk for skin alteration related to impaired memory, fragile skin, type one diabetes, peripheral vascular disease, and incontinence. Interventions included occupational therapy to eval (evaluation) and treat for wheelchair positioning, monitor skin integrity daily during cares and weekly skin inspection by nurse, treatment to open areas per order, cue and encourage to turn and reposition every two to three hours and as needed, pressure redistribution mattress to bed, pressure redistribution cushion to wheelchair and chair, and dietary interventions which included to encourage supplements as ordered. R2's physician orders, indicated: -Barrier cream after each incontinent episode and ensure to apply on the scrotum every shift with start date of 9/14/23 . -Wound cares to scrotum with incontinent cleanser (dimethicone active ingredient) and soft dry wipes every shift with start dated of 4/14/25 . R2's progress notes dated 4/7/25 to 6/25/25, indicated R2 was hospitalized on [DATE] and returned to the facility on 4/12/25. Progress notes reviewed indicated R2's skin was warm and dry with no open areas. R2's 4/12/25 hospital encounter, directed staff to continue cleansing scrotum with incontinent cleanser (dimethicone active ingredient) and soft dry wipes. R2's June 2025 Medication and Treatment Administration Record (MAR and TAR), indicated staff administered barrier cream every shift. Although R2’s wound care orders for his scrotum lacked being identified on the MAR and TAR. During interview on 6/25/25 at 10:46 a.m., nursing assistant (NA)-A stated R2 had skin rashes which appear and heal but skin was clear now. During observation and interview on 6/25/25 at 10:59 a.m., registered nurse (RN)-E stated R2 had a scrotal wound which appeared and cleared. R2's scrotal area had barrier cream and appeared red after the barrier cream was wiped off. RN-E stated R2's scrotum was macerated at times. RN-E reviewed ingredients in the topical products used for R2. Tena Proskin cleansing cream had active ingredients of glyceryl stearates/cetearyl isononanoate. DermaRite PeriGuard ointment had active ingredient of petrolatum. Neither included dimethicone as an active ingredient ordered by provider. During interview on 6/26/25 at 10:37 a.m., the ADON stated R2 had a wound to his scrotum approximately two years ago and no current wound concerns to his scrotal area. The ADON was unsure of where the scrotal wound order with dimethicone came from. During interview on 6/26/25 at 11:00 a.m., licensed practical nurse (LPN)-B stated staff applied barrier cream to R2's scrotum and was not aware of anything else. LPN-B reviewed R2's order for wound care with dimethicone cream and stated the order did not show up on the MAR or TAR. During interview on 6/26/25 at 2:01 p.m., the director of nursing (DON) expected staff to follow orders and clarify orders as needed once residents returned from the hospital. The facility Skin Assessment and Wound Management policy dated 2/2025, directed staff to implement appropriate preventative skin measures and follow ongoing treatments per provider order.

Based on observation, interview, and document review, the facility failed to appropriately assess and help maintain range of motion and prevent possible contracture who had limited functional movement in the right hand for 1 of 2 residents (R16) reviewed for range of motion (ROM). Findings include:R16's Minimum Data Set (MDS) assessment dated [DATE], identified R16 had cognitive impairment and displayed no delusional thinking, with some rejection of cares. Further, R16 required moderate assistance to eat and perform oral hygiene.During observation and interview on 6/23/25 at 3:51 p.m., R16 was resting in bed and her daughter held up R16's right hand and stated she was concerned R16's hand and fingers were becoming more contracted; stating R16 is no longer able to hold silverware or brush her teeth on her own. R16 could previously do those things. During observation on 6/24/25 at 12:40 p.m., R16 had food present and was attempting to feed self. R16 was unable to use the silverware, instead R16 was picking up food with her left index finger and thumb.During interview on 6/25/25 at 10:27 a.m., assistant director of nursing (ADON) stated she does not recall if R16 had a brace for her right hand. ADON stated the importance of a brace for R16 would be to maintain function and prevent loss of range of motion (ROM).During interview on 6/25/25 at 12:33 p.m., physician assistant (PA) confirmed R16 had a contracture of the right hand; stating a physical therapy (PT) consult was ordered in December 2024. PA stated the normal process is the provider team will order the PT consult, once the PT consult is complete, the PT team will make recommendations. Once the provider team has recommendations, they will write PT orders for the resident based on the recommendations. PA confirmed R16 had an Xray of the right hand on 3/12/25, this imaging was limited due to the flexed position of the right hand. PA stated a brace could be important for R16 so that she does not lose any more ROM in her right hand.During interview on 6/25/25 at 12:53 p.m., physical therapy director (PT-D) stated the physical therapy department completed a PT consult on 12/11/24. The consult on this date did not address ROM needs of the right hand; the consult only addressed wheelchair positioning and upper body strengthening. PT-D confirmed the physical therapy department had not seen R16 since December 2024.A facility policy titled Therapy Services Agreement dated 11/17/2019, identified the facility maintains rehabilitation services with a therapy contractor. However, the facility retains responsibility for, and overall supervision of facility residents.

Based on interview and document review, the facility failed to ensure timely reassessment after administration of as needed narcotic medication for 1 of 2 residents (R296) reviewed for pain.Findings include: R296's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R296 had intact cognition and diagnoses of hypertension, cirrhosis (scarring of liver caused by many diseases and conditions which includes alcohol use disorder), gastro-esophageal reflux disease (condition in which stomach contents move up into the esophagus), viral hepatitis (infection which causes liver inflammation and damage), diabetes mellitus, fracture, anxiety disorder, depression, and chronic obstructive pulmonary disease (condition caused by damage to airways and other parts of the lung). R296 received as needed pain medications. The MDS indicated R296 had pain almost constantly and the pain occasionally effected sleep and interfered with therapy activities and day-to-day activities. R296's care plan, indicated R296 had chronic hip pain and acute lumbar spine fracture, history of substance abuse, and followed by the pain management team. The care plan indicated R296 made statements of only wanting oxycodone as pain relief, rated pain at eight or nine out of ten without nonverbal indicators of pain or discomfort, and had a history of opioid abuse.The care plan directed staff to provide nonmedicinal forms of pain relief such as positioning, rest, and massage, administer pain medication as ordered, document on effectiveness of pain medication, encourage R296 to verbalize discomfort, monitor for potential medication side effects related to medication usage. R296's Pain Evaluation dated 6/19/25, indicated R296 rated his pain at ten out of ten with a verbal description of moderate. The evaluation indicated R296 complained or showed evidence of pain or possible pain daily. R296's pain treatment included gabapentin 100 milligrams (mg) twice a day and oxycodone 5 mg as needed every six hours. R296's physician order dated 6/19/25 indicated, oxycodone HCl (hydrochloride), opioid painkiller used to relieve moderate to severe pain, 5 milligrams (mg) by mouth every six hours as needed for pain. R296's progress notes, order administration notes, pain scores, and medication administration record dated 6/20/25 through 6/23/25 were reviewed and indicated:-On 6/20/25 at 11:23 a.m., oxycodone was given for back pain rated at seven out of ten for pain. At 2:35 p.m., the as needed medication was marked as effective and follow-up pain score was zero out of ten.-On 6/20/25 at 8:04 p.m., oxycodone was given for pain rated at two out of ten. On 6/21/25 at 1:40 a.m., the as needed medication was marked as unknown. No other interventions or notifications were noted.-On 6/21/25 at 5:17 a.m., oxycodone was given for pain rated eight out of ten. At 6:56 a.m., a progress note indicated R296 slept for the most part of the night and requested as needed oxycodone which was given. At 11:36 a.m., the as needed medication was marked as ineffective and follow-up pain score was seven out of ten.-On 6/21/25 at 11:40 a.m., oxycodone was given for back pain rated at seven out of ten. At 12:54 p.m., a progress note indicated R296 had lower back pain rated at seven out of ten, pain medication was given, and pain was unchanged. No other interventions or notifications were noted. At 4:19 p.m., the as needed medication was marked as effective and follow-up pain score was two out of ten.-On 6/21/25 at 6:22 p.m., oxycodone was given for pain rated at three out of ten. At 8:05 p.m., a progress note indicated R296 had no signs or symptoms of pain. At 8:49 p.m., the as needed medication was marked as effective and follow-up pain score was two out of ten.-On 6/22/25 at 2:34 a.m., oxycodone was given for pain rated at seven out of ten. At 3:43 a.m., the as needed medication was marked as effective and follow-up pain score was zero out of ten.-On 6/22/25 at 9:23 a.m., oxycodone was given for back pain rated at seven out of ten. At 12:46 p.m., a progress note indicated R296 had lower back pain rated seven out of ten, pain medication given, and pain unchanged. At 2:04 p.m., the as needed medication was marked as ineffective and follow-up pain score was seven out of ten. No other interventions or notifications were noted.-On 6/22/25 at 6:20 p.m., a progress note indicated R296 did not have signs or symptoms of pain.-On 6/22/25 at 9:55 p.m., oxycodone was given for pain rated four out of ten. On 6/23/25 at 5:10 a.m., the as needed medication was marked as ineffective and the follow-up pain score was eight out of ten. No other interventions or notifications were noted.-On 6/23/25 at 5:11 a.m., oxycodone was given for pain rated eight out of ten. At 11:57 a.m., the as needed medication was marked as ineffective and the follow-up pain score was seven out of ten. No other interventions or notifications were noted.-On 6/23/25 at 12:22 p.m., oxycodone was given for back pain rated at seven out of ten. At 5:58 p.m., the as needed medication was marked as effective and the follow-up pain score was zero out of ten. During interview on 6/23/25 at 2:29 p.m., R296 stated he struggled with pain to his right side of his abdomen where there was a recent bleed, which led to hospitalization, and chronic back pain from a fracture. R296 stated his pain rated at a seven or eight out of ten. R296 stated he wanted to run away from his pain and was unsure his pain would completely go away. R296 stated nonpharmacological interventions were not effective for his pain. During interview on 6/25/25 at 12:26 p.m., R296 stated his pain was bad today from wearing his back brace and transportation to and from an appointment in the morning. R296 stated his back and right abdominal pain was at an eight out of ten when he received as needed pain medication around 11:00 a.m R296 stated the nurse had not returned to ask him about the medication effectiveness. R296 stated the pain medication took the edge off and rated pain at a six or seven out of ten depending on how much he moved. During interview on 6/25/25 at 1:58 p.m., registered nurse (RN)-C stated R296 complained of pain from his back brace when returned from an appointment and gave him as needed oxycodone around 10:00 a.m RN-C stated they had been in R296's room since the oxycodone administration but had not asked him about his pain. RN-C stated R296's pain should be re-assessed within an hour of as needed pain medication administration. RN-C stated staff should attempt other interventions when as needed pain medications were not effective. R296's progress notes, order administration notes, pain scores, and medication administration record dated 6/25/25, indicated R296 received oxycodone for pain rated zero out of ten at 10:21 a.m At 4:27 p.m., the as needed medication administration was marked as effective and follow-up pain score was zero out of ten. During interview on 6/25/25 at 2:07 p.m., nursing assistant (NA)-D stated R296 asked for his pain medication every six hours and did not look like he was in pain. NA-D stated R296 saw a pain management team weekly who lessened his PRN medication dosing per day but changed back after R296 screamed and cursed. During interview on 6/26/25 at 10:29 a.m., the assistant director of nursing (ADON) expected staff to follow-up on resident's pain 15 to 30 minutes or up to an hour after PRN pain medication administered. ADON stated staff kept the provider updated about R296's pain management concerns and offered to help R296 change providers. The ADON stated they would educate staff about timely follow-up after PRN medication administration. During interview on 6/26/25 at 2:01 p.m., the director of nursing (DON) expected staff to reassess resident's pain level after or less than thirty minutes from when a PRN pain medication was given. DON stated the reassessment of pain level was important to ensure resident's pain was addressed and to ensure the provider did not need to address resident's continued pain. The facility Pain Management Protocol dated 3/23/23, directed staff to evaluate and report how much and how often residents utilized PRN pain medication. The policy directed staff to reassess residents' pain and related consequences at regular intervals to ensure pain was controlled. The policy directed staff to document effectiveness of interventions for pain and resident's satisfaction with the current level of pain control.

Based on interview and document review, the facility failed to comprehensively assess past trauma and implement individualized care plan interventions utilizing a trauma-informed approach for 1 of 1 (R19) resident reviewed who had post-traumatic stress disorder (PTSD).Findings include:R19's Minimum Data Set (MDS) dated [DATE], identified intact cognition, was independent with eating, dressing, toileting, and walking. Diagnosis included depression, schizophrenia, and post-traumatic stress disorder (PTSD). The Care Area Assessment Summary of the MDS for psychosocial well-being was not completed.R19's provider's history and physical note dated 10/9/23 indicated R19 had a diagnosis of schizophrenia, depression, and suicidal ideation. Further, R19 had PTSD due to religious persecution, starvation, and violence suffered in the Sudan; further being complicated by increased life stressors, unspecified psychosis, and alcohol use disorder.Initial review of R19's care plan dated 10/10/23, the focus lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization. During an interview on 6/24/25 at 2:20 p.m., nursing assistant (NA)-C was not aware of R19's PTSD diagnosis or history, triggers, or patient-centered trauma informed care interventions.During an interview on 6/24/25 at 2:24 p.m., registered nurse (RN)-D stated she was not aware of R19's PTSD diagnosis or history. RN-D stated R19 can become withdrawn, quiet, and refuse to come out of her room at times. RN-D stated she is not aware if these are coping mechanisms related to her PTSD. RN-D reviewed the care plan for R19, confirmed the care plan did have a PTSD care plan. RN-D stated the care plan only stated that R19 had a PTSD diagnosis; the care plan did not specify what the PTSD was from nor what the triggers are. RN-D stated that is why she probably didn't know or remember R19 had PTSD was because the care plan didn't outline anything about R19's PTSD.During interview on 6/25/25 at 10:27 a.m., assistant director of nursing (ADON) stated R19 did have a care plan for PTSD. ADON confirmed the care plan had the following interventions:-referral for psych services as appropriate-staff will utilize trauma informed care when working with resident-connect resident to community services as appropriate -consider past trauma when engaging with resident-Complete PHQ-9 (depression screening) per facility policy and as needed-Notify relevant providers about change in condition or behavior-Encourage collaboration with social services or psych to improve social connections and minimize symptomologyADON confirmed the care plan did not provide detail about R19's PTSD diagnosis or triggers, nor did the care plan outline resident-specific interventions.Per facility policy titled Trauma Informed Care dated 2/24/23, residents that have a history of trauma will have goals and interventions added to their care plan to address potential triggers and approaches to minimize or eliminate the effect of the trigger on the resident.

Based on observation, interview, and record review the facility failed the ensure residents were free from unnecessary medications for 1 of 2 residents (R25) reviewed for diuretic use. Findings include: R25's admission Minimum Data Set (MDS) assessment, dated 5/21/25, indicated R25 was cognitively intact with no behaviors or delirium. R25 had range of motion to one side of her upper body and required partial to moderate assistance with activities of daily living. R25 received diuretic medication. R25's diagnosis list included chronic respiratory failure, essential hypertension (high blood pressure), chronic kidney disease, and chronic diastolic congestive heart failure (CHF-heart disease that causes buildup of fluid in the body). R25's care plans included diuretic therapy related to hypertension and congestive heart failure. Interventions included administer medication as ordered and potential side effects that included dizziness, postural hypotension (drop in blood pressure with position changes), fatigue, and increased risk of falls. R25's admission orders dated 5/15/25 included torsemide 20 mg (milligrams) tablet for chronic heart failure. For weight 208-216 lbs (pounds)take 40 mg twice a day, for weight greater than 217 lbs take torsemide 80 mg BID. For weight less than 208 lbs, hold torsemide. R25's weight from date of admission on [DATE] to 6/25/25 ranged from 183.9 to 198 lbs. R25's medication administration record (MAR) for May and June indicated the following: -Torsemide 40 mg by mouth two times a day for CHF for weight 208-216 lbs. for weight less than 208 hold torsemide. -Torsemide 80 mg by mouth two times a day for CHF for weight greater than 217lbs. For weight less than 208 lbs hold torsemide. Both orders contained a check box in the electronic medical record to document the weight and if the medication was given along with staff initials. The May MAR indicated R25 received the following doses of torsemide:5/16-120 mg - PM shift. Weight 193.55/18-120 mg - PM shift. Weight 1945/20-120 mg - PM shift. weight 191.55/21-120 mg - PM shift. Weight 192.55/28-120 mg - PM shift. Weight 195.5 The June MAR indicated R25 received the following doses of torsemide:6/3-120 mg - PM shift. Weight 192.56/4-120 mg - PM shift. Weight 1936/8-120 mg - AM and PM shift. Weight 197.56/12-120 mg - AM shift Weight 1956/17-120 mg - PM shift. Weight 195.56/18-40 mg - AM shift. Weight 1886/19-40 mg - AM shift. Weight 184.56/20-40 mg - AM shift. Weight 185.56/21-40 mg - AM shift and 80mg on PM shift. Weight 183.86/22-40 mg - AM shift and 120 mg on PM shift. Weight 184.56/23-40 mg - AM shift. Weight 184.56/24-40 mg - AM shift. Weight 183.46/25-120 mg - AM shift. Weight 183.9 During interview on 6/25/25 at 1:00 p.m., registered nurse (RN)-A stated R25 received torsemide 80 mg and 40 mg for a total of 120 mg the morning of 6/25/25. R25's weight was 183.9. RN-A reviewed the torsemide order and stated, it doesn't make sense, it's confusing, I should have clarified it. RN-A confirmed the torsemide should have been held based on R25's weight. RN-A stated if the MAR indicated a check mark, the medication was given. If the MAR indicated 5 the medication was held and 9 indicates a progress note was made, and the medication was probably not given. During interview on 6/25/25 at 1:58 p.m., the nurse practitioner (NP) stated resident's weights are reviewed automatically and confirmed R25's weights have been less than 200 since admission. The NP confirmed the order for torsemide and stated R25 should not have received any doses of torsemide since admission. During interview and observation on 6/25/25 at 2:08 p.m., RN-A stated R25 has two cards of torsemide 20mg tablets. Both cards were noted in the medication cart. Both cards contained spots which could house the medication one card had 16 punched out and the other card had 3 punched out. RN-A stated if R25 needed 80 mgs, 4 tablets would be removed and if 40 mg was required, 2 tablets would be given. RN-A stated if tablets were missing from the cards, the medication was given, however there was no way to indicate from the cards what dose or what date R25 received the medication. During an interview on 6/25/25 at 2:25 p.m., the licensed practical nurse (LPN)-A stated a 2 on the MAR indicates refused, 3 indicates a resident is out, 5 means a medication is held, and 9 indicates a nurse's note was made. LPN-A stated she reviews the staff progress notes if a 9, 5, or 3 is documented. If the medication is marked and a note is not made, then it is assumed the medication is given. LPN-A reviewed the torsemide order on R25's June MAR and noted several doses contained .9 (initials of staff protected). LPN-A stated the xxx9 with the check mark indicated the medication wasn't given because it contained the number 9. It was noted all of R25's medications on those days had .9. When asked if that meant R25 did not receive any of her prescribed medications for those days LPN-A said no. LPN-A confirmed .9 was the initials of a staff who administered the medication those days. A copy of the electronic medical record staff identifier confirmed .9 identifies the staff member and does not indicate a medication was not given. During interview on 6/26/25 at 9:35 a.m., the director of nursing (DON) stated R25 received torsemide 120 mg on the evening of 6/22/25 however the remaining days the staff reported punching out the medication out of the card, reviewing the weights, and then wasting the medication in the medsafe. A medication destruction record was requested however, the director of nursing stated staff are only required to document wasting narcotic medications, there is no record of other medications wasted. The director of nursing stated she would expect the staff to review R25's weights prior to punching out the medication. She would also expect the staff to correctly document in the MAR if a mediation was given or not. A policy for medication administration was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure medical records were complete and accurately documented for 2 of 2 residents (R92, R25) reviewed. Findings include: For additional details please see F684 and F757. R92's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, did not have delusions or hallucinations, physical, verbal, or other behavioral symptoms, and did not reject care. R92's diagnoses included cancer, wound infection, diabetes, and arthritis. Furthermore, R92 was at risk for developing pressure injuries, had surgical wounds, and took an anticoagulant (blood thinner). During observation and interview on 6/23/25 between 2:14 p.m., and 2:17 p.m., R92 had bruises bilaterally to the back of her upper arms. R92's right arm had a bruise approximately the size of a grapefruit and the bruise located on R92's left arm went from R92's arm pit area to her elbow and was purple towards the elbow and a faded yellow color on the upper part of R92's left arm. R92's left posterior arm at armpit crease had a small nail head sized open area. An ABD (dressing) pad was tucked in next to the area, but did not cover the open area. R92's orders were reviewed and lacked documentation or treatment instruction for an ABD pad related to the open area to the left arm pit area. R92's Physician's Orders form, indicated the following orders: 6/6/25, Complete Daily Skilled Note under forms in PCC (facility electronic medical record). State why the resident is currently being covered for #6 skin issue, #7 infection, #9 diabetes, #13 anticoagulant. 6/8/25, Monitor for … bruising, …. 0=No Symptoms, +=See NN (nurse note). 6/8/25, weekly skin inspection by the licensed nurse. Complete weekly skin inspection in PCC. R92's record lacked specific assessment and monitoring to bruising to R92's upper arms. R92's orders lacked instruction for treatment to R92's open area to her left upper posterior arm. R92's Skin Evaluation and Skin Risk Factors form dated 6/5/25 at 8:07 p.m., indicated R92 had the following skin conditions: a surgical incision to the right breast that measured 3.7 centimeters (cm) long, by 0.3 cm wide, a surgical incision to the right armpit that measured 4.2 cm long by 0.5 cm wide. Further, R92 had bruising to the right and left lateral upper arms. The form lacked information regarding and assessment of the coloring of the bruising, size of the bruising or how R92 obtained the bruising. Further the form indicated R92 had the following risk factors that included medications, obesity, and diabetes. R92's Skin and Wound Evaluation forms dated 6/6/25, 6/17/25, and 6/24/25 the form dated 6/24/25, lacked information R92 had an open area to the left upper posterior arm. R92's Daily Skilled Note dated 6/5/25 at 10:09 p.m., lacked an further assessment of R92's bruises, or that R92 had a bruise. R92's Daily Skilled Note dated 6/6/25 at 1:01 p.m., lacked an assessment of R92's bruises or that R92 had a bruise. R92's Daily Skilled Notes dated 6/7/25 at 12:42 p.m., 6/8/25 at 1:03 p.m., 6/9/25 at 12:54 p.m., 6/9/25 at 9:45 p.m., 6/10/25 at 2:03 p.m., lacked an assessment of R92's bruises or that R92 had a bruise, and further lacked information the bruises identified 6/6/25, had resolved. R92's Daily Skilled Notes dated 6/11/25 at 1:35 p.m., lacked an assessment of R92's bruises or that R92 had a bruise. Further, under a heading, Resident Response to Treatments & Additional Comments that indicated R92 did not have bruising or bleeding noted from anticoagulants. R92's Daily Skilled Note dated 6/12/25 at 11:39 a.m., and 6/13/25 at 11:32 a.m., lacked a check mark in the check box next to anticoagulant use. The form lacked an assessment of R92's bruises or that R92 had a bruise. R92's Daily Skilled Notes dated 6/17/25 at 6:56 p.m., 6/18/25 at 10:23 a.m., 6/19/25 at 9:25 a.m., 6/20/25 at 1:29 p.m., 6/21/25 at 2:11 p.m., 6/23/25 at 11:37 a.m., and 6/24/25 at 1:06 p.m., indicated R92 was alert and oriented to person, place, and time, did not have behaviors that included resisting care. The form indicated the same check box next to skin issues, and anticoagulant use. Further, the form indicated R92 was free from signs and symptoms of bleeding related to anticoagulant use, and the anticoagulant was administered as ordered. The forms lacked an assessment of R92's bruises or that R92 had a bruise, and further lacked information the bruises identified 6/6/25, had resolved. R92's progress notes were reviewed from 6/5/25, to 6/24/25, and lacked documentation of bruising to arms or an open area assessment of the left upper posterior arm. During interview on 6/25/25 at 9:27 a.m., to 9:44 a.m., registered nurse (RN)-B stated R92 had wound pictures of R92's sore on her right side, but further stated she did not see any bruising documented and verified orders and forms and stated there was no documentation of bruising. RN-B indicated the Weekly Skin Assessments and Daily skin note lacked documentation of R92’s bruising. At 9:44 a.m., RN-B verified R92 had bilateral bruising to both arms along with the open area to R92's left arm near her arm pit and stated it had not been documented or measured and stated it should have been. During interview on 6/25/25 at 9:56 a.m., the director of nursing (DON) stated if a resident had a bruise an order needed to be placed to monitor the bruise and the guardian and physician would be notified and they would complete a risk management form. DON stated the bruise was identified on admission although verified R92's medical record lacked information on the color, shape, or size of R92's bruise identified on 6/5/25. Further, the DON verified R92's chart lacked documentation R92 had an open area to her left arm and stated R92 refused her bath on 6/22/25, and stated there were no further assessments on R92's bruises. DON stated staff would document new bruises in the Daily Skin Notes. A policy, Skin Assessment and Wound Management, dated 2/2025, indicated the purpose of the assessment was to provide guidelines for assessing and managing wounds. Further, prevention and identification included implementing preventative skin measures, a skin evaluation and skin risk factors form was completed before initial MDS, annually, and upon significant change. Further, staff would perform routine skin inspections with daily care and nurses were to be notified if skin changes were identified and a weekly skin inspection was completed by licensed staff. Further when a significant alteration in skin integrity is noted such as large or multiple bruising, or other non-pressure related wounds the following actions will be taken: notify the provider, treatment ordered, notify the representative, complete education with the resident including risks and benefits, initiate a skin and wound evaluation, notify the nurse manager, review and update the care plan including interventions. A policy was requested, however in an email dated 6/25/25 at 12:01 p.m., the DON indicated the facility did not have a policy regarding complete and accurate documentation. R25 R25's admission Minimum Data Set (MDS) assessment, dated 5/21/25, indicated R25 was cognitively intact with no behaviors or delirium. R25 had range of motion to one side of her upper body and required partial to moderate assistance with activities of daily living. R25 received diuretic medication. R25's care plans included diuretic therapy related to hypertension and congestive heart failure. Interventions included administer medication as ordered and potential side effects that included dizziness, postural hypotension (drop in blood pressure with position changes), fatigue, and increased risk of falls. R25's admission orders dated 5/15/25 included torsemide 20 mg tablet for chronic heart failure. For weight 208-216 lbs take 40 mg twice a day, for weight greater than 217 lbs take torsemide 80 mg BID. For weight less than 208 lbs, hold torsemide. R25's medication administration record (MAR) for May and June indicated the following: -Torsemide 40 mg by mouth two times a day for CHF for weight 208-216 lbs. for weight less than 208 hold torsemide. -Torsemide 80 mg by mouth two times a day for CHF for weight greater than 217lbs. For weight less than 208 lbs hold torsemide. Both orders contained a spot to document the weight and a spot to document if the medication was given along with staff initials. The May MAR indicated R25 received torsemide five times weighing under 208 lbs. The June MAR indicated R25 received torsemide 13 times weighing under 208lbs. During interview on 6/25/25 at 1:00 p.m., registered nurse (RN)-A stated R25 received torsemide 80 mg and 40 mg for a total of 120 mg the morning of 6/25/25. R25's weight was 183.9. RN-A confirmed the torsemide should have been held based on R25's weight. During interview on 6/25/25 at 1:58 p.m., the nurse practitioner (NP) stated resident's weights are reviewed automatically and confirmed R25's weights have been less than 200 since admission. The NP confirmed the order for torsemide and stated R25 should not have received any doses of torsemide since admission. During an interview on 6/25/25 at 2:25 p.m., the licensed practical nurse (LPN)-A stated a 2 on the MAR indicates refused, 3 indicates a resident is out, 5 means a medication is held, and 9 indicates a nurse's note was made. LPN-A stated she reviews the staff progress notes if a 9, 5, or 3 is documented. If the medication is marked and a note is not made, then it is assumed the medication is given. LPN-A reviewed the torsemide order on R25's June MAR and noted several doses contained .9 (initials of staff protected). LPN-A stated the xxx9 with the check mark indicated the medication wasn't given because it contained the number 9. It was noted all of R25's medications on those days had .9. When asked if that meant R25 did not receive any of her prescribed medications for those days LPN-A said no. LPN-A confirmed .9 was the initials of a staff who administered the medication those days. A copy of the electronic medical record staff identifier confirmed .9 identifies the staff member and does not indicate a medication was not given. During interview on 6/26/25 at 9:35 a.m., the director of nursing (DON) stated she reviewed R25's MAR and spoke to all the staff. The DON stated R25 received torsemide 120 mg on the evening of 6/22/25 however the remaining days the staff reported punching out the medication out of the card, reviewing the weights, and then wasting the medication in the medsafe. A medication destruction record was requested however, the director of nursing stated staff are only required to document wasting narcotic medications, there is no record of other medications wasted. The director of nursing stated she would expect the staff to review R25's weights prior to punching out the medication. She would also expect the staff to correctly document in the MAR if a mediation was given or not A policy for medication administration was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure proper placement of catheter bag for 1 of 1 resident (R2) reviewed for catheter use.Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had severe cognitive impairment, no behaviors or rejections of care, and required substantial/maximal to dependent assistance with activities or daily living. R2's diagnoses included peripheral vascular disease, neurogenic bladder, diabetes mellitus, dementia, anxiety, and depression. R2 had an indwelling catheter, was always incontinent of bowel, and was at risk for pressure ulcers. R2's care plan printed, indicated R2 had a suprapubic catheter. Staff were to provide assistance with peri-cares in the morning, at bedtime, and as needed, monitor for signs/symptoms of UTI, monitor catheter output, provide catheter care per policy, change catheter per policy, apply protect cream after each incontinent episode, encourage only and nutritional intake, and monitor bowel movements as they occurred. R2's physician order dated 6/23/25, indicated R2 had a size 16 Fr (French) suprapubic catheter. During observation on 6/23/25 at 12:15 p.m., R2 was sitting in his wheelchair at the end of the hallway in front of the television. R2's catheter bag was on the floor. At 1:00 p.m., R2's catheter bag was still on the floor. At 1:23 p.m., R2's catheter bag was hooked on the back of his wheelchair strap and still touched the floor. During interview on 6/23/23 at 1:24 p.m., nursing assistant (NA)-E verified R2's catheter bag was touching the floor. NA-E stated there was a cover to place R2's catheter bag in, forgot to put the cover on the wheelchair, and believed the cover was in R2's room. During interview on 6/26/25 at 2:01 p.m., the director of nursing (DON) expected catheter bags to be placed inside a cover and off the floor for infection control purposes. The Infection Prevention and Control Program dated 11/2024, directed staff to prevent infection by instituting measures to avoid complications or spread of infection and educating staff and ensuring they adhere to proper techniques and procedures.

Based on observation, interview, and document review, the facility failed to ensure the facility's survey results were kept in a location readily accessible to all residents and/or visitors who wished to review. This had the potential to affect all 97 residents and/or visitors.Findings include:During an interview with the facility resident council on 6/25/25 at 1:03 p.m., the members stated the survey binder should be in the front lobby of the facility. During interview with R3 on 6/26/25 at 10:55 a.m., R3 stated she had not seen the survey binder in the front lobby for a little bit and state it would be nice to know what the facility needs to work on. During observation on 6/26/25 at 11:03 a.m., the facility survey binder was not readily visible nor readily available in the facility lobby without having to ask. During interview on 6/26/25 at 10:38 a.m., administrator confirmed the survey binder was not visible nor easily accessible without having to ask. The administrator located the survey binder in a storage basket with other binders on a higher shelf in the lobby. A policy regarding posting survey results was requested, administrator stated the facility does not have a policy regarding survey results.

Based on interview and document review, the facility failed to ensure alleged violations of an injury of unknown origin that resulted in suspicion of serious bodily injury were immediately reported, no later than 2 hours, to the State Agency (SA) and administrator for 1 of 1 resident (R2) reviewed for abuse. Findings include: R2's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment. R2's provider progress note by physician's assistant (PA)-A dated 2/19/25 no time indicated, indicated R2 was seen to discuss discharge planning to return home. R2's left wrist was noted to be bruised and swollen with tenderness to palpation, with no reported falls and injuries. The provider ordered an X-Ray for the left wrist. The progress notes lacked information about a staff discovery of R2's swollen wrist. On 3/12/25 at 10:11 a.m., during an interview, social worker (SW)-A stated he was not aware of R2's wrist injury however, confirmed any injury of unknown origin should have been reported to the SA and was unsure if the report had been completed. On 3/12/25 at 3:48 p.m., during an interview, the director of nursing (DON) stated R2's wrist injury should have been reported to the SA per the policy and confirmed no report had been made to the SA. On 3/12/25 at 2:00 p.m., during an interview, registered nurse (RN)-D stated she was aware R2 had an X-Ray ordered for her wrist but was not sure why. RN-D indicated if R2 had an injury of unknown origin, the facility should have reported it to the SA. RN-D stated RN-C discovered the swollen wrist and notified the PA. On 3/12/25 at 2:36 p.m., during an interview, RN-C stated she noticed R2's wrist was swollen on 2/19/25, and told the PA who was in the facility. RN-C stated PA-A gave an order for an X-Ray to determine if the wrist was fractured. RN-C stated she knew the incident should have been reported to the SA. RN-C stated she did not report to the SA however, had reported it to the PA. On 3/12/25 at 2:51 p.m., during an interview, PA-A stated a nurse informed her about R2's swollen wrist and when PA-A assessed it, the right wrist was noted to be bruised, swollen, and tender to palpate, with no related reports of falls or injuries. PA-A stated, You could call in an injury of unknown origin. PA-A stated the injury should have been reported to the SA, and was unsure if it had been. On 3/12/25 at 3:05 p.m., during an interview, the administrator stated if a resident had a bruise of unknown source, he would report it to the SA. The administrator acknowledged he was not aware of the injury and staff had not reported it to him. The Abuse Prohibition/Vulnerable Adult policy dated 2/2025, indicated injuries of unknown injury that were not observed and suspicious because of the extent of the injury would be reported to the State Agency and investigated.

Based on interview and document review, the facility failed to ensure the Centers for Disease Control (CDC) guidance to prevent or minimize the transmission of COVID-19 was followed when 1 of 1 resident (R3) who had been negative for COVID-19 was placed in a room with a COVID-19 positive resident for 12 days. This resulted in an immediate jeopardy (IJ) for R3 who was exposed to R2 for 12 days which resulted R3 to contract COVID-19. The IJ began on 12/3/20, when R3's roommate tested positive for COVID-19 and was not separated from R3, who had tested negative for COVID-19. The administrator and director of nursing (DON), registered nurse (RN)-A and RN-B, were notified of the IJ on 12/16/20, at 4:33 p.m. The IJ was removed on 12/17/20, at 1:55 p.m. Findings include: Current Centers for Disease Control (CDC) guidance indicated nursing home residents are at high risk of being affected by respiratory pathogens like COVID-19 due to older age and underlying chronic medical conditions. Patients with prolonged close contact with [DIAGNOSES REDACTED] CoV-2 infection should quarantine for 14 days. These patients should not be cohorted with positive COVID-19 patients unless they are also confirmed to have COVID-19 through testing. During an interview on 12/15/20, at 12:20 p.m. the director of nursing (DON) reported the facility kept R2 and R3 together even though R3 tested negative. They did not separate R2 and R3 because R3 had already been exposed to R2. Since R2 had been positive they moved both R2 and R3 to the COVID-19 unit on 12/9/20, despite R3 negative test result. During an interview on 12/16/20, at approximately 2:15 p.m. the administrator verified R3 had now tested positive. R2's face sheet dated 12/3/20, indicated COVID-19 [DIAGNOSES REDACTED]. R2's significant change Minimal Data Set ((MDS) dated [DATE], identified R2 had [DIAGNOSES REDACTED]. R2's progress note on 12/3/20, at 5:43 p.m. indicated the facility notified R2 of her positive COVID-19 results and initiated quarantine. R2's physician note dated 12/4/20, stated R2 tested positive for COVID on 12/3/20, and respiratory symptoms had been stable at baseline. R2's physician orders [REDACTED]. R2's care plan dated 12/4/20, identified R2 had a positive [DIAGNOSES REDACTED]. R3's quarterly MDS dated [DATE], indicated had a [DIAGNOSES REDACTED]. R3's physician's orders [REDACTED]. R3 must remain under quarantine. R2 had been R3's roommate. R3's progress note dated 12/3/20, at 5:38 p.m. indicated R3 had been notified her roommate tested positive for COVID-19. R3's progress note dated 12/3/20, at 5:38 p.m. indicated R3 had been updated her roommate tested positive for COVID-19. R3's progress note dated 12/6/20, at 7:50 a.m. indicated R3's COVID-19 test identified COVID 19 was not detected. R3's progress note dated 12/9/20, at 8:53 p.m. indicated R3 indicated to temporarily move from the non-COVID unit to the COVID unit due to COVID 19 exposure to R2. Although R3 had not tested COVID 19 positive, she was still transferred to the COVID unit with R2. R3's progress note on 12/14/20, at 11:44 p.m. indicated R3 had a COVID-19 test sent to the lab. R3's progress note on 12/16/20, at 8:53 p.m. indicated R3 tested positive on 12/15/20, at 9:30 p.m. and staff transferred R3 to the COVID unit. R3's care plan dated 12/16/20, indicated R3 had been diagnosed with [REDACTED]. Staff were directed to encourage R3 to stay in her room with door closed until symptoms resolve or 14 days has been exceeded. On 10/12/17, the care plan indicated potential for altered respiratory status related to smoking. During an interview on 12/15/20, at 10:02 p.m. the administrator reported R2 and R3 had shared a room. R2 tested positive for COVID-19 on 12/3/20. R3 had rapid COVID-19 tests taken when residents on R3's floor (second floor) became positive. A polymerase chain reaction (PCR) test (test to detect COVID-19 by looking for traces of [MEDICAL CONDITION]' genetic material) on 12/6/20, indicated R3 had been negative for COVID-19. The administrator stated since R3 had been exposed to R2 they kept them together. R2 and R3 were on the COVID unit but had planned to move R3 later that day to the first floor to quarantine for 14 days since she had no detection of COVID-19 on 12/6/20 when the PCR test was completed. During an interview on 12/15/20, at 2:12 p.m. the DON and registered nurse (RN)-A reported the thought process behind keeping R3, who tested negative, and R2, who tested positive together was because R3 had already been exposed to R2. The facility wanted to get more test results for R3 and wanted to make sure R3 did not have any symptoms before they moved R3 to the first floor quarantine unit to monitor and quarantine. During an interview at 12/15/20, at 2:15 p.m. the DON and RN-A reported the facility moved both R2 and R3 together to the COVID-19 unit on 12/9/20, since R2 had tested positive. During an interview on 12/15/20, at 2:21 p.m. RN-A reiterated that even though R3 had been negative the facility kept her with R2 as she had been exposed. R3 had been negative on all COVID-19 tests and had been waiting for the results of a PCR test. They wanted to make sure R3 was negative before they moved her to possibly expose another resident. During an interview on 12/15/20, at 3:25 p.m. the DON and RN-A reported each day they had gotten more and more cases and their plan to move a resident kept changing. Although R3 received negative test results on 12/6/20, they wanted confirmation R3 continued to test negative by giving another PCR before moving R3 since she had been exposed to R2 (confirmed positive). During an interview on 12/16/20, at 1:16 p.m. the DON and RN-B verified that it is not acceptable to have to have positive and negative COVID-19 residents together and it was not acceptable to continue to expose an exposed resident to a positive resident since they had been roommates. The DON reported R2 and R3 had been roommates from 12/3/20, until 12/15/20. R2 and R3 were moved together to the COVID-19 unit on 12/9/20. During an interview on 12/16/20, at 1:20 p.m. the DON and RN-B indicated they had considered some alternative placement presented for R2 or R3. However at the time of the interview the DON could not verify why some alternative placements were not considered. She indicated she would return with that information. During an interview at 12/16/20, at 3:30 p.m. the DON verified she was not able to provide reasoning why the facility did not use any of the eight alternatives presented to separate R2 and R3 earlier. The facility Infection Prevention and Control Guideline dated 3/25/20, identified the goal to control the infections of residents with the need for a process to manage a resident when a private room is not available. Additionally, the guideline defined cohorting as the practice to group residents infected or colonized with the same infectious agent together and to prevent contact with susceptible residents. According to the Centers for Disease Control (CDC)'s recommendations, dated 4/30/20, residents with confirmed COVID should be moved to a dedicated unit, in a private room if possible, and the exposed roommate should be kept in a private room, if possible, or cohorted with other residents who had been exposed to COVID. The immediate jeopardy that began on 12/16/20, was removed and the deficient practice corrected on 12/17/20, when the facility began to educate staff and completed competency testing on content provided. Education included regulation and guidance on how to cohort residents. Additionally, all residents had been assessed for appropriate infection control practices and appropriate cohort processes and there had been no possible residents cohorting with negative residents or sharing a bathroom within the facility as of 12/16/20.

Based on interview and document review the facility failed to provide appropriate fall interventions for 1 of 3 residents (R1) reviewed for accidents. This failure resulted in actual harm when R1 fell from the wheelchair and sustained a broken left clavicle (collarbone) and a subdural hematoma (when blood pools between the brain and its outmost covering). R1 subsequently died . Findings include: R1's annual Minimal Data Set (MDS) assessment dated [DATE], identified R1 was moderately cognitively impaired. R1's [DIAGNOSES REDACTED]. R1 was wheelchair bound, required extensive assistance with activities of daily living (ADLS) and had limited range of motion (ROM) with both lower extremities. R1's care plan last revised [DATE], identified R1 required the use of safety devices to include: bilateral grab bars, air mattress, specialty wheelchair with seat belt and short cord on call light. R1's care plan instructed staff to ensure proper positioning with proper body alignment while using restraining safety device and evaluate safety device use quarterly and PRN (as needed): evaluate/record continuing risks/benefits, alternatives, need for ongoing use, reason for safety device use. R1's care plan further identified R1 was at risk for falls/injury r/t (related to) impaired mobility secondary to [MEDICAL CONDITION]. R1's care plan instructed staff to follow [MEDICAL CONDITION] precautions. R1's care plan did not define [MEDICAL CONDITION] precautions. R1's physician order [REDACTED]. R1's fall assessment dated [DATE], indicated R1 was at high risk for falls with a score of 7. The assessment had no further information that identified fall risk interventions. R1's physician progress notes [REDACTED]. R1's progress note dated [DATE], at 12:37 p.m. indicated, Resident was in his chair eating in the dining room. Overhead alert that resident was on the floor struggling to breath. [MEDICAL CONDITION] activity was expected (sic). 911 was called. Family was called. Vitals taken. Resident was sent to the hospital. The facility Report of Resident Fall dated [DATE], indicated the only assistive device and intervention in use at the time of the event was a wheel chair. The check box next to seat belt was not checked. The report did not indicate whether the wheelchair was in a reclined position. When interviewed on [DATE], at 12:02 p.m. nursing assistant (NA)-A stated she was the first one to respond when another resident (R6) yelled that someone was on the floor. NA-A further stated the back of R1's wheel chair was in an upright position, straight up and down and it should have been reclined after lunch. NA-A further stated R1's chair was supposed to be positioned so he could be seen from the hallway when no staff were present. NA-A verified and stated no staff were in the dining area at the time when R1 fell and his chair was not positioned in view of the hallway. NA-A stated R1 did not have a seat belt on the day R1 fell from the wheel chair. NA-A further stated R1 was on falls precautions which required checks every ,[DATE] minutes. NA-A stated she was not aware of [MEDICAL CONDITION] precautions. When interviewed on [DATE], at 12:13 p.m. R6 (who witnessed the event) stated R1 sat in the wheel chair in the corner of the dining room and she and R1 were talking and then R1 fell forward out of the chair onto the floor. R6 stated no staff were present so she ran and yelled for staff to come help. When interviewed on [DATE], at 12:48 p.m. NA-B stated she was in a resident room assisting a resident when she heard R6 yell that someone fell . NA-B stated she ran to the dining area and saw R1 on the floor in front of his wheel chair and R1 had a bump on his head. NA-B further stated that R1 was a falls risk and that R1 should be moved to an area of the room that could be seen from the hallway after he was done with lunch. NA-B further stated the wheel chair should be straight up for meals but reclined between meals. NA-B stated R1 did not have a seat belt on that day. NA-B stated R1 was a high falls risk and she would follow the care plan and perform more frequent checks on R1. When interviewed on [DATE], at 1:03 p.m. NA-C stated was in the dining area assisting another resident with lunch the day R1 fell . NA-C stated NA-D assisted R 1 with lunch. NA-C further stated when she left the dining area NA-D was still there but he said was leaving to buy another resident something from the vending machine. NA-C stated, I told him to tilt (R1) back a little when done eating. NA-C stated not remembering if R1 ever had a seat belt and not sure if R1 had one on that day. When interviewed on [DATE], at 1:56 p.m. registered nurse (RN)-A stated R1 needed assistance with meals and the NA's should always stay there with him and then after meals they should either transfer him back to bed or move his wheel chair so he would be in sight. RN-A stated R1 was out of sight the day he fell and the only other person in the dining area at the time of the fall was R6. RN-A further stated that if a resident was on falls risk, staff were supposed to keep an eye on them all the time and that staff should not leave R1 in the dining area unsupervised. When interviewed on [DATE], at 2:02 p.m. licensed practical nurse (LPN)-A stated being told that R1 normally ate in the dining area and then he was taken back to his room. I heard (R6) yell. I saw him postictal (altered state of consciousness after an epileptic [MEDICAL CONDITION]). I do believe it was a [MEDICAL CONDITION]. LPN-A further stated R1's wheel chair was in the back corner of the room and R1 was lying on the floor in front of his wheel chair. When interviewed on [DATE], at 2:08 p.m. LPN-B stated she responded to the nurse stat call and saw R1 had been positioned on his side. R1's eyes rolled back and was non-responsive with a hematoma on forehead. R1 appeared to have suffered a [MEDICAL CONDITION]. LPN-B stated R1 was done with lunch and positioned in the far corner of the dining area. LPN-B further stated that the NA assisting R1 that day had been called away to assist another resident. LPN-B could not recall ever seeing a seat belt used on R1. When interviewed on [DATE], at 4:10 p.m. family (F)-A stated the wheel chair was specially made for R1 to be tilted back in a 30 to 45 degree angle . F-A described a visit in August of 2020 when he was visiting during lunch and R1 was sitting upright for the meal. R1 leaned so far forward his head went to his knees. A staff came by and said he needs to have this belt on. When interviewed on [DATE], at 5:11 p.m. NA-D stated assisted R1 with lunch the day he fell . NA-D further stated he left R1 in the dining area to tend to another resident's request. NA-D stated R1's chair was supposed to be up for meals and then reclined when done. NA-D further stated he thought he remembered putting the seat belt on R1 that day when he got up in the wheel chair and that he reclined R1 that day after lunch. When interviewed on [DATE], at 5:28 p.m. LPN-C stated R1 had grab bars and pillows on the bed but was not aware of any other safety devices. LPN-C further stated if a seat belt was on the care plan it should have been used. When interviewed on [DATE], at 10:49 a.m. R1's primary physician (P)-A stated he visited with R1 frequently and that R1 had a history of [REDACTED]. P-A stated R1 had a tilt in space wheel chair to prevent R1's epiglottis from closing. P-A further described the tilt in space wheel chair as having a higher height than a regular wheel chair which increased the chance of injury from a fall. P-A further stated that if R1 would have had a strap or seat belt on it would have prevented the fall from the wheel chair that day. When interviewed on [DATE], at 12:45 p.m. director of nursing (DON) stated a resident on [MEDICAL CONDITION] precautions should be checked on frequently since [MEDICAL CONDITION] could cause falls. DON stated that the nurse manager or nurse on floor at the time of the fall would complete the report of resident fall. The report should include what assistive devices and interventions were in use at the time of the fall. DON stated she did not believe a seat belt was on R1 at the time of the fall since it was not indicated on the post fall report. (R1) should have had a seat belt on. DON further stated they would use a seat belt on a resident if there was an order and it was care planned. DON stated anticipated R1 to return to the facility and would have reassessed his falls interventions and updated his care plan at that time. R1 was sent to the hospital following his fall on [DATE]. Nursing progress noted dated [DATE], indicated R1 had a broken clavicle due to the fall. Nursing progress notes dated [DATE], identified R1's family called to inform the facility that R1 died in the hospital on [DATE]. The facility's Fall Evaluation Safety Guideline dated [DATE], indicated, Fall prevention is achieved through an IDT (interdisciplinary team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. The policy further indicated, Understanding contributing and predicting factors that resent will assist with determining individualized care approaches. The policy further indicated falls evaluation should include evaluation of sitting balance and should include a physical device review. The undated facility's Fall Investigation Guideline indicated the IDT should perform a post-fall huddle to discuss possible causal factors and to identify the root cause analysis which would guide modifications to the care plan interventions.

Based on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to provide adequate supervision and safety for an unsupervised smoker for 1 of 3 residents (R1) reviewed for accidents. R1 [MEDICAL CONDITION] her right leg after intentionally starting her socks and pants on fire. Findings include: R1's Admission Record dated 10/18/19, indicated R1 is diagnosed with [REDACTED]. R1's hospitalization record dated 9/24/19, indicated R1 has a [DIAGNOSES REDACTED]. R1's care plan printed 11/26/19, identified an admission date of [DATE] and indicated R1 has behavior problems related to refusing medications and yelling/screaming at staff and other residents; impaired cognitive function and thought process; mood problems related to adjustment to placement; [MEDICAL CONDITION] disease, depression, and anxiety; receiving antipsychotic medications; receiving mood stabilizer medications for [MEDICAL CONDITION] disease; was recently hospitalized due to [MEDICAL CONDITION]; history of chemical dependency with narcotics; at risk for injury when smoking; and had a history of [REDACTED]. R1's admission Minimum Date Set (MDS) assessment dated [DATE], indicated R1's brief interview for mental status scored eleven on a scale of fifteen, indicating R1 was cognitively moderately impaired. The MDS also indicated R1's PHQ-9 mood assessment scored eighteen of twenty seven, indicating R1 as moderately depressed severe, which warrants active treatment with psychotherapy, medications, or combination. R1's MDS assessment of behaviors indicated R1 has worsening verbal behaviors directed towards others and other behaviors such as vocal symptoms exampled by screaming. R1's MDS functional status indicated R1 required limited to extensive assistance with all activities of daily living. R1's admission Target Behavior Documentation interventions, effective date 10/23/19, directed staff to monitor and intervene for impaired judgement and impulsiveness. R1's admission to the facility Smoking Risk Evaluation tool dated 10/18/19, indicated R1 was a safe smoker. The Smoking Risk Evaluation tool did not direct that R1 would be authorized to keep her own cigarettes and lighter. No additional Smoking Risk Evaluations were completed. The facility's Smoker's List displayed at each nurses' station dated 11/26/19, identified R1 as a smoker. The Smoking Risk Evaluation tool did not describe a system for how cigarettes and lighters would be accounted for. Document review of a civil commitment by[NAME]County Court dated 9/4/19, findings of fact documented, due to R1's mental illness, indicated serious physical harm to herself was likely and physical harm had been attempted. R1's physician Order Summary Report dated 10/27/19, directed staff to monitor behaviors such as impulsiveness and behaviors. A physician progress notes [REDACTED]. A behavioral incident was documented 11/30/20 at 2:44 p.m. when the Social Services staff entered R1's room to find her undressed, and the resident reported it would be easier to defecate on the bed instead of using the bathroom. Additionally, a social service late entry progress note dated 10/29/19, at 11:54 a.m. indicated social services (social services staff not identified) spoke with R1 during evaluations and R1 had reported she had thoughts of hurting herself and wishing she were dead. A progress note dated 11/19/19, at 11:14 p.m. described a situation from 11/19/19, at 5:50 p.m. where the fire alarm was activated, and during the resident's room search, one of the nursing assistants (not specifically identified) found R1 sitting in her chair with a lighter in her hand, and her right pant leg was on fire. The indicated registered nurse (RN)-A arrived and observed R1 was still pointing the lighter at her pants and trying to relight the lighter. RN-A and the nursing assistant evacuated resident from her room due to the room being full of smoke. RN-A assessed R1's right leg and it was found to be burned. The note indicated R1 had stated, I don't feel anything. On 11/19/19, at 6:10 p.m. R1 was transported to Hennepin County Medical Center (HCMC) Burn Unit. A progress note dated 11/20/19, at 1:58 p.m. indicated RN-B from HCMC had reported R1 would have surgery the following day and there was no hospital discharge plan at that time. The facility Event Manager Report investigation by the director of nursing (DON) dated 11/26/19, at 9:22 a.m. indicated R1 had stated her socks were too tight, and she was trying to stretch them out with the lighter. The Event Manager Report further indicated that on 11/17/19 two staff members (not identified) had previously observed R1 cutting her socks because they were too tight. The report indicated the two staff members had replaced the socks but had not reported the concern of the socks being too tight to the charge nurse. Observation on 11/26/19, at 1:16 p.m. identified a patio at the backside of the building as the smokers' patio. Numerous residents could be observed independently walking and self-propelling their wheelchairs to and from the smokers' patio. During observations on 11/26/19, at 1:16 p.m. and on 11/27/19, at 8:30 a.m., no staff were present on the smokers' patio with residents smoking. During interview on 11/27/19, at 8:49 a.m. nursing assistant (NA)-A stated, (R1) is not a smoker and if someone who is a smoker wants a cigarette, they have to come to the medication cart and get their cigarette(s) and a lighter. The resident can then go to the patio to smoke. NA-A further stated, If a resident does not have a lighter they will use someone else's lighter at the smoking patio. Smokers are identified in their chart as smokers. NA-A did not address whether residents could store their own cigarettes and/or lighters. During interview on 11/27/19, at 8:53 a.m. the maintenance director stated the patio is the designated smoking area for the facility and added, It's secured by a fence, so the Wanderguard at the door has been disabled. Residents are free to come and go to smoke. During interview on 11/27/19, at 11:23 a.m. the DON stated the facility interviewed staff right after the burn incident and an incident report was completed. The DON stated there were no new interventions identified to keep R1 safe from an accident but there will be when R1 returns. DON further stated R1 was deemed a safe smoker so she was allowed to keep her cigarettes and lighter in her room. When asked about the facility's directive for Smoking Guidelines to securely store cigarettes and lighters, the DON replied, Some residents can have their cigarettes and lighters in their room and others have to have them in the medication cart. DON further stated she was unaware that R1 had any behaviors that would exclude her from being a safe smoker. Villa Healthcare Smoking Guidelines dated 11/28/17, directed: The evaluation will be used at the time of admission and with changes of condition. Although the guidelines directed that lighters and cigarettes would be securely stored, they did not indicate whether residents could store their own cigarettes and lighter.