Every finding on record at The Villas at the Cedars

Based on interview and document review, the facility failed to consider the views of resident council members and act promptly upon concerns, take action and provide follow-up for 6 of 6 residents (R23, R32, R39, R48 R75, R107) reviewed for resident council. This deficient practice had the potential to affect all 94 residents who resided in the facility. Findings include:R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R32's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R39's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R48's annual MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R75's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R107'S quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.Resident council meeting minutes were reviewed from March 2026 through August 2026, (excluding May 2026, due to lack of attendance). The minutes were hand-written on a uniform template titled Resident Council Meeting Minutes.The meeting template had sections titled, Council Concerns and Old Business. The section for Council Concerns had a column for the written concern, a column for form completed, and a column for person responsible. Each month, the minute-taker listed multiple resident council concerns ranging from food, dining, late medication passes, weekend housekeeping, sticky floors, lack of towels, pool staff not knowing residents, staff shortage, activity suggestions, trash not being emptied and call lights.In the column marked form completed, out of 21 opportunities for a form to have been completed and submitted to the person responsible, there were only three check marks. The column for person responsible included the following departments: dietary, administration, nursing, housekeeping, activities and maintenance.The section titled Old Business did not reflect follow up or resolution of concerns identified the previous month(s).During the surveyor-lead resident council meeting on 9/9/26 from 2:25 p.m. to 3:15 p.m., R107 stated when concerns were expressed whether individually or at resident council meetings, residents would be assured by staff it would be addressed, but residents did not see action taken, follow-up, nor were they given an explanation why not. The following residents agreed: R23, R32, R39, R48, R75. Attendees stated they communicated concerns or grievances verbally at resident council meetings, or verbally directly to staff members, or in writing, and all concurred they did not receive follow up. During an interview on 9/10/26 at 10:48 a.m., the therapeutic recreation director (TRD)-A stated she was responsible for facilitating resident council meetings and taking minutes. TRD-A stated the council minutes were overseen by the administrator and each department leader was responsible for follow up and resolution of concerns identified for their department. TRD-A was specifically asked to provide documentation that the director of nursing (DON) was informed of resident concerns related to short staffing, weekend staffing, call lights, and late medications that had been identified in the minutes. TRD-A admitted she did not speak directly to the DON, or any department leader, nor did she give them anything in writing. TRD-A said the administrator and department leaders were aware of concerns from resident council because she talked about them at morning meetings, they were brought up a QAPI (quality assurance performance improvement) meetings, and the administrator and leaders could look at the binder of minutes located in her office if they wanted to know. TRD-A stated to provide follow up of resident council concerns to the resident council members, she had the resident council president read the facility all-staff meeting PowerPoint. When asked if that reflected follow up of their concerns and if it was appropriate information for residents, TRD-A answered yes. A copy of the PowerPoint had been requested but not received. During an interview on 9/10/26 at 2:55 p.m., the administrator was informed of the lack of follow up and resolution for concerns identified at resident council meetings, and of conversation with TRD-A. The administrator stated she expected leaders to be informed of resident concerns in order to resolve them and expected the follow up information be provided to resident council members. Facility Resident Council policy undated, indicated the purpose of the council was to provide a forum for residents to have input in the operation of the facility, discuss concerns and suggestions for improvement, dissemination of information and gathering feedback from residents, engage residents in life-enrichment programs tailored to the needs/wants of residents. A Resident Council Response Form would be utilized to track issues and their resolution. The facility department head related to any issues would be responsible for addressing the item(s) of concern.

Based on interview and observation, the facility failed to offer and/or provide a suitable and nourishing snack after dinner and before bedtime for 5 of 7 residents (R23, R32, R39, R48, R107) who voiced concern at resident council meeting. This deficient practice had the potential to affect residents who would like or required an evening snack. Findings include:R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R32's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R39's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R48's annual MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R107'S quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.During an interview on 9/9/26 at 5:52 p.m., culinary services director (CSD)-H stated meals were served at 8:30 a.m., 12:30 p.m., and 5:30 p.m., indicating potentially 15 hours between supper one day and breakfast the next morning. During the surveyor-lead resident council meeting on 9/9/26 from 2:25 p.m. to 3:15 p.m., residents in attendance stated they did not get offered snacks after supper and before bedtime. R39 stated he was not offered a snack and would like one.R32 stated she was not offered a snack and would like one. R23 stated she usually received a sandwich, but might like something else in addition.R48 stated she was not offered a snack and would like one.R107 stated she was not offered a snack and would like one. Not all residents in attendance knew if they could get a snack if they asked. R39 stated, I wouldn't know who to ask. R32 stated staff kept the snacks in a room behind the desk and were not consistent with whom they gave snacks. R32 stated she had asked for a snack the other night was told by staff they didn't have any. R23 stated she sometimes didn't get a sandwich and felt left out. R48 stated she could get a snack if she asked but felt staff pick and choose which residents to give snacks. Further, R32 stated snacks were not very good, just graham crackers, pretzels, and candy. During an interview and observation on 9/9/26 at 4:58 p.m., nursing assistant (NA)-E on first floor, stated if a resident wanted a snack, they could ask and we would give it. The snack basket in a room behind the nurse's station included; Nilla wafters, fig cookies, pretzels, graham crackers, fruit cup, applesauce, pudding. NA-E stated there were usually chips and oatmeal cookies, but none were in the basket. During an interview on 9/9/26 at 5:26 p.m., NA-F on 2nd floor stated there was a basket of snacks in the back of the nurse's station and if a resident wanted a snack, they could ask; they did not go around and to ask residents if they wanted one. NA-F stated some residents automatically received a sandwich from dietary that had their name on it. During an interview on 9/10/26 at 11:53 a.m., the director of nursing (DON) was informed residents were not offered a snack after supper and before bedtime or not consistently offered. The DON stated the dietary department provided the snacks and were responsible to have them available. The DON was not aware snacks were in basket at the nurses' stations and residents needed to ask for them. The DON stated she expected staff to offer snacks to residents. In an email communication on 9/10/26, at 1:20 p.m., the administrator indicated the facility had been aware of this and was working on providing education next week regarding the process to offer snacks to residents after supper and before bedtime. Facility Snack Cart policy dated 9/2012, indicated it was the policy to provide a nourishing snack one time a day. Snack carts would be brought around to resident rooms by nursing assistants. The supper cook would see to it that the dining room refrigerator was stocked with juices, ice cream cups, sandwiches, and special snacks. Snacks were available at any time a resident requested.

Based on interview and record review, the facility failed to administer long-acting insulin at consistent times according to the manufacturer's instructions and short-acting insulin prior to meals in accordance with professional standards for 1 of 1 resident (R46) reviewed for insulin use. In addition, the facility failed to provide necessary care and services in accordance with physician orders and residents' assessed needs when the facility failed to implement and monitor a physician-ordered fluid restriction for 1 of 1 resident (R13) reviewed for fluid restriction, implement physician-ordered interventions for edema management for 2 of 2 residents (R13, R4) reviewed for edema, and administer medication in accordance with the physician's order for 1 of 1 resident (R107) reviewed for medication administration. Further, the facility failed to ensure that professional standards of practice were followed for vascular access device maintenance for 1 of 1resident (108) discharged resident who had a Peripherally Inserted Central Catheter (PICC) line in place,Findings include: R46 The manufacturer's Basaglar (insulin glargine, a long-acting insulin) Basic's guide dated 9/14/22, indicated that Basaglar works over a 24-hour period to lower blood sugar and should be taken at the same time each day. The undated facility Meal Times posting, indicated breakfast was at 8:15 a.m., lunch was at 12:15 p.m., and supper was at 6:15 p.m., R46's admission Minimum Data Set (MDS) dated [DATE], indicated R46 had intact cognition and no rejection of care behaviors. The MDS indicated R46 was diagnosed with diabetes and kidney disease. The MDS indicated R46 had Insulin injections seven days during the look back period. The MDS indicated that R46 required partial to moderate assistance with upper body dressing, was dependent for bathing, and required moderate assistance with bed mobility. R46's order summary dated 9/10/26, included the following insulin orders: -35 units of Basaglar KwikPen twice daily. -25 units of lispro (fast-acting insulin) three times a day before meals. -Lispro administered per sliding scale (varying amounts of insulin administered depending on blood sugar results) three times a day before meals. R46's insulin administration record dated 8/14/26 to 9/7/26 was reviewed and included the administration of the following insulins with the following dates and times: -Basaglar KwikPen: -scheduled time of 8 a.m.: 8/20/26 at 10:35 a.m., 8/24/26 at 10:19 a.m., and 8/25/26 at 10:18 a.m. -scheduled time of 8 p.m.: 8/14/26 at 11:59 p.m., 8/15/26 at 10:06 p.m. -Insulin Lispro (record intermixed sliding scale insulin with the 25-unit dose): -scheduled time of 8 a.m.: 8/13/26 at 10:57 a.m., 8/20/26 at 10:35 a.m., 8/24/26 at 10:19 a.m., 8/25/26 at 10:18 a.m. and 10:19 a.m. -scheduled time of 12 p.m.: 8/16/26 at 2:30 p.m. and 9/4/26 at 2:05 p.m. -scheduled time of 4 p.m.: 8/14/26 at 7:07 p.m. R46's Medication Administration Record (MAR) dated 8/14/26 to 9/7/26, indicated staff were to take R46's blood sugar reading four times a day. R46's blood sugar ranged from 83 to 368 during the period. During an interview on 9/8/26 at 11:58 a.m., R46 stated sometimes the nurses were really busy so he would get his meal before he would receive his insulin. R46 stated he felt like his blood sugar sometimes got high because of this. During an interview 9/10/26 at 7:19 a.m., nursing assistant (NA)-B stated R46 woke up around 7:30 to 8 a.m. and usually ate breakfast around 8:15 a.m. NA-B stated breakfast usually ran until 9 a.m. During an interview on 9/10/26 at 9:58 a.m., licensed practical nurse (LPN)-A stated she always prioritized insulin above other medications but sometimes when staff called in or if another resident had an urgent need insulin would be given after the residents meal instead of before. During an interview on 9/10/26 at 1:30 p.m., the consultant pharmacist (CP) stated that it was standard practice to give Lispro 15 minutes before meals for the best efficacy. The CP stated she would not be as concerned about the Basaglar being given at the exact same time every day as it was long acting but ideally it should be given 12 hours apart. During an interview on 9/10/26 at 1:59 p.m., the director of nursing (DON) stated that insulin should be given as close to mealtimes as possible. The facility's Preparation and General Guidelines policy dated 1/2026, indicated medications should be administered within 60 minutes of scheduled times except before, with, or after meal orders, which should then be administered based on mealtimes. R13 R13's significant change MDS dated [DATE], identified R13 had severe cognitive impairment and required assistance with ADLs. R13's diagnoses included deep vein thrombosis (DVT) (a blood clot in a deep vein), heart failure, renal failure, diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, and dependence on renal dialysis. R13's signed physician orders dated 8/10/26, included an order for a 2,000 milliliter (mL) per day fluid restriction initiated on 8/7/26, and an order for compression stockings to both lower extremities for edema management initiated on 8/8/26. The compression stockings were to be applied in the morning and removed at bedtime. R13's care plan printed 9/11/26, identified R13 was at risk for altered nutritional status related to low albumin, end-stage renal disease (ESRD), and low body weight. Interventions included a 2,000 mL fluid restriction over 24 hours. Dietary staff were to provide 400 mL at breakfast, 400 mL at lunch, and 400 mL at supper. Nursing staff were allotted 300 mL during the 7:00 a.m. to 3:00 p.m. shift, 300 mL during the 3:00 p.m. to 11:00 p.m. shift, and 200 mL during the 11:00 p.m. to 7:00 a.m. shift. The care plan directed staff to monitor R13's fluid intake to ensure a total of 2,000 mL per day. The fluid restriction intervention was initiated on 11/19/25. The care plan lacked evidence that R13's edema was identified or that interventions for edema management, including the physician-ordered compression stockings, were included. R13's August and September 2026 treatment administration records (TARs) lacked evidence that R13's daily fluid intake was monitored or documented. On 9/8/26 at 12:39 p.m., R13 was observed sitting in a wheelchair in the common area. Significant edema was observed in both lower extremities, with the right lower extremity more edematous than the left. R13 wore blue gripper socks, and the physician-ordered compression stockings were not in place. On 9/9/26 at 8:34 a.m., R13 was observed sitting at a dining room table eating breakfast. R13 wore blue gripper socks, and the physician-ordered compression stockings were not in place. On 9/9/26 at 11:09 a.m., R13 was observed being assisted by staff to leave for dialysis. Edema was observed in R13's lower extremities, and the physician-ordered compression stockings were not in place. During interview on 9/10/26 at 11:10 a.m., CM-D stated the fluid restriction order was not entered into the TAR until 9/9/26 and confirmed that, prior to 9/9/26, R13's fluid intake had not been monitored. CM-D stated R13 had an order for compression stockings initiated on 8/8/26 and had no history of refusing to wear them. CM-D confirmed R13 was not wearing the ordered compression stockings, no compression stockings were located in R13's room, and stated she would obtain another pair for R13. R4 R4's 5-day Minimum Data Set (MDS) dated [DATE], identified R4 had intact cognition and required assistance with activities of daily living (ADLs). R4's diagnoses included atrial fibrillation (an irregular heart rhythm), heart failure, hypertension (high blood pressure), diabetes mellitus, schizophrenia, schizoaffective disorder, weakness, and reduced mobility. R4's signed physician orders dated 7/24/26, included an order to apply ACE wraps to both lower extremities during the day shift and remove the wraps during the evening shift before bedtime. The order was initiated on 7/3/26. R4's care plan printed 9/11/26, identified altered elimination related to impaired mobility. An intervention directed staff to apply ACE wraps in the morning and remove them at bedtime for edema management. The intervention was initiated on 8/25/26. On 9/9/26 at 5:11 p.m., R4 was observed lying in bed. ACE wraps were not observed on R4's lower extremities. On 9/10/26 at 10:59 a.m., R4 was observed lying in bed. ACE wraps were not observed on R4's lower extremities. During interview on 9/10/26 at 11:00 a.m., nursing assistant (NA)-C stated R4 did not currently have any treatments that staff applied to her legs for edema. NA-C stated R13 wore gripper socks and that he was unaware of compression stockings that were to be applied to R13. NA-C stated he was also unaware that R13 had a fluid restriction. During interview on 9/10/26 at 11:10 a.m., CM-D stated R4 previously had an order for compression stockings; however, R4 complained the stockings hurt, and an order was obtained from the provider for ACE wraps, which R4 tolerated. CM-D confirmed R4 was not wearing the ordered ACE wraps, no ACE wraps were located in R4's room, and R4 needed the ACE wraps due to significant edema. R107 R107's quarterly MDS dated [DATE], identified R107 had intact cognition and required assistance with ADLs. R107's diagnoses included ESRD, heart failure, hypertension (high blood pressure), neurogenic bladder (impaired bladder function related to a nervous system condition), diabetes mellitus, anxiety disorder, chronic pain, and dependence on renal dialysis. R107's physician order dated 9/1/26, included an order for Lokelma 5 grams (g) by mouth on Tuesdays, Thursdays, Saturdays, and Sundays for hyperkalemia (elevated potassium level). R107's September 2026 medication administration record (MAR) printed 9/10/26, indicated the scheduled Lokelma dose on 9/3/26 was not administered. Staff documented code 6, which indicated the resident was hospitalized . R107's census report in the electronic medical record (EMR), however, indicated R107 had returned to the facility from the hospital on 8/25/26. The MAR identified the scheduled Lokelma doses on 9/5/26 and 9/6/26 as administered. On 9/8/26, the scheduled dose was not administered, and staff documented code 2, which indicated R107 refused the medication. During interview on 9/8/26 at 3:52 p.m., R107 stated a nurse brought her a medication that morning that she did not recognize. R107 stated she asked the nurse what the medication was and why she was receiving it; however, the nurse was unable to explain the medication or its purpose. R107 stated she refused the medication because she did not know what it was or why she was receiving it. During interview on 9/9/26 at 3:19 p.m., R107 stated she spoke with the director of nursing (DON) and learned what the medication was and its purpose. R107 stated, It makes sense to me now. During observation and interview on 9/10/26 at 10:41 a.m., registered nurse (RN)-F stated R107's Lokelma was supplied as a powder, with each dose packaged in an individual packet. R107's Lokelma was observed in the medication cart in a zippered pharmacy-labeled bag containing R107's identifying and medication information. The pharmacy label was dated 9/2/26 and identified a dispensing quantity of 16 packets. RN-F counted the medication and confirmed 15 packets remained. RN-F stated the remaining quantity indicated only one packet had been used. RN-F reviewed R107's physician orders and confirmed the Lokelma order had a start date of 9/3/26. RN-F stated R107 had not previously refused medications from her. During interview on 9/10/26 at 11:10 a.m., registered nurse case manager (CM)-D reviewed R107's September 2026 MAR and confirmed staff documented code 6, indicating hospitalization, for the scheduled Lokelma dose on 9/3/26; however, R107 was present in the facility. CM-D confirmed staff documented the Lokelma doses on 9/5/26 and 9/6/26 as administered; however, 15 of the 16 packets dispensed remained in the medication cart. CM-D stated the remaining quantity did not support that both documented doses had been administered. CM-D stated nursing staff sometimes documented quickly and selected entries without completing the task or paying close attention to the documentation. During interview on 9/11/26 at 8:31 a.m., the DON stated R107 had spoken with her regarding the medication, and they clarified the medication and its purpose. The DON stated staff should not document medications as administered when they were not administered and should not use another resident's similar medication that was stored in the same location as R107's medication. The DON stated either circumstance was a concern and that she expected staff to follow physician orders and accurately document medication administration. Regarding edema management, the DON stated she expected staff to follow physician orders for the application and removal of ACE wraps and compression stockings. If a resident refused the ordered treatment, staff were expected to document the refusal and the reason the treatment was not completed. The DON stated the ACE wraps and compression stockings were physician ordered to treat and manage edema and expected staff to follow the orders. R108 R108's admission Minimum Data Set (MDS) dated [DATE], identified R108 was cognitively intact. Diagnosis included end stage renal (kidney) disease and cirrhosis (scaring) of the liver. Review of R108's Electronic Medical Record (EMR) confirmed no orders for PICC care and/or maintenance in the progress notes or the Treatment Administration Record (TAR) or Medication Administration Record (MAR). Identified R108 was admitted to the facility on [DATE] and discharged [DATE]. During an interview and concurrent EMR review on 09/10/2026 at 7:41 a.m., Director of Nursing (DON) confirmed there was no specific provider order detailing the maintenance, frequency, or flushing requirements for R108's PICC line. The DON acknowledged that while the PICC line maintenance was included in a batch order initiated on 4/16/2026, this type of entry did not properly translate to or populate on the MAR. Due to the ordering system failure and lack of explicit tracking, there was no clinical record or documentation demonstrating that R108's PICC line was flushed pre- or post-medication administration or maintained according to standard vascular access protocols throughout R108's admission to the facility from 04/14/20206 to 05/08/2026. DON acknowledged failing to maintain PICC placed R108 at risk for severe complications including infection, and blockage of the PICC. Facility's Standing Orders for Nursing Facilities and Skilled Nursing Facilities, 2026 had no standing orders for PICC line maintenance, care, and/or use. The facility's Support Stockings/TED Hose policy, dated 11/2019, indicated the facility would provide residents with safe and proper assistance with support stockings/TED hoses. The facility's Fluid Restriction Guidelines policy, dated 9/2012, indicated fluid restrictions were implemented only with a physician's order. Staff were to be notified of a resident's fluid restriction through verbal and written communication. Communication between the Hospitality Services Director and/or dietitian, the DON and/or Nurse Manager, and the resident was to occur to establish the amount of fluid to be provided and suggested times for administration. The policy directed staff to measure fluid intake every shift in accordance with facility policy. A facility policy related to following provider orders was requested but was not received.

Based on interview and document review, the facility failed to ensure directions to report grievances anonymously were made available to all residents, resident representatives, and families, for 5 of 5 residents (R23, R32, R39, R48, R75, R107) reviewed for resident council. This deficient practice had the potential to affect all 94 residents who resided in the facility. Findings include:R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R32's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R39's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R48's annual MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R75's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.R107'S quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood.Prior to the surveyor-lead resident council meeting on 9/9/26, surveyors did not see a grievance drop box on any of the three floors. On first floor near the dining room was a folder in an acrylic wall pocket containing grievance forms, along with instructions indicating: please turn form in to nurse, supervisor and management. The forms were titled Grievance/Concern Form and had spaces for the name of the resident and other identifiable information. During the resident council meeting on 9/9/26 from 2:25 p.m. to 3:15 p.m., attendees (R23, R32, R39, R48, R75, R107) stated they could not report grievances anonymously. Some in attendance were aware of grievance forms in the hallway outside the dining room on first floor but did not know if they could file a concern or grievance anonymously.During an interview and observation on 9/10/26 at 10:35 a.m., the administrator stated residents could report anonymously by using the complaint hotline number, posted on a large poster on second floor. The administrator stated this population of elderly individuals would be able to report a concern or grievance using the hotline. The administrator admitted the poster was only on second floor, not on first floor or the lower level where residents resided. The corporate poster read: COMPLIANCE AND COMPLAINT HOTLINE. Attention residents, families, visitors, and staff. Do you have an ethics or compliance concern? Do you want to report suspicious activity? To report an issue, please call our compliance Hotline: xxx-xxx-xxxx. Or visit our website MyCompliancexxxxxx.com Access Code XXXX. As part of our compliance program, we offer an independent third-party hotline that is available 24 hours a day - every day of the week. We encourage you to communicate and support our facilities vision, commitment, and core values. The information that you share is 100% anonymous and confidential. We value your input and look forward to hearing from you. During an interview on 9/10/26 at 10:48 a.m., the therapeutic recreation director (TRD)-A stated residents and families could report concerns anonymously by sliding a grievance form under the administrator or director of nursing (DON) office door. TRD-A was unaware of another way. TRD-A was shown a copy of the corporate compliance reporting hotline poster. TRD-A stated she had not brought that to resident council to inform/educate residents on it - no one had asked her to do that. During an interview on 9/10/26 at 1:11 p.m., social services director stated she was not aware of a way residents could report a concern or grievance anonymously; she treated all grievances with confidentially. During an interview on 9/10/26 at 1:15 p.m., along with R23, looked at the corporate poster on second floor - the poster the administrator stated directed residents to file a concern or grievance anonymously. R23 stated she hadn't read the poster before as she assumed it was for staff. After looking closer, R23 stated she saw it was for residents too. R23 stated she had not been aware of the process, nor had it been explained to residents. During an interview on 9/10/26 at 2:55 p.m., the administrator stated the corporation had the hotline available for about three years. The administrator was informed residents who attended the surveyor-lead meeting did not know about it and that some staff did not know about it. There was not a poster on each floor, and nothing in the admission packet about it for residents, resident representatives and family members.Facility Complaint and Grievance policy with review date of 11/2025, indicated any resident, resident representative, or applicant for admission who has reason to believe that he/she had been mistreated, denied services, or discriminated against in any aspect by the facility may file a complaint or grievance. Grievances could be submitted anonymously, and individuals had the right to file a grievance without fear of discrimination or reprisal. Forms were to be made readily available within the facility to report a complaint or grievance. Any complaints, regardless of how they were received by the facility, would be investigated per the policy. Forms would be available in an area accessible to residents 24/7 and upon request. Unless anonymity had been requested, the written grievance must be signed and dated by the person making the complaint. The form would be completed and returned to the administrator's office. The written grievance should be submitted to the administrator as soon as is reasonably possible after the date of the incident prompting the complaint. *No mention in the policy about the corporate ethics and compliance hotline or website that the administrator identified would be used to report a concern or grievance anonymously.

Based on observation, record review, and interview, the facility failed to ensure a call light was within reach and failed to provide an appropriate call light for 1 of 1 resident (R101) reviewed for accommodation of needs. R101 was unable to use the standard call light provided and required a soft-touch call light.Findings include:R101's quarterly Minimum Data Set (MDS), dated [DATE], identified R101 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R101's diagnoses included non-Alzheimer's dementia (a decline in memory and thinking abilities), malnutrition (inadequate nutritional intake), and renal failure (decreased kidney function).During observation on 9/8/26 at 12:47 p.m., R101 was seated in her wheelchair in her room looking out the window. R101's call light was lying on the bed and was not within her reach. The call light consisted of a cylinder with a red push button on the top.During observation on 9/8/26 at 4:32 p.m., R101 was seated in her wheelchair in her room looking out the window. R101's call light was lying on the floor and was not within her reach.During observation on 9/9/26 at 11:02 a.m., R101 was seated in her wheelchair in her room looking out the window. R101's call light was hanging off the end of the bed and was not within her reach.During observation on 9/9/26 at 5:11 p.m., R101 was seated in her wheelchair in her room looking out the window. R101's call light was attached to her wheelchair and hung down toward the floor, nearly touching the floor, and was not within her reach. R101 yelled out nonsensical words and mumbled.During observation on 9/10/26 at 7:23 a.m., R101 was seated in her wheelchair in her room looking out the window. R101's call light was lying on the bed and was not within her reach.During interview on 9/10/26 at 7:25 a.m., nursing assistant (NA)-D stated residents' call lights should always be placed within their reach. NA-D confirmed R101's call light was not within her reach and stated R101 was unable to use the call light.During interview on 9/10/26 at 10:41 a.m., registered nurse (RN)-F stated R101 was unable to independently move her wheelchair around her room and that her call light should always be placed within her reach.During interview on 9/10/26 at 11:00 a.m., NA-C stated call lights should be within residents' reach at all times. NA-C stated R101 was unable to use the type of call light currently provided to her.During interview on 9/10/26 at 11:10 a.m., registered nurse case manager (CM)-D stated call lights should be within residents' reach at all times. CM-D stated R101 was unable to independently propel her wheelchair around her room and should have had a soft-touch call light because she was unable to push the button on the standard call light provided in her room. CM-D confirmed R101's call light was not within her reach and was not a soft-touch call light.During interview on 9/10/26 at 12:50 p.m., the director of rehab services (DRS) reviewed R101's therapy recommendations and stated R101 required a soft-touch call light because she was unable to use a standard call light.During interview on 9/11/26 at 8:31 a.m., the director of nursing (DON) stated she expected call lights to be kept within residents' reach while in their rooms. The DON stated if a resident was unable to use a standard call light, staff should assist with obtaining a soft-touch call light. The DON stated R101 should not have been provided a standard call light because she was unable to use it and should have had a soft-touch call light implemented.The facility's Call Light policy, dated 5/16/23, indicated the purpose of the protocol was to ensure residents, when in their rooms and toilet and bathing areas, had a means of directly contacting caregivers and that the facility had a process to routinely ensure the resident call light system was operational. A nurse call system was to be provided for each resident's bed or other sleeping accommodation. Call cords, buttons, or other communication devices were to be placed within reach of each resident.

Based on observation, interview, and document review, the facility failed to maintain dignity for 1 of 1 resident (R8) reviewed for shaving.Findings include:R8's significant change Minimum Data Set (MDS), dated [DATE], identified R8 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R8's diagnoses included Alzheimer's disease (a progressive disorder that affects memory, thinking, and behavior) and non-Alzheimer's dementia (a decline in memory, thinking, and the ability to perform daily activities).R8's care plan, printed 9/11/26, identified R8 had an ADL self-care performance deficit related to dementia and was unable to participate in cares or anticipate needs. The care plan identified R8 was to be neat, clean, and well-groomed daily, and required assistance from one staff member with personal hygiene.During observation on 9/8/26 at 12:37 p.m., R8 was seated in her wheelchair in the common area. Multiple long, white hairs, approximately 1/2-inch in length, were observed on R8's chin, and were visible from a distance.During observation on 9/9/26 at 8:37 a.m., R8 was seated at a table in the dining room. The previously observed long, white hairs remained present on R8's chin.During observation on 9/10/26 at 7:22 a.m., R8 was seated in her wheelchair in her room. The previously observed long, white hairs remained present on R8's chin.During interview on 9/10/26 at 10:41 a.m., registered nurse (RN)-F stated nursing assistants assisted residents with shaving. RN-F stated R8 was unable to shave independently and required staff assistance with shaving.During interview on 9/10/26 at 11:00 a.m., nursing assistant (NA)-C stated R8 was unable to perform her own cares and required staff assistance. NA-C confirmed R8 had multiple long, white chin hairs, and stated they should have been shaved and staff should have assisted R8 with shaving when the chin hairs were observed.During interview on 9/10/26 at 11:10 a.m., registered nurse care manager (CM)-D stated R8 was unable to shave independently and staff should have assisted R8 with shaving when the facial hair was first observed.During interview on 9/11/26 at 8:31 a.m., director of nursing (DON) stated she expected staff to offer R8 assistance with shaving. The DON stated shaving should have been completed when facial hair was observed and on bath days. The DON stated assisting R8 with shaving was important to maintaining R8's dignity.When the facility's policy related to resident dignity was requested, the administrator provided an email dated 9/11/26 at 11:48 a.m., in which the administrator stated the facility followed resident rights as its dignity policy, and provided a copy of the Minnesota Department of Health Combined Federal and State [NAME] of Rights. The [NAME] of Rights indicated residents had the right to a dignified existence and self-determination. The facility was to treat each resident with respect and dignity and provide care in a manner and environment that promoted the maintenance or enhancement of the resident's quality of life while recognizing each resident's individuality.

Based on interview, and document review, the facility failed to ensure a system was in place to monitor for resident BiPAP (bilevel positive airway pressure, used to assist in delivering oxygen to the body and ridding it of excess carbon dioxide) machine tolerance and intervention effectiveness to reduce the risk of possible complication for 1 of 1 resident (R46) reviewed for BiPAP machine use.Findings include:R46's admission Minimum Data Set (MDS) dated [DATE], indicated R46 had intact cognition and no rejection of care behaviors. The MDS did not include non-invasive ventilation use. The MDS indicated R46 required partial to moderate assistance with upper body dressing, was dependent for bathing, and required moderate assistance with bed mobility.R46's care plan dated 8/10/26, indicated R46 had sleep apnea and included interventions of ensuring filters were clean and instructed the client on the proper oxygen adaptor/oxygen tubing placement. The care plan did not have direction/further direction on BiPAP machine use.R46's order summary dated 9/9/26, included an order for respiratory therapy BiPAP machine settings and an order to encourage BiPAP use every night and for all naps. The orders did not indicate what BiPAP machine mask should be used.R46's Medication and Treatment Administration Record (MAR) dated 8/20/26 to 9/9/26, indicated staff documented they encouraged R46 to use his BiPAP machine every night and for all naps, but it did not indicate if/when R46 wore his BiPAP and for how long.R46's progress note dated 8/20/26 at 3:41 p.m., indicated R46 felt claustrophobic with his current BiPAP machine mask so the respiratory therapist was going to bring an alternative mask once orders were received.R46's provider note dated 8/25/26 at 12:00 a.m., indicated the reason for the visit was a follow up related to BiPAP machine tolerance and constipation. The note indicated R46 was to use the BiPAP machine in 30-minute intervals to build up tolerance. The note indicated R46 had obstructive sleep apnea (OSA) and a pulmonary embolism resulting in a previous hospitalization. The note indicated R46 had abnormal laboratory levels related to inconsistent BiPAP machine use due to claustrophobia. The note indicated R46 stated he had improved sleep wearing an oxygen mask at night and was only using the BiPAP in 30-minute intervals to build tolerance. The note indicated he was counseled that the oxygen mask helped with oxygenation but does not open the airway to allow him to blow off excess carbon dioxide which can build up in the body.During an interview on 9/8/26 at 1:49 p.m., R46 stated he was supposed to use a BiPAP machine at night, but he hadn't been as staff had told him his oxygen levels were higher just using supplemental oxygen. R46 stated he had started with a normal BiPAP machine mask but that was making him claustrophobic, so he was given a new nasal (covers solely the nose instead of the nose and mouth) BiPAP mask that didn't cover as much of his face, but given what staff had told him, he hadn't worn the new mask much. R46 stated if he was going to wear the BiPAP machine he would need help putting it on.During an interview on 9/9/26 at 1:54 p.m., licensed practical nurse (LPN)-A confirmed she was R46's nurse for the shift. LPN-A stated she thought R46 used his BiPAP machine every night. LPN-A stated R46 only used the BiPAP machine at night, so she had not helped him put it on. LPN-A stated she thought R46 would need help applying the mask.During an interview on 9/10/26 at 11:41 a.m., registered nurse care manager (CM)-C stated she thought R46 used a BiPAP machine every night. CM-C stated usually an order was added to the MAR that staff could document on to show if the intervention was being used. CM-C confirmed she had reviewed R46's medical record and could not find documentation to show how often R46 had been using his BiPAP machine.During an interview on 9/10/26 at 2:02 p.m., the director of nursing (DON) stated she had been aware new interventions were being attempted to help with R46's BiPAP machine compliance. The DON stated she had not been notified R46 had still not been using his BiPAP machine since the implementation of these new interventions. The DON confirmed she had reviewed R46's medical record and stated it looked like an order had been missing where staff could document if R46 was using his BiPAP machine or not.A policy regarding BiPAP machine use was requested and not received.

Based on observation, interview, and document review, the facility failed to assess to determine whether self-administration of medications was clinically appropriate and safe for 3 of 3 residents (R4, R61, R50) reviewed for self-administration of medications. Findings include: R4 R4's 5-day Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and required assistance with activities of daily living (ADLs). R4's diagnoses included diabetes mellitus (a condition that causes elevated blood sugar levels), schizophrenia (a mental health disorder that can affect thoughts, perceptions, and behavior), and schizoaffective disorder (a mental health disorder with symptoms of both a mood disorder and schizophrenia). Observation on 9/9/26 at 11:07 a.m. revealed R4 was lying in bed with headphones on. A bottle of glucose tablets was on R4's bedside table. Observation on 9/9/26 at 5:11 p.m. revealed R4 was lying in bed listening to headphones. The bottle of glucose tablets remained on R4's over-the-bed table. Observation on 9/10/26 at 7:28 a.m. revealed R4 was lying in bed. The bottle of glucose tablets remained on R4's bedside table. During interview on 9/10/26 at 10:59 a.m., R4 stated staff administered all her medications; however, she kept glucose tablets at her bedside and took them whenever she felt she needed them. R4's care plan, printed 9/11/26, lacked evidence that R4 had been assessed and determined capable of safely self-administering medications. R4's signed physician orders, dated 7/24/26, lacked an order for glucose tablets. R4's electronic medical record (EMR) lacked evidence that a self-administration of medication assessment had been completed for the glucose tablets. R61 R61's quarterly MDS, dated [DATE], identified R61 had intact cognition and was independent with ADLs. R61's diagnoses included diabetes mellitus (a condition that causes elevated blood sugar levels) and chronic pain (persistent or long-term pain). R61's September medication administration record (MAR), printed 9/9/26, identified an order for semaglutide 2 milligrams (mg) subcutaneously every Wednesday for Type 2 diabetes mellitus. The order initiated 7/29/26, indicated R61 could keep the medication in a lock box in the resident's room and self-administer it. R61's signed physician orders dated 7/21/26, included an order for a Dexcom G7 sensor every 10 days for blood glucose monitoring initiated 5/20/26. During observation and interview on 9/8/26 at 3:04 p.m., R61 stated she stored her insulin, identified as semaglutide, in her personal refrigerator in her room and self-administered the medication. During the interview, R61 prepared and applied a Dexcom G7 sensor to her upper arm and stated she managed the sensor herself. R61's care plan printed 9/11/26, identified R61 could self-administer mupirocin 2% ointment, Fleet enema, and semaglutide (Ozempic) according to physician directions and could keep an albuterol inhaler on her person. The care plan directed staff to provide the medications to R61 when requested and leave them at the bedside. Interventions directed staff to monitor R61's use of bedside medications, assess R61's ability to correctly self-administer inhalers and enemas quarterly, and administer all other medications and monitor for response and side effects as needed. The care plan lacked evidence of an intervention to assess R61's ability to safely self-administer semaglutide or independently apply and manage the Dexcom G7 sensor. R61's EMR lacked evidence that self-administration assessments had been completed to determine R61's ability to safely self-administer semaglutide or independently apply and manage the Dexcom G7 glucose sensor. During interview on 9/10/26 at 10:41 a.m., registered nurse (RN)-F stated an assessment was required before a resident could self-administer medications to determine whether the resident was capable of safely self-administering them. RN-F confirmed R4 was not able to self-administer medications and stated R61 was able to self-administer an enema, insulin, and eye drops. During interview on 9/10/26 at 11:10 a.m., registered nurse care manager (CM)-D stated when a resident requested to self-administer medications, nursing staff met with the resident and completed an assessment to determine whether the resident could safely self-administer the medication. If the resident was determined capable, nursing obtained an order from the provider. CM-D reviewed R4's orders and assessments, stated R4 should not have had glucose tablets in the room, and confirmed a self-administration assessment had not been completed for the glucose tablets. CM-D accompanied the surveyor to R4's room, confirmed the glucose tablets remained at the bedside, and removed them from the room. CM-D reviewed R61's orders and assessments and confirmed R61 had self-administration assessments for mupirocin and a Fleet enema; however, assessments had not been completed for semaglutide or the Dexcom G7 glucose sensor. CM-D stated assessments should have been completed to determine R61's competency and ability to safely self-administer. CM-D further stated R61 did not have an order to independently change the Dexcom G7 sensor and nursing staff should have been present during the sensor change. During interview on 9/11/26 at 8:31 a.m., the director of nursing (DON) stated when a resident wanted to self-administer medications, including semaglutide and a Dexcom glucose sensor, an assessment was required to determine the resident's competency, and nursing staff were required to obtain an order from the provider. The DON stated she expected an assessment and provider order for R4's glucose tablets, an assessment for R61's self-administration of semaglutide, and an assessment and provider order for R61 to independently change the Dexcom glucose sensor. R50 R50's admission Record documented the diagnoses of obesity, cognitive communication, end stage renal disease / on dialysis, dementia and Type 2 diabetes. R50's quarterly Minimum Data Set (MDS), dated [DATE] indicated moderate cognitive impairment, and dependent on staff for most of resident's activities of daily living (ADLs). During observations of morning cares, on 9/10/26 at 7:21 a.m., nursing assistant (NA)-A had just finished performing R50's bed bath and informed resident that she was going to lotion his body. R50 requested NA-A use Vaseline and pointed to the shelving at the foot of the bed. NA-A was unable to find the Vaseline, but found a large container of bacitracin zinc ointment, along with tubes of other facility provided barrier creams. R50 stated not to use that ointment, he wanted Vaseline. He stated his wife uses bacitracin zinc ointment when she is here. R50 finally agreed to the facility provided zinc barrier cream for his buttocks and peri-area. During interview on 9/10/26 at 8:04 a.m., NA-A stated the bacitracin zinc ointment was brought in by the family. NA-A stated the family brings in a lot of creams and other over the counter medications, which they keep locked in the 2-drawer file cabinet. In review of R50's Order Summary Report printed 10/10/26, there was no physician order for the use of the bacitracin zinc ointment. During a follow-up observation and interview on 9/10/26 at 10:59 a.m., care managers (CM)-A, CM-B and the director of rehab services (DRS) entered the room and were shown the large container of bacitracin zinc ointment. The care managers noted there was a prescription label on the container, however illegible except for the residents' name and directions to be used on an open area on an arm. The care managers asked R50 where it came from. R50 stated his wife brings in creams and other things from home and places them in the locked file cabinet at the foot of his bed. The DRS asked R50 permission to unlock the file cabinet, with permission and key given to staff. A review of the cabinet yield no further prescription medication. CM-B informed R50 that she would have to take the bacitracin zinc ointment and check with the physician if it could be continued to be used. A review of R50's Self Administration of medication Evaluation (2013), dated 9/2/26, documented only the following: [R50] able to [self-administer] oral medication after nurse setup and supervise. He has not expressed the desire to [self-administer] meds. Ok with nursing managing medication. A review of R50's Comprehensive Care Plan (last reviewed 9/8/26) and current physician orders (print date of 10/10/26), neither documented R50 to self-administer medications. During interview on 9/10/26 at 10:59 a.m., CM-A stated R50's Self-Administration assessment, doesn't allow medications to be left, the nurses are still to supervise and observe R50 is taking the medications. The facility's Self-Administration of Medications policy, dated 2/2024, indicated residents had the right to self-administer medications when the interdisciplinary team (IDT) determined self-administration was clinically appropriate and safe. The policy indicated the IDT assessed the resident's cognitive and physical abilities, including the ability to understand the medication's purpose, dosage, administration times, and potential side effects; physically administer the medication; and safely and securely store the medication. When self-administration was determined to be safe and appropriate, the determination was documented in the resident's medical record and care plan. The policy further indicated medications found at the bedside that were not authorized for self-administration were to be turned over to the nurse in charge.

Based on record review and interview, the facility failed to ensure necessary wound care treatments were initiated, carried out, and documented as ordered for 1 of 1 resident (R108) who presented with skin impairment of a scab on the coccyx (commonly referred as the tailbone) upon admission.Findings include:R108's admission Minimum Data Set (MDS) dated [DATE], identified R108 was cognitively intact. Diagnosis included end stage renal (kidney) disease and cirrhosis (scaring) of the liver. Review of R108's Electronic Medical Record (EMR) and Treatment Administration Record (TAR) confirmed wound care treatments were completed only on 4/15/2026 with no further documented treatments or ongoing care provided thereafter during the stay at the facility. Review of R108's EMR confirmed wound orders were placed on 04/14/2026 but were not initiated into the treatment plan of care. Review of R108's EMR confirmed a wound order for coccyx was placed on 04/15/2026, and discontinued on 04/16/2026, for wound care to coccyx. During an interview and concurrent record review on 09/10/2026, at 7:54 a.m., the Director of Nursing (DON) confirmed R108's admission record indicated a scab on coccyx was present upon admission. DON confirmed wound orders for treatment of the scab were placed on 4/14/26 but were not initiated into the treatment cycle. DON confirmed that additionally, a wound order for coccyx was placed on 4/15/26 and discontinued on 4/16/2026 for wound care. DON confirmed wound care to the coccyx was performed only on 04/15/2026 while R108 was admitted to the facility from 04/14/2026 to 05/08/2026. DON acknowledged failing to perform wound care placed R108 at risk for complications to develop at wound site such as infection and wound becoming more severe. Facility Standing Orders for Nursing Facilities and Skilled Nursing Facilities, 2026 had a category of Skin and Wound Management which included:Institute facility wound management process. If facility wound management. If facility wound management process not available, see below:Assess all wounds and dressings daily.Complete wound measurements weekly if not a higher frequency by ordering providerCleanse minor skin tears, abrasions, pressure injury, and minor injuries with normal saline or non-cytotoxic wound cleanser. Cover with non-adherent dressing and secure appropriate cover dressing avoiding tape to the skin.Pressure InjuryStage 2 or 3 with moderate to heavy drainage: Apply adhesive foam dressing. Cover as aboveStage 2 or 3 with minimal drainage: Apply hydrogel to wound bed. Cover as above.May initiate skin sealant to intact periwound skin, let dry prior to covering.Notify provider next business day of new wound or injury.Change all dressings every 3 days and as needed.May institute pressure reduction mattress and/or occupational therapy wheelchair positioning eval and treat as clinically indicated for patients with, or at high risk for, skin breakdown (e.g., mobility impairment, prolonged bed rest or fragile skin).Discontinue dressings and other treatments when wound resolved.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded, with the potential for inaccurate federal reimbursement and resident care planning for 2 of 3 residents (R23, R46) reviewed for MDS accuracy. Findings include: R23's quarterly MDS dated [DATE], indicated R23 did not get an injection or a hypoglycemic (medication that decreases blood sugar levels) medication during the look back period (LBP). R23's Medication Administration Record (MAR) dated 7/1/26 to 7/30/26, indicated R23 received 500 milligrams (mg) of metformin daily during the LBP. The MAR indicated R23 received one, five mg injection of tirzepatide (a hypoglycemic medication also used for weight loss) during the LBP. R46's admission MDS dated [DATE], indicated R46 had received seven days of insulin (a medication used to lower blood sugar) injections during the LBP. The MDS did not indicate that R46 had received a hypoglycemic. R46's MAR dated 6/1/26 to 7/30/26, indicated R46 received 57 units of glargine (long-acting insulin) once to twice daily during the LBP. During an interview on 9/10/26 at 8:48 a.m., MDS coordinator (MDSC)-A stated R46's insulin should have been coded as a hypoglycemic. MDSC-A stated R23 should have been coded as receiving an injection and did not think metformin would be coded as a hypoglycemic but would double check her resource. MDSC-A stated did not believe tirzepatide was a hypoglycemic medication. At 10:08 a.m., MDSC-A stated she had talked with the cooperate MDS nurse who had told her both metformin and the tirzepatide should have been coded as hypoglycemic medications. A policy regarding MDS completion was requested and was not received. Instead, the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2025 was received. The RAI manual indicated that hypoglycemic medications including insulin should be coded under section N of the MDS if it was taken by the resident any time during the seven-day LBP.

Based on observation, interview, and record review, the facility failed to maintain resident's wheelchair in a clean and sanitary condition for 1 of 1 resident (R8) reviewed for environment.Findings include:R8's significant change Minimum Data Set (MDS), dated [DATE], identified R8 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R8's diagnoses included Alzheimer's disease, non-Alzheimer's dementia, arthritis, and seizure disorder.On 9/8/26 at 2:34 p.m., R8's wheelchair seat and frame contained visible brown and white dried, food-like debris. The wheelchair armrests and multiple areas of the frame had a dried, crusted brown and white substance adhered to the surfaces.On 9/9/26 at 8:37 p.m., R8 was seated in her wheelchair at a table in the dining room. R8's wheelchair remained visibly soiled with dried debris and a crusted brown and white substance on the wheelchair surfaces.On 9/10/26 at 7:22 a.m., R8 was seated in her wheelchair in her room. R8's wheelchair remained visibly soiled with dried debris and a crusted brown and white substance on the wheelchair surfaces.During interview on 9/10/26 at 10:41 a.m., registered nurse (RN)-F stated it was everyone's responsibility to wipe down wheelchairs when they observed the wheelchairs were dirty.During interview on 9/10/26 at 11:00 a.m., nursing assistant (NA)-C stated wheelchairs should have been cleaned whenever they appeared dirty.During interview on 9/10/26 at 11:10 a.m., registered nurse case manager (CM)-D stated wheelchairs were cleaned during the night shift when staff went room to room to clean them. CM-D stated if a wheelchair was excessively dirty, staff would wash the entire wheelchair. CM-D observed R8's wheelchair and confirmed it was dirty, with a crusted substance on the armrests and frame and debris on the seat. CM-D stated the condition of R8's wheelchair was unacceptable and described it as gross.During interview on 9/11/26 at 8:31 a.m., the director of nursing (DON) stated she expected wheelchairs to be thoroughly wiped down by the bath aide on residents' shower days and cleaned as needed by nursing assistants. The DON stated maintaining clean wheelchairs was important for resident dignity, hygiene, and infection control.Facility policy related to cleaning and maintaining resident wheelchairs was requested but was not received.

Based on interview and document review, the facility failed to ensure non-pharmacological interventions were attempted and/or recorded before administration of as-needed (PRN) pain medication to reduce the risk of potential complications for 2 of 5 residents (R9, R23) reviewed for unnecessary medications.Findings include:R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had intact cognition and was diagnosed with kidney failure, diabetes, and hypertension. The MDS indicated R9 had pain or hurting occasionally in the past five days of the look back period (LBP) which had occasionally made it hard to sleep and limited day-to-day activities. R9's care plan dated 5/26/26, indicated R9 was to receive non-medicinal forms of pain relief such as positioning, rest, massage, etc. as well as pain medication as ordered by the provider. R9's medication administration record (MAR) dated 8/25/26 to 9/8/26, indicated R9 had orders for the following PRN pain medications:- 10 milligrams (mg) of oxycodone every six hours PRN with a start date of 8/4/26 and discontinued on 8/28/26. This medication was administered under this order twice during the period.-Five mg of oxycodone every eight hours PRN with a start date of 8/28/26 and discontinued on 8/31/26. This medication was administered under this order twice.-10 mg of oxycodone every six hours PRN with a start date of 8/31/26. This medication was administered under this order 14 times during the period. R9's medical record was reviewed and lacked evidence R9 was routinely offered or received nonpharmacological pain interventions prior to administration of as needed pain medications. R23's quarterly MDS dated [DATE], indicated R23 had intact cognition and was diagnosed with kidney failure, diabetes, and arthritis. The MDS indicated R23 received scheduled and as needed pain medication but did not receive non-medication interventions for pain. R23's care plan dated 5/13/26, indicated R23 was to receive non-medicinal forms of pain relief such as positioning, rest, massage, etc. as well as pain medication as ordered by the provider. R23's MAR dated 8/25/26 to 9/8/26, indicated R9 received the following as-needed pain medications:-Five mg of oxycodone three times a day PRN with a start date of 7/16/26 and discontinued on 8/31/26. This medication was given under this order 10 times during the period.- 10 mg of oxycodone twice a day RPN started on 8/31/26. This medication was given under this order 15 times during the period.R23's medical record dated 8/25/26 to 9/8/26 was reviewed and lacked evidence R23 was routinely offered or received nonpharmacological pain interventions prior to administration of as needed pain medications. During an interview on 9/8/26 at 4:06 p.m., R9 stated he had pain all over his body and it was a six right now as his back hurt. R9 stated staff did not offer him any nonpharmacological pain interventions such as heat or cold therapy. During an interview on 9/9/26 at 9:07 a.m., R23 stated she had pain all over her body and stated she did not believe that staff had offered her nonpharmacological interventions to assist with her pain. During an interview on 9/10/26 at 11:31 a.m., registered nurse (RN)-C stated R23's pain was generally in her amputation site, back, or leg. RN-C stated that R9 also had pain, but he would decline to say where it was when asked. RN-C was unsure if R9 would utilize non-pharmacological pain interventions if offered but thought R23 might be open to interventions such as ice, pillow placement, and completing crafts. RN-C stated if nonpharmacological pain medications were offered, she would expect them to be documented in the progress notes. During an interview on 9/10/26 at 1:38 p.m., RN case manager (CM)-A, stated when nurses gave as needed pain medications especially narcotics, nonpharmacological interventions should be offered first. CM-A stated the nurse should then document this in a progress note. During an interview on 9/10/26 at 2:05 p.m., the director of nursing (DON) stated she would expect nonpharmacological interventions to be offered and documented prior to giving as-needed narcotics. The facility's Preparation and General Guidelines policy dated 1/2026, outlined the procedure for administering as needed medications, but the procedure did not include offering/attempting non-pharmacological interventions.

Based on observation, document review, and interview, the facility failed to ensure the medication administration record (MAR) accurately reflected the administration of a scheduled medication for 1 of 1 resident (R4) reviewed for accurate clinical records. R4's scheduled olanzapine was administered by nursing staff; however, the MAR identified the medication as U-SA, which indicated unsupervised self-administration, and did not provide nursing staff the ability to document when the medication was administered.Findings include:R4's 5-day Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and required assistance with activities of daily living (ADLs). R4's diagnoses included schizophrenia and schizoaffective disorder (mental health disorders that can affect thinking, mood, and behavior).R4's signed physician order dated 7/24/26, identified an order for olanzapine 15 milligrams (mg) by mouth two times a day for depression, unsupervised self-administered. The order was initiated on 7/21/26.R4's electronic medical record (EMR) lacked evidence R4 had been assessed and determined able to self-administer medications.R4's MAR identified scheduled doses of olanzapine as U-SA, indicating unsupervised self-administration, and lacked documentation to accurately reflect when nursing staff administered the medication.During interview on 9/10/26 at 10:59 a.m., R4 stated nursing staff administered all of her medications.During interview on 9/10/26 at 10:41 a.m., registered nurse (RN)-F stated an assessment was required before a resident could self-administer medications to determine whether the resident was capable of safely self-administering them. RN-F confirmed R4 was not able to self-administer medications.During interview on 9/10/26 at 11:10 a.m., registered nurse care manager (CM)-D stated R4 was not able to self-administer medications. CM-D reviewed R4's MAR and confirmed U-SA was identified for each scheduled administration of olanzapine and the MAR did not reflect when nursing staff administered the medication. CM-D stated R4's olanzapine order had been entered incorrectly into the EMR because the unsupervised self-administration option had been selected instead of the clinician option, which prevented nursing staff from documenting administration of the medication.During observation and interview on 9/10/26 at 1:39 p.m., trained medication aide (TMA)-A confirmed R4's olanzapine was stored in the medication cart and was administered by nursing staff. TMA-A stated staff were unable to document the medication as administered because the MAR did not provide an area to document the administration.During interview on 9/11/26 at 8:31 a.m., the director of nursing (DON) stated she expected staff to notify the case manager or DON when the documentation issue was identified so it could be corrected.A facility policy related to documentation was requested but was not received.

Based on interview and document review, the facility failed to ensure range of motion (ROM) exercises were completed as planned for 2 of 2 residents (R8, R101) reviewed for ROM.Findings include:R8R8's significant change Minimum Data Set (MDS), dated [DATE], identified R8 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R8's diagnoses included Alzheimer's disease (a progressive disease that affects memory and thinking), arthritis (inflammation or degeneration of the joints that can cause pain, stiffness, and decreased joint movement), non-Alzheimer's dementia (a decline in memory, thinking, and the ability to perform daily activities from causes other than Alzheimer's disease), and seizure disorder (a condition that causes recurrent seizures).R8's care plan printed 9/11/26, identified R8 had an alteration in mobility related to cognitive impairment. An intervention, initiated 8/1/26, directed staff to provide gentle passive range of motion (PROM) to the bilateral upper extremities (BUE) and bilateral lower extremities (BLE) daily during morning and evening cares.The Nursing Assistant Registered (NAR) group sheet, printed 9/9/26, directed R8 to receive gentle PROM to BUE and BLE, as tolerated, during morning and evening cares.R8's functional maintenance program (FMP), dated 7/30/26, directed staff to provide ROM exercises to BUE and BLE daily during morning and evening cares, with repetitions as tolerated. The FMP specified gentle PROM was to be provided during morning and evening cares.R8's August 2026 treatment administration record (TAR) directed PROM to the BUE and BLE daily during morning and evening cares. The TAR documented PROM as completed on the day and evening shifts from 8/25/26 through 8/31/26. However, the TAR lacked specific instructions identifying the exercises staff were to perform and the number of sets and repetitions to be completed.R8's September 2026 TAR directed PROM to the BUE and BLE daily during morning and evening cares. The TAR documented PROM as completed on the day and evening shifts from 9/1/26 through 9/9/26. However, the TAR lacked specific instructions identifying the exercises staff were to perform and the number of sets and repetitions to be completed.R8's electronic medical record (EMR) lacked evidence of a measurable FMP that identified the specific ROM exercises to be performed and the number of sets and repetitions to be completed.In an email dated 9/10/26 at 10:20 a.m., the administrator stated R8's FMP documentation had been entered as an order on the TAR rather than as a task, as was done for R101. The administrator further stated point-of-care (POC) documentation was only accessible for the previous 30 days.R101R101's quarterly MDS, dated [DATE], identified R101 had severe cognitive impairment and required assistance with ADLs. R101's diagnoses included hypertension (high blood pressure), renal failure (decreased ability of the kidneys to function), non-Alzheimer's dementia (a decline in memory, thinking, and the ability to perform daily activities from causes other than Alzheimer's disease), and malnutrition (inadequate nutrition to meet the body's needs).R101's care plan, printed 9/11/26, identified restorative PROM was to be provided to the left and right lower extremities during cares. An intervention, initiated 7/25/25, directed staff to provide restorative PROM to the BLE daily with cares. Additional interventions, initiated 4/27/26, directed staff to provide PROM to the bilateral upper and lower extremities daily for three sets of 10 repetitions and restorative PROM/active range of motion (AROM) exercises to the hips, knees, and ankles according to the exercise list in R101's room. The care plan also directed staff to provide bed mobility exercises consisting of rolling from left to right and moving from a lying position to sitting on the edge of the bed.The NAR group sheet, printed 9/9/26, directed R101 to receive PROM to the BLE daily during morning and bedtime cares for three sets of 10 repetitions.R101's FMP, dated 4/22/26, directed ROM exercises to the BLE, including the hips, knees, and ankles, for three sets of 10 repetitions. The FMP indicated the exercises were to be encouraged daily.R101's FMP task documentation from 8/10/26 through 9/10/26 directed restorative PROM/AROM exercises to the hips, knees, and ankles according to the exercise list in R101's room; bed mobility exercises consisting of rolling from left to right and moving from a lying position to sitting on the edge of the bed; and PROM to the bilateral upper and lower extremities daily for three sets of 10 repetitions. Of the 30 days reviewed, the FMP task was documented as completed on 8 days.R101's EMR lacked evidence of an FMP that identified the specific ROM exercises to be performed.During interview on 9/10/26 at 7:25 a.m., nursing assistant (NA)-D stated neither R8 nor R101 had ROM exercises to be completed.During interview on 9/10/26 at 10:41 a.m., registered nurse (RN)-F stated nursing assistants were responsible for completing and documenting residents' ROM exercises. RN-F stated when a resident had ROM exercises to be completed, the exercises would be posted in the resident's room to direct nursing assistants on which exercises to perform.During interview on 9/10/26 at 11:00 a.m., NA-C stated neither R8 nor R101 had ROM exercises to be completed.During interview on 9/10/26 at 11:10 a.m., registered nurse case manager (CM)-D stated nursing assistants were responsible for completing ROM exercises and documenting completion in the task documentation. CM-D stated R8 did not have any ROM exercises to be completed by staff. CM-D stated when a resident had exercises to be completed, the exercise program would be posted in the resident's room. CM-D confirmed there was no exercise program posted in R8's room and stated this indicated R8 did not have ROM exercises to be completed. CM-D also stated R101 did not have any ROM exercises to be completed by staff and confirmed there was no exercise program posted in R101's room.During interview on 9/10/26 at 12:50 p.m., the director of rehabilitation services (DRS) stated R8 had been discharged from therapy services the previous month and should have continued to receive ROM exercises to the bilateral lower extremities. The DRS described exercises for R8 that included single-leg lifts and gentle stretching of the lower extremities. The DRS stated residents' prescribed exercises had previously been posted in their rooms so staff knew which exercises to perform; however, the facility had instructed the DRS that the exercises were no longer to be posted. The DRS further stated FMPs had previously specified the number of sets and repetitions to be completed; however, the facility had instructed the DRS to discontinue writing the programs in that manner and instead document that PROM was to be completed during cares. The DRS stated R101 should have received exercises to the bilateral shoulders, including extension and flexion, and exercises to the BLE.During interview on 9/11/26 at 8:31 a.m., the director of nursing (DON) stated when a resident was identified with decreased ROM and/or weakness, staff were expected to notify therapy to determine whether a ROM program was appropriate. Therapy would then provide an FMP for the resident. The DON stated nursing assistants were expected to complete the prescribed ROM exercises, and the exercises should have been included on the nursing assistants' daily care sheets. The DON stated ROM exercises were important to help maintain the mobility of residents' joints. The DON stated the facility's FMP was not a good program and acknowledged there was a communication issue between departments and staff.A facility policy related to ROM and/or functional maintenance programs was requested but was not received.

Based on interview and document review the facility failed to verify and accurately transcribe orders for 1 of 3 residents (R1) when a blood pressure medication with conflicting dose and types were prescribed for R1 and then then transcribed incorrectly. Additionally, the facility failed to timely administer prescribed pain medication for 1 of 3 residents (R2) who was admitted post-surgically after a cervical (neck) spinal fusion.Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, with diagnoses that included heart failure, orthostatic hypotension (blood pressure that drops significantly when first sitting up or standing up), and stroke. R1's hospital Discharge summary dated [DATE] indicated R2 was prescribed metoprolol succinate (long-acting type) 50 milligrams (mg) twice daily, in the morning and bedtime. R1's facility orders indicated the following:Metoprolol succinate ER (extended release) 50 mg, give 1 tablet daily by mouth 12/13/25 to 1/16/25 at 8:00 a.m. Metoprolol succinate ER (extended release or long-acting), give 50 mg 1 tablet daily by mouth from 12/12/25 to 1/15/26 at 8:00 p.m. R1's December 2025 Medication Administration Records (MAR) indicated the following:Metoprolol succinate ER 50 mg was administered daily at 8:00 a.m., and at bedtime from 12/12/25 to 12/31/25, with one dose omitted 12/14/25 at bedtime with no reason for the omission documented. R1's cardiology provider note dated 1/15/26, indicated R1 entered the appointment prescribed metoprolol succinate 50 mg once daily and recommendations after the appointment included increasing the metoprolol succinate to 75 mg daily. R1's cardiology provider order from the cardiology clinic dated 1/15/26 indicated increase metoprolol succinate to 75 mg twice daily (BID), contrary to the dose recommended in the cardiology Provider Note. R1's facility orders indicated the following:Metoprolol succinate ER 24 hour sprinkles 25 mg, give 3 tablets by mouth two times a day 1/16/26 to 2/4/26. The progress notes lacked indication facility staff clarified the conflicting cardiology order and cariology provider note from the same visit, or clarified with the cardiologist the discrepancy in dosing with the admitting order from the hospital. R1's provider orders sent from the facility pharmacy to the facility dated 1/30/26 indicated metoprolol succinate ER 50 mg, take 1 tablet once daily. R1's facility orders indicated:Metoprolol succinate ER 24 hour sprinkles 25 mg, give 3 tablets by mouth two times a day 1/16/26 to 2/4/26 Metoprolol tartrate 50 mg, give 1 tablet by mouth daily 1/30/26 to 2/2/26 instead of metoprolol succinateMetoprolol tartrate 50 mg, give 1 tablet by mouth daily 2/3/26 to 2/5/26 The facility orders were clarified and corrected on 2/6/26 to:Metoprolol tartrate 50 mg, give 1 tablet by mouth daily 2/6/26 , instead of metoprolol succinate that was prescribed The progress notes lacked indication nursing staff clarified the conflicting and duplicate orders. R1's January and February MARs indicated both metoprolol succinate 75 mg BID and metoprolol tartrate 50 mg daily were given from 1/30/26 to 2/4/26, and doses of metoprolol succinate were given twice daily from 1/15/26 to 2/4/26 without clarifying the conflicting order of once daily versus twice daily. R1's January 2026 MAR indicated the following:Metoprolol succinate ER 50 mg was administered daily at 8:00 a.m., from 1/1/26 to 1/15/26.Metoprolol succinate ER 50 mg was administered daily at 8:00 p.m., from 1/1/26 to 1/14/26. Metoprolol succinate ER Sprinkle 25 mg, 3 tablets were administered daily at 8:00 a.m., and 4:00 p.m., except one dose was omitted on 1/30/26 at 4:00 p.m. Metoprolol tartrate [wrong form or metoprolol] 50 mg was administered one time at 6 p.m., on 1/30/26. R1's February 2026 MAR indicated the following:Metoprolol tartrate 50 mg was administered at 12:00 p.m. on 2/3/26 and refused on 2/4/26. Metoprolol tartrate 50 mg was administered at 6:00 p.m. on 2/1/26 and 2/2/26. Metoprolol succinate ER Sprinkle 25 mg, 3 tablets were administered at 8:00 a.m. from 2/1/26 to 2/4/26 and 4:00 p.m. from 2/1/26 to 2/3/26. Metoprolol tartrate was administered at 8:00 a.m. from 2/5/25 to 2/20/26. R1's provider progress note dated 2/10/26 at 2:09 p.m., indicated R1 received double the prescribed dose of metoprolol, with repeated symptoms of dizziness. During an interview on 1/26/26 at 8:36 a.m., R1 stated she didn't question her medications when they were administered but felt like she was getting sicker instead of better. R1 stated her cardiology provider told her she was getting the wrong dose of metoprolol, and the nurse practitioner (NP)-A, told her, she had been getting the wrong dose. R1 stated she was supposed to get metoprolol 50 mg once a day, and the dose was increased to 75 mg daily for a while but was getting 75 mg twice daily instead. R1 could not state what dates the changes occurred. During an interview on 2/27/26 at 10:38 a.m., the NP-A stated she remembered talking to R1 about her dizziness and there were duplicate orders for metoprolol which was an error. The NP-A stated she called R1's cardiologist to clarify the orders because R1 was taking metoprolol succinate 75 mg (a long-acting medication to manage blood pressure and heart rate typically given once daily) twice daily and should not have been. The order was changed to metoprolol tartrate (short-acting) 50 mg once daily because that was in error. The NP-A stated R1 did not appear to have severe adverse effects from the medication errors, had no blood pressure variations from the extra doses and no change in her heart rate, only some dizziness and lightheadedness which she had prior to the errors. During an interview on 2/27/26 at 11:47 a.m., licensed practical nurse (LPN)-B stated she noticed in February two doses of metoprolol were in R1's orders, one for 50 mg daily, and one for 75 mg twice daily, and stated R1 expressed concern about the medication dosing. The LPN-B stated she looked at the provider orders for changes and informed registered nurse (RN)-C of her concern. During an interview on 2/27/26 at 3:55 p.m. RN-C stated R1 was on the correct metoprolol dose from 12/12/25 until 12/30/25, but then a nurse received a telephone order from the cardiologist to decrease the medication from 75 mg twice a day to 50 mg once a day but didn't discontinue the 75 mg twice daily order. The process after for when a telephone order was received was to have another nurse and a nurse manager verify the orders, but that had not occurred. The nurses involved in the error were educated about the error and the process. RN-C acknowledged not seeing two different doses ordered by the cardiologist, both metoprolol succinate 75 mg daily and metoprolol succinate 75 mg daily. During an interview on 2/27/26 at 4:36 p.m., RN-A stated the error was when the medication order was entered into the medical record, with the wrong type of metoprolol; tartrate was ordered instead of succinate. RN-A acknowledged not knowing the difference between the two, but educated about the error on 2/26/26, a month after the error occurred. RN-A further acknowledged after the medication order was entered, he should have completed a progress note about the dose change to alert the other nurses but had not. RN-A stated R1 told him she had gotten both doses and had dizziness, which could have occurred as a result of taking more metoprolol than prescribed. Further RN-A stated the 2nd and 3rd verification checks for the telephone order had not occurred, and should have before the medication was administered to the resident but had not. During an interview on 2/27/26 at 1:35 p.m. pharmacist (PH)-A stated metoprolol succinate is an extended-release medication and is typically prescribed once daily. The PH-A stated R1 should not have gotten both metoprolol tartrate 50 mg daily and metoprolol succinate 75 mg twice daily. once dose should have been discontinued when the other started. Getting both doses could cause blood pressure to be too low and could cause dizziness and falls. During an interview on 3/3/26 at 11:53 a.m. the director of nursing stated the education started for R1's medication error on 2/26/26, to teach the difference between metoprolol succinate and metoprolol tartrate. The wrong dose and type would have unintended effects in the blood pressure, with potential for low blood pressure and falls. It was a transcription error that went unnoticed. R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had intact cognition, had diagnoses that included spinal stenosis (narrowing of the spaces within the spine which puts pressure on the nerves and spinal cord) of the cervical (neck) region and required active care at the facility for aftercare for surgery that involved fusion of the spinal bones. R2 received opioid pain medications as needed (PRN), and pain occasionally interfered with activities.R2's hospital discharge orders included:Oxycodone 5 mg every 4 hours as needed for pain. Tylenol 325 mg 2 tablets by mouth every 4 hours as needed for mild pain R2's initial admission nursing assessment dated [DATE] at 1:30 p.m., indicated R2 had occasional mild pain in the previous five days. R2's pain evaluation dated 1/28/26, indicated R2 had pain that occasionally affected sleep, therapy activities, and day-to-day activities, and administer Oxycodone 5 mg 1 tablet every 4 hours as needed (PRN) for pain. R2's baseline care plan dated 1/28/26 indicated intact cognition, pain/comfort issues, with a goal for adequate pain relief, and interventions that included non-medicinal forms of pain relief such as position, rest, and massage, and included pain medications as ordered by the physician. R2's provider orders dated indicated the following:1/28/26 at 11:30 a.m., acetaminophen 325 milligrams (mg), 2 tablets by mouth every 4 hours as needed for mild pain1/28/26 at 11:30 a.m., oxycodone HCl (narcotic pain medication administered for moderate to severe pain), 5 mg, 1 tablet by mouth every 4 hours as needed for pain R2's January 2026 MAR indicated the following:acetaminophen was not administered in January, although the progress notes on 1/29/26 at 9:47 p.m. indicated it was administered. Oxycodone was administered for the first time on 1/29/26 at 8:59 p.m. for pain rated as 7/10 and twice on 1/30/26 and 1/31/26 for pain rated between 7-10/10. [The January 2026 MAR indicated R2's pain was rated as 0/10 on 1/30/26 at 9:10 a.m., but during an interview on 2/27/26 at 4:36 p.m., registered nurse (RN)-A stated the pain rating was entered incorrectly and should have been entered as 10/10.]The MAR lacked indication oxycodone was administered again on 1/29/26 at 9:47 p.m., but the progress notes at that time indicated it was administered with acetaminophen and Flexeril (muscle relaxer). R2's progress note dated 1/29/26 at 7:53 p.m., indicated R2's family member requested pain medications for R2, for pain R2 rated as 7/10. The progress note indicated the nurse had to call a provider to request an order for oxycodone 5 mg. The progress notes lack indication the medication was available or administered prior to that date and time. Further the progress notes indicated oxycodone 5 mg was administered on 1/29/26 at 8:59 p.m., and again on 1/29/26 at 9:47 p.m., with acetaminophen and Flexeril for pain management, which was too early according to the every 4 hours as needed time frame in the order. During an interview on 2/26/26 at 11:29 a.m., with R2 and family member (FM)-A, R2 stated when he arrived at the facility his pain was constant, and would get harder at times, rated as an 8/10 or 9/10. It would get pretty damn hard. The FM-A stated R2 did not get pain medications until 1/30/26 but should have on 1/29/26. During an interview on 2/26/26 at 11:29 a.m., FM-A stated R2 came to the facility after surgery for fused spinal discs in his neck, and when R2 arrived the facility did not have R2's pain medication, oxycodone 5 mg, that was ordered. FM-A stated during a visit with R2 on 1/29/26 around 6:00 p.m., R2 was in pain. The FM-A stated, He shouldn't have had to wait for them [pain medications - oxycodone]. He was hurting so much. Further, FM-A stated R2 reported to her he had a terrible ride to the facility, and the facility did not have pain medication to help with the pain when he arrived. During an interview on 2/26/26 at 1:31 p.m., licensed practical nurse (LPN)-A stated when a resident was newly admitted , the process was the admitting nurse completed a form for the pharmacy to request medications, faxed the form with any required prescriptions to the pharmacy, and then the nurse called the pharmacy to ensure the pharmacy received the fax. The LPN-A stated the pharmacy delivers medications to the facility twice a day. Additionally, the LPN-A stated residents should not have to wait for pain medications because nurses can get narcotic pain medication from the facility medication bank with an access code provided by a pharmacist and a witness and did not know why R2 waited so long to get pain medication but it was an error to not have them. During an interview on 2/27/26 at 10:38 a.m., the NP-A stated if R2 had pain rated as 7/10 or higher, he would have had pain medications and would not be comfortable. NP-A stated the nurse could have called the pain team for a one-time dose and waiting over 24 hours for pain relief was too long, and NP-A thought the medication was available in the facility medication bank. During an interview on 3/3/26 at 11:53 a.m., the DON stated the process for obtaining pain medications upon admission was to get the hospital orders, review the orders, and if the orders didn't include required pain medication orders, to get an order from the hospital or the facility provider. The DON acknowledged a disruption in the process for obtaining pain medications upon admission for R2, and there were gaps in the process the nurses had not followed. It sounded like [R2] had pretty severe pain. A Medication Error Policy was requested and not provided.

Based on interview and document review the facility failed to report a change in condition to the provider and family for 1 of 3 residents (R2) when R2 had an acute episode of hypoxemia (low levels of oxygen in the blood characterized by symptoms that may include shortness of breath and bluish lips) during a combined physical and occupational therapy assessment. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition, R2 did not require oxygen or respiratory assistive devices, and had diagnoses that included chronic lung disease. R2's admission Data Collection (nursing assessment) dated 1/28/26 at 3:45 p.m., indicated R2's oxygen saturation rate on 1/28/26 at 2:26 p.m., was 96% on room air with a respiration rate of 18 breaths per minute, normal respirations, and R2 used a continuous positive airway pressure (CPAP) machine (used to treat sleep apnea - a condition where breathing repeatedly stops and starts during sleep). R2's provider orders dated 1/28/26, indicated CPAP machine on at night and for oxygen at 2 liters per nasal cannula to maintain oxygen saturation above 90%. R2's baseline care plan dated 1/28/26, indicated intact cognition and alteration in oxygen/gas exchange with interventions to monitor oxygen saturations as ordered and as needed (PRN), monitor for cyanosis (bluish or discoloration of lips caused by lack of oxygen), monitor and document on respiratory status, administer oxygen as ordered, and keep doctor informed of changes. R2's physical therapy (PT) assessment dated [DATE], and signed at 6:05 p.m., indicated R2 demonstrated signs of respiratory distress, the registered nurse (RN) was immediately informed, and R2 was placed on CPAP. R2's occupational therapy (OT) assessment 1/29/26, signed at 8:13 p.m., indicated R2's oxygen saturations fluctuated significantly with his lips turning blue during the evaluation, nursing was notified, and R2 was placed on CPAP. R2's progress notes from 1/29/26 at 11:52 a.m., to 1/30/26 at 9:17 a.m., lacked indication R2's provider or family were notified of the hypoxic incident. During an interview on 2/26/26 at 11:29 a.m., R2 stated on his second day at the facility (1/29/26), during therapy, he had a hard time breathing, a nurse assessed his oxygen saturation rate, and it was 66%, and the nurse put the CPAP on him as there was no oxygen in the room. During an interview on 2/26/26 at 2:46 p.m., family member (FM)-B stated when she visited R2 the evening of 1/29/26, R2 stated a nurse was in his room earlier because his lips were turning blue. The FM-B asked if nursing checked his oxygen again later, and R2 stated staff had not checked it again. A nurse went to assess R2's vital signs (VS) and stated the oxygen was low, at 89%, but not as low as earlier in the day. FM-B further stated the facility staff had not informed her of the hypoxic event, R2 did. During an interview on 2/27/26 at 11:47 a.m., licensed practical nurse (LPN)-B stated if R2's oxygen rate was at 66%, or 89%, the oxygen rate was low. The nurse should have documented the rate and notified the provider. LPN-B acknowledged the medical record lacked indication the provider was notified. During an interview on 2/27/26 at 2:13 p.m., registered nurse (RN)-B stated if a nurse intervened for a resident's low oxygen rate, the nurse should have notified the provider and the family. During an interview on 3/3/26 at 10:09 a.m., RM-D stated if a resident had a sudden low oxygen saturation, that was considered a change in condition, and a provider and family should have been notified. During an interview on 2/27/26 at 10:38 a.m., the nurse practitioner (NP)-A stated if R2 had an episode of O2 saturations of 66% she would have liked to be notified, and the family should have been notified. During an interview on 3/3/26 at 11:53 a.m., the director of nursing (DON) stated she would have expected the nurse to notify R2's provider and family of the change. The Notification of Changes policy dated 3/2024 indicated it is the policy of this facility that changes in a resident's condition or treatment be shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician).

Based on interviews and document review, the facility failed to assess and monitor 1 of 3 residents (R2) per the provider orders on admission and failed to comprehensively assess and monitor 1 of 3 residents (R2) after a change in condition when R2 participated in therapy, his lips turned blue and had a significant decrease in oxygen saturation rate. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had intact cognition, required no oxygen or respiratory assistive devices, and had diagnoses that included chronic lung disease. R2's baseline care plan dated 1/28/26 indicated intact cognition and an alteration in oxygen/gas exchange with interventions to monitor oxygen saturations as ordered and as needed (PRN), monitor for cyanosis (bluish or discoloration of lips caused by lack of oxygen), monitor and document on respiratory status, administer oxygen as ordered, and keep doctor informed of changes. R2's provider orders indicated the following:Starting 1/28/26 at 3:00 p.m., monitor vital signs every 4 hours for 24 hours for one day through 2/17/26 at 2:15 p.m. Starting 1/28/26 at 3:00 p.m., monitor for pain every shift through 2/17/26 at 2:15 p.m. Starting 1/28/26 at 3:00 p.m., chart the resident's condition in nurse's notes every shift for seven days Starting 1/28/26 at 3:00 p.m., check oxygen saturation levels every shift through 2/17/26 at 2:15 p.m. Starting 1/28/26 at 11:00 p.m., complete a Daily Skilled Note every night shift on Wednesdays and Sundays through 2/17/26 at 2:15 p.m. Starting 1/29/26 at 3:00 p.m., complete a Daily Skilled Note every evening shift on Tuesday, Thursday, and Saturday through 2/17/26 at 2:25 p.m. Starting 1/30/26 at 7:00 a.m., complete a Daily Skilled Note everyday shift on Monday, Wednesday, Friday through 2/17/26 at 2:15 p.m. R2's physical therapy (PT) assessment dated [DATE], and signed at 6:05 p.m., indicated R2 demonstrated signs of respiratory distress, the registered nurse (RN) was immediately informed, and R2 was given the CPAP (continuous positive airway pressure -used to keep the airway open during sleep). R2's occupational therapy (OT) assessment 1/29/26, signed at 8:13 p.m., indicated R2's oxygen saturations fluctuated significantly with lips turning blue during the evaluation, nursing was notified, and R2 was placed on CPAP. R2's oxygen saturation levels were documented in the electronic health record (EHR) as follows:1/28/26 at 2:26 p.m. at 96% on room air (RA)1/28/26 from 3-11 p.m., oxygen saturation levels were not assessed/recorded1/29/26 at 12:42 a.m. at 97% on CPAP 1/29/26 at 4:03 a.m. 93% on RA1/29/26 at 9:51 a.m., 91% per nasal cannula (NC)1/29/26 at 9:53 a.m., 93% on RA1/29/26 at 8:41 p.m., 91% on CPAP1/30/26 at 3:03 a.m., 94% on CPAPR2's oxygen saturation level documentation lacked indication of a decreased saturation level, reported during PT and OT assessments. Further, the record lacked indication of vital signs, which include oxygen saturation rates, were monitored every 4 hours, for 24 hours after admission, as ordered. R2's vital signs records indicated blood pressure, pulse, respirations, and temperature were assessed:1/28/26 at 2:26 p.m.1/29/26 at 12:42 a.m.1/29/26 at 4:03 a.m.1/29/26 at 9:51 a.m. R2's vital sign records indicated R2's pulse and respirations were also assessed on 1/29/26 at 2:28 p.m., but lacked evidence of temperature and blood pressure, or oxygen saturation rate. The records also lacked indication vital signs were assessed every four hours for 24 hours as ordered. R2's January 2026 Treatment Administration Record (TAR) lacked indication of the following:Daily Skilled Notes were completed as ordered on evening shift 1/31/26.Vital signs were entered on the TAR on 1/28/26 at 4:00 p.m. and 8:00 p.m. R2's progress notes R2's progress notes from 1/28/26 at 2:45 p.m., to 9:17 a.m., lacked indication any additional oxygen saturation rates were assessed, and lacked Daily Skilled Notes and nursing assessments on 1/30/26 and 1/31/26. R2's February 2026 TAR lacked indication of the following:Pain assessments every shift as ordered. Staff charted the resident's condition in nurse's notes every shift for seven days (through 2/3/26) as orderedOxygen saturation levels were checked every shift as orderedDaily Skilled Notes were completed as ordered During an interview on 2/26/26 at 11:29 a.m., R2 stated on his second date at the facility, 1/29/26, during therapy, he had a hard time breathing, a nurse assessed his oxygen saturation rate, and it was 66%, and the nurse put the CPAP on him. During an interview on 2/26/26 at 2:46 p.m., FM-B stated when she visited R2 the evening of 1/29/26, R2 indicated a nurse was in his room earlier because his lips were turning blue and FM-B asked if nursing checked his oxygen again later, and R2 stated staff had not checked it again. FM-B went to the nurse's desk to ask for staff to check R2's vital signs, and no one came for about 45 minutes, and then went to ask again, but was told the nurse was on a meal break. A nurse manager went to assess R2's vital signs (VS) and stated the oxygen was low, at 89%, but not as low as earlier in the day. FM-B could not recall who the nurse was who checked R2's VS. FM-B further stated there was no oxygen in R2's room on 1/29/26; it came on 1/30/26. During an interview on 2/27/26 at 11:47 a.m., licensed practical nurse (LPN)-B stated if R2's oxygen rate was at 66%, or 89%, the oxygen rate was low and the nurse who assessed him should have documented the low rate in the progress notes and notified the provider. LPN-B acknowledged the medical record lacked indication the event happened or the provider was notified. LPN-B further acknowledged R2's vital signs were not monitored as ordered, and oxygen saturation levels were not checked as ordered, and daily charting was not completed as ordered. During an interview on 2/27/26 at 2:13 p.m., RN-B stated R2 did not have daily skilled notes for 1/30/26 and 1/31/26, should have had progress notes charted every shift, but did not, and R2's vital signs and oxygen assessments were not performed as ordered. If the resident was not assessed, the resident and family would be concerned about his care. RN-B stated she was not aware R2 had a low oxygen saturation during therapy, but if a nurse intervened because of low oxygen, it should have been charted, and R2 should have had more frequent assessments afterwards, and acknowledged the incident and more frequent assessments were not documented. During an interview on 2/27/26 at 10:38 a.m., the nurse practitioner (NP)-A stated if R2 had an episode of O2 saturations of 66% she would have liked to be notified, and the family should have been notified. The NP-A stated the episode should have been documented if it was not. During an interview on 3/3/26 at 11:53 a.m., the director of nursing (DON) acknowledged R2's medical record lacked documentation of R2's hypoxic event and the nurse's interventions. The DON stated after R2's change in condition nursing staff should have completed an assessment, provided care as needed, called the provider and family, and would have expected further assessment and monitoring but there was no record that occurred. Further, the DON stated she would have expected orders were followed, and care provided per the provider orders. Polices for assessment and monitoring and for following orders as prescribed were requested but not provided.

Based on interview and document review the facility failed to sufficiently manage pain for 1 of 3 residents (R2) when R2 reported severe pain and was not provided with pain medications until more than 24 hours later.Findings include: R2's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition and a diagnosis that included spinal stenosis (narrowing of the spaces within the spine which puts pressure on the nerves and spinal cord) of the cervical (neck) region and required active care at the facility for aftercare for surgery that involved fusion of the spinal bones. R2 received opioid pain medications as needed (PRN), and pain occasionally interfered with activities. R2's baseline care plan dated 1/28/26, indicated intact cognition, pain/comfort issues, with a goal for adequate pain relief, and interventions that included non-medicinal forms of pain relief such as position, rest, and massage, and included pain medications as ordered by the physician. R'2s provider orders dated indicated the following:Dated 1/28/26 at 3:00 p.m., monitor for pain daily, every shift through 2/17/26 at 2:15 p.m.Dated 1/28/26 at 11:30 a.m., acetaminophen 325 milligrams (mg), 2 tablets by mouth every 4 hours as needed for mild painDated 1/28/26 at 11:30 a.m., oxycodone HCl (narcotic pain medication administered for moderate to severe pain), 5 mg, 1 tablet buy mouth every 4 hours as needed for painDated 1/28/26 at 3:00 p.m., use non-pharmacological pain interventions including ice, heated blankets, massage, repositioning, music, essential oils, food/drink, and relaxing/breathing. Document interventions used.R2's January 2026 Medication Administration Record (MAR) indicated the following:acetaminophen was not administered in January, although the progress notes on 1/29/26 at 9:47 p.m., indicated it was administered.Oxycodone was administered for the first time on 1/29/26 at 8:59 p.m. for pain rated as 7/10 and twice on 1/30/26 and 1/31/26 for pain rated between 7-10/10. [The January 2026 MAR indicated R2's pain was rated as 0/10 on 1/30/26 at 9:10 a.m., but during an interview on 2/27/26 at 4:36 p.m., registered nurse (RN)-A stated the pain rating was entered incorrectly and should have been entered as 10/10.]The MAR lacked indication oxycodone was administered again on 1/29/26 at 9:47 p.m., but the progress notes at that time indicated it was administered. R2's January 2026 Treatment Administration Record (TAR) indicated R2's pain was rated as follows:1/28/26 during the 11-7 p.m. shift rated as 7/101/30/26 during the 7-3 a.m. shift rated as 2/10All other shifts through the 11-7 p.m. shift indicated pain was rated as 0/10.The TAR further indicated the only non-medicinal pain intervention offered on 1/28/26 for pain rated as 7/10 was food and drink. R2's January 2026 pain assessment log indicated pain ratings as follows:1/29/26 at 2:41 p.m. rated as 7/101/29/26 at 8:59 p.m. rated as 7/10 R2's progress notes indicated the following:1/28/26 progress notes lacked documentation about pain assessments1/29/26 at 7:53 p.m., indicated a family member was at the nursing desk requesting pain medications for R2. Family reported R2's pain level was rated as 7/10, which meant from experience, it was really meant 9/10 because R2 had, Learned to live through pain. A nurse assessed R2's pain, which R2 rated as 7/10, and the nurse then called the on-call provider to request an oxycodone prescription be sent to the pharmacy so the nurse may pull the medication from the facility's medication bank.1/29/26 at 8:59 p.m., indicated oxycodone 5 mg was retrieved from the mediation bank and administered to R2 for pain.1/29/26 at 9:47 p.m., oxycodone 5 mg was retrieved from the medication bank and administered with acetaminophen and Flexeril (muscle relaxer).1/30/26 at 2:04 a.m., oxycodone 5 mg During an interview on 2/26/26 at 11:29 a.m., with R2 and family member (FM)-A, R2 stated when he arrived at the facility his pain was constant, and would get harder at times, rated as an 8/10 or 9/10. It would get pretty damn hard. During an interview on 2/26/26 at 11:29 a.m., FM-A stated R2 came to the facility after surgery for fused spinal discs, and when R2 arrived, the facility did not have R2's pain medication, oxycodone 5 mg, that was ordered. FM-A stated during a visit with R2 on 1/29/26 around 6:00 p.m., the R2 was shouldn't have had to wait for oxycodone. He was hurting so much R2. FM-A added, he had a terrible ride to the facility, and the facility did not have pain medication to help with the pain when he arrived.During an interview on 2/26/26 at 1:31 p.m., licensed practical nurse (LPN)-A stated when a resident was newly admitted , the admitting nurse completed a form for the pharmacy to request medications, faxed the form with any required prescriptions to the pharmacy, and then the nurse calls the pharmacy to ensure the pharmacy received the fax. The LPN-A stated the pharmacy delivers medications to the facility twice a day. Additionally, the LPN-A stated residents should not have to wait for pain medications because nurses can get narcotic pain medications from the facility medication bank with an access code provided by a pharmacist and a witness and did not know why R2 waited so long to get pain medication.During an interview on 2/26/26 at 2:47 p.m., FM-B stated when she visited on 1/29/26, R2 had not had pain medications, and a nurse was trying to get them for him. He admitted [DATE] and didn't have pain relief or medication available. FM-B stated R2 reported pain at a rating of 9/10, or 10/10, and didn't want to move around or eat due to the severe pain and had pressed his call light an hour prior to the arrival of family to request pain medications but hadn't gotten them as of the time of the family visit.During an interview on 2/27/26 at 2:13 p.m., RN-B stated she saw R2's FM-A at the nurse's desk on 1/29/26 but didn't normally work at that station. RN-B went with the FM-A and assessed R2's pain, and the FM-A was adamant R2 was uncomfortable and the pain was usually more than R2 stated. R2 rated his pain as 7/10, in his head not his neck, and RN-B told the FM-A she would check to see what R2 had ordered for pain medications. RN-B stated R2's oxycodone was not in the facility because of a miscommunication about the prescription but was able to order the medication from pharmacy. RN-B stated she instructed the unit nurse (she didn't recall who), R2 could have acetaminophen and Flexeril. RN-B stated with pain rated as 7/10, she would not offer non-pharmacological relief first and further stated R2 should have gotten pain relief on 1/28/26 and should not have had to wait until 1/29/26. RN-B did not recall giving another dose previously without charting it. Additionally, RN-B stated when R2 had unmanaged pain, he could have required rehospitalization. The process for obtaining a narcotic prescription was for a nurse to check for the prescription upon admission, and if it is not present, or is not complete, the nurse would call the hospital or the on-call provider to get a prescription. If the resident was not being assessed, or the pain was not managed, the resident and family would be concerned about his care. During an interview on 2/27/26 at 10:38 a.m., the nurse practitioner (NP)-A stated if R2 had pain rated as 7/10 or higher, he would have had pain medications and would not have comfortable. NP-A stated the nurse could have called the pain team for a one-time dose, waiting over 24 hours for pain relief was too long, and NP-A thought oxycodone 5 mg was available in the facility medication bank. NP-A stated she was not notified that the staff couldn't get the pain medication. During an interview on 3/3/26 at 11:53 a.m., during an interview the director of nursing (DON) stated when residents were admitted , they typically came with orders, the facility admitting nurse reviewed the orders, and if pain medications were required but not ordered, the nurse would get an order from the provider. The DON acknowledged there was a disruption in the process for R2 to get pain medications timely, and there continues to be gaps in the process the facility nurses are not following. The DON stated nurses had education about the process, but still had a medication error afterwards, so were still not following the process.The Pain Management protocol dated 3/23/23, indicated a review of each resident's diagnoses and conditions was conducted that commonly cause or predispose to pain, with a review of individual pain upon admission. The staff and provider will identify the location, intensity, frequency, pattern and severity of pain, and observe the resident during rest and movement for evidence of pain. Nursing staff would identify situations or interventions where an increase in pain may be anticipated. The resident's care plan would reflect the pain management needs. If the prescribed medications were not available or there was a delay in obtaining the medication, the provider will be notified, and alternative medications or interventions would be obtained to meet the resident's pain management needs.

Based on interview and document review, the facility failed to ensure a medication was available for administration for 1 of 3 residents (R1) reviewed for medication errors. This resulted in immediate jeopardy (IJ) when R1 was not administered physician prescribed anti-seizure medication which resulted in hospital intensive care unit (ICU) admission for medical management and treatment. The IJ began on 1/17/26 when the facility failed to ensure R1 received scheduled dose Lacosamide (anti-seizure medication) on 1/17/26, 1/18/26, and 1/19/2026 (six doses) and an additional dose not administered on morning of 1/20/26 this caused R1 to have 3 seizures over the span of 7 minutes resulting in hospital ICU admission where R1 remains. The administrator, the director of nursing, and the regional director of operations were notified of the IJ on 1/27/26 at 4:40 p.m. The facility had implemented actions to prevent recurrence prior to the survey therefore, the citation was issued at past non-compliance (PNC).Findings include:R1's admission record dated 4/26/24, identified R1's diagnoses included encephalopathy (any dysfunction of the brain that alters mental state, causing symptoms like confusion), seizure disorder, and generalized weakness.R1's hospital Discharge summary dated [DATE], identified R1's primary admitting diagnoses included status epilepticus, seizure disorder, alcoholic dementia, and metabolic encephalopathy.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, administered anti-seizure medication and was independent for toileting, transfer, and mobility.R1's activity of daily living (ADLs) care plan dated 2/12/25, indicated R1 required anti-seizure medication to be administered as ordered by the provider. Additionally, it directed staff to ensure a position to prevent injury during seizure activity, open airway, and document characteristics. ADLs care plan dated 2/12/25, directed staff to monitor neurological status after any activity for residual impairment and notify the provider of any seizure activity.R1 Physician orders included:-Lacosamide Oral tablet 200 mg. Give 1 tablet by mouth two times a day for uncontrolled seizures (start date 6/17/25.)-Monitor for seizure activity: unusual smells, tastes, sounds, or sensations, Nausea, intense fear and panic, sensation in certain parts of your body, jerky movement in of the arm, leg, or body, weakness and falling to the ground: Every shift (start date 6/16/25) January 2026 Medication Administration Record (MAR) identified R1 did not receive either scheduled dose of Lacosamide oral 200 mg on 1/17/26, 1/18/26, and 1/19/26 (six doses) with notations the medication was not available. Additionally, on 1/20/26 the 8:00 a.m. dose was also not administered. The record identified three different nurses did not administer the doses. In review of R1's record between 1/16/26 through 1/20/26, there was no indication R1's physician was notified nor evident the pharmacy was notified the doses were not administered and/or none available to administer according to the physician order. January 2026 Treatment Administration Record (TAR) identified the physician order to monitor for seizure activity with corresponding checked mark boxes with nurses' initials indicating the task was complete. Review of R1's record which included progress notes did not include the results of the monitoring associated with this task nor was it evident of increased monitoring for signs and symptoms of seizure activity after the prescribed doses of Lacosamide were missed.R1's progress note dated 1/20/26 at 11:31 a.m., indicated when R1 was non-responsive and tremoring, the provider onsite ordered her to be sent to the hospital.R1's hospital admission notes dated 1/20/26 identified R1 was admitted to the intensive care unit (ICU) at the hospital with seizures activity and concern for status epilepticus, requiring intubation on ventilator for airway protection. The note further indicated R1 had been out of Lacosamide (an anti-seizure medication) for the past three days as it had not been available. R1's head computed tomography (CT) scan identified R1 was found to have a thin subdural hemorrhage versus [NAME] thickening along the left cerebral convexityR1's late entry progress note dated 1/20/26 at 1:33 p.m. for 1/16/26 at 1:31 p.m., indicated licensed practical nurse (LPN)-A noticed R1's seizure medication was low so she called and left a voicemail to the provider but did not hear back from the provider before the end of her shift. R1's late entry progress note dated 1/20/26 at 1:30 p.m. for 1/17/26 at 1:31p.m. indicated R1's seizure medication was not delivered, LPN-A called and left a voicemail to the provider. R1's late entry progress note dated 1/20/26 at 1:30 p.m. for 1/19/26, indicated LPN-A left two messages for the provider and did not get a return call back. R1's late entry progress note dated 1/20/26 at 2:15 p.m. for 1/19/26 at 3:58 p.m., indicated staff called the pharmacy to reorder R1's seizure medication which would be delivered on the first run.Attempts were made to interview LPN-A on 1/26/26 at 3:30 pm and again on 1/27/26 at 11:50 a.m., which were not answered, no return phone call was received. During an interview on 1/26/26 at 3:38 p.m., LPN-B stated he cared for R1 the evening shifts of 1/17/26 and 1/18/26. LPN-B stated R1 was supposed to get her seizure medication (Lacosamide 200 mg) two times a day. He could not find the medication in the cart, so he did not give the evening scheduled dose on 1/17/26 and 1/18/26. LPN-B did not notify the pharmacy or the provider or the nurse manager for further directions. LPN-B explained he should have called the pharmacy and the provider but was busy and forgot. LPN-B asserted he did not give any report to the night nurse to follow up and monitor R1 for seizure episodes. Additionally, LPN-B was suspended on 1/20/26 pending the investigation and received re-education regarding medication administration.During an interview on 1/27/26 at 11:04 a.m., LPN-C stated after getting a report on 1/19/26 about anti-seizure medication not available from the day shift nurse, she called the pharmacy to reorder the medication, and the pharmacy confirmed its delivery for that night. LPN-C stated anti-seizure medication arrived as she was leaving the facility. She did not give any report to the night nurse regarding R1 and did not notify the provider, so the anti-seizure medication was not given on 1/19/26. She was terminated on 1/25/26. A packing slip summary dated 1/19/26 indicated R1's Lacosamide 200 mg was delivered on 1/19/26 at 9:00 p.m.During an interview on 1/27/26 at 12:03 p.m., a registered nurse (RN)-A stated she cared for R1 on 1/20/26 in the morning and found R1 very sleepy, difficult to arouse so she determined it was not safe to administer medications which included the anti-seizure medication. RN-A notified the provider onsite of R1's change in condition. RN-A explained she had not been informed R1 had missed three days of anti-seizure medication.During an interview on 1/27/26 at 12:46 p.m., RN-B, unit manager, stated LPN-C shared with her on 1/20/26 about R1 missing anti-seizure medication for three days. After R1 was sent to the hospital, RN-B found 10 anti-seizure tablets (Lacosamide 200 mg) in the medication cart. RN-B expected nurses to contact the pharmacy when a medication was unavailable and notify the provider as well as the nurse manager if doses were not administered; these procedures were not followed in this case. During an interview on 1/26/26 at 3:03 p.m., a pharmacist (PH-A) stated she could not find any electronic request for the seizure medication (Lacosamide 200mg) on 1/17/26 and 1/18/26. The pharmacy had a prescription on file to supply the facility upon request, so there was no need for new script from the provider. PH-A explained that residents who missed an anti-seizure medication should be monitored for seizure episodes to prevent complications such cardiac issues and even stroke. During an interview on 1/27/26 at 10:05 a.m., a nurse practitioner (NP-A) stated she did not have any record about the facility notification regarding the seizure medication not available nor a refill request. NP-A stated on 1/20/26, RN-A alerted her R1 was having change in condition and when she went to the room to evaluate R1, she found R1 actively seizing. NP-A observed three seizures episodes within seven minutes before the emergency medical services (EMS) arrived to transport her to the hospital. NP-A explained the complication for R1 not having her seizure medication could result in brain injury or even death. She expected nursing staff to notify the medical team regarding any seizure medication not available.During an interview on 1/27/26 at 1:17 p.m., the director of nursing (DON) stated when he got the report about anti-seizure medications not administered, the interdisciplinary team initiated an incident investigation. The facility identified R1 missed three days (6 doses) of prescribed seizure medication (Lacosamide 200 mg). R1 experienced a change of condition and was sent to the hospital on 1/20/26. The DON explained staff failed to obtain the medication from the pharmacy resulting in missed doses, did not update the provider when doses were missed. Additionally, nurses did not follow re-order procedure of medications and follow up was not completed to ensure timely delivery of medication. The DON reported they had identified three nurses involved, interviewed, and suspended them pending the investigation. All residents receiving anticonvulsant medications for seizure disorder were identified and reviewed for any missed doses and full house medication administration re-education for nurses and the TMAs (trained medication aide) was initiatedMedication Ordering/Medication Not Available policy dated January 2026 required all nurses and TMAs (Trained Medication Aide) to follow the medication ordering procedure when a medication is running out and/or unavailable. If the medication is down to 3 days or less, the nurse should verify that the medication has been reordered.Medication and treatment orders' policy indicated orders for medication and treatments will be consistent with principles of safe and effective order writing.The facility put the following corrective measures in place and was verified as completed: -LPN-A, LPN-B and LPN-C were suspended pending investigation and re-education was provided on 1/20/26.-The facility reviews their policy and procedure for safe medication and developed a plan to ensure a sufficient supply of medications for residents for timely administration on 1/20/26.-All residents with seizure medications were reassessed to ensure their safety on 1/20/26.-The facility began re-education and competencies test to nursing staff to ensure compliance of medication administration on 1/20/26On 1/26/26 through 1/27/27 staff were interviewed and were able to articulate the ordering procedure when a medication is running out and /or unavailable. This deficient practice is being cited at past Non-compliance.

Based on interview and record review, the facility failed to review and revise the comprehensive care plan in a timely manner following a verbal altercation for 1 of 3 residents (R2) reviewed for abuse. This failure placed R2 at risk for psychosocial distress and potential recurrence of resident-to-resident conflict.Findings include:R2's hospital Discharge summary dated [DATE], identified R2 diagnoses included severe recurrent major depression (MDD) and neurocognitive deficits.R2's associated clinic of psychology note dated 12/22/25, identified R2 diagnoses included posttraumatic stress disorder and major depressive disorder, recurrent episode, moderate.R2's activity of daily living (ADLs) care plan dated 3/7/25 indicated R2 was at risk for decreased cognitive related to PTSD (post traumatic syndrome disorder) and MDD. ADLs care plan dated 3/10/25 directed staff to monitor for signs of emotional distress or mood and behavior changes and safety monitoring will be implemented as needed to ensure residents safety. ADls care plan dated 3/10/25 directed staff to utilize trauma informed care when working with the resident. The care plan dated 3/10/25 identified triggers as unannounced visitors and no male attendees, nightmares, and flashbacks.IncidentReview of an alleged incident report dated 1/16/26 outlined R2 was involved in a verbal altercation with another resident (R3). The report indicated R3 became visibly upset, raised his voice, and R2 asked him to leave the room. R3 continued yelling in the hallway toward the nursing station, requiring staff intervention. Review of R2's care plan showed no evidence the facility reviewed R1's comprehensive care plan following the altercation, no documentation of updated interventions addressing triggers, supervision needs, conflict-prevention strategies, or psychosocial follow up. No documentation of a care plan meeting or interdisciplinary review since the incident on 1/16/26.During an interview on 1/21/26 at 4:30 p.m., R2 stated she did not feel safe in the facility because people continued entering her room without knocking. R2 reported on 1/16/26, R3 entered her room and displayed aggressive behavior by putting his fingers in her face, which triggered her PTDS and caused fear for her safety. During an interview on 1/22/26 at 2:38 p.m., R3 stated on 1/16/26, he knocked before entering R2's room to visit her roommate. R3 reported R2 became rude and threatened to call the police. R3 stated he became upset and left the room. R3 denied being aggressive toward R2 and reported he continued to knock and open the door slightly so his friend could come out for smoke break after the incident.During an interview on 1/21/26 at 3:50 p.m., a nursing assistant (NA)-A stated she did not recall receiving an education recently on trauma-informed care. NA-A explained she was not aware of an incident between R2 and R3 but realized R2 stayed in her room for the most part. Staff typically separate residents and initiate 15-minute safety checks after altercations. NA-A asserted she was not aware of any recent review of R2's care plan.During an interview on 1/22/26 at 1:26 p.m., a registered nurse (RN)-B, the unit manager stated when staff made her aware of the altercation between R2 and R3 on 1/16/26, she went in the unit while R3 was still yelling in the hallway. RN-B explained R2 reported R3 put his fingers in her face, invading her personal space. RN-B stated R3 reported R2 was the aggressor, being rude and wanted to call the police on him which R2's roommate confirmed. RN-B explained she instructed R3 not to return to the room and to call his friend instead for smoke break. RN-B stated she did not update R2's care plan with new interventions addressing triggers, supervision needs, conflict -prevention strategies, or psychosocial follow-up following the altercation.During an interview on 1/27/26 at 1:17 p.m., the director of nursing (DON) explained the care plan should have been reviewed and revised after an altercation incident to address triggers, supervision needs, and other safety measures. The DON stated he did not recall any care plan meeting or interdisciplinary (IDT) review following the altercation.The facility Trauma Informed care policy dated 2/24/23 showed staff were required to add goals and interventions to the care plan for the residents with a history of trauma to address potential triggers and approaches to minimize or eliminate their effects. The policy directed the interdisciplinary team (IDT) to monitor the effectiveness of interventions and update the care plan as needed.

Based on interview and document review, the facility failed to comprehensively and accurately re-assess, develop and implement interventions to reduce/prevent significant and continued weight loss for 1 of 3 resident (R2) reviewed for weight loss. This resulted in actual harm when R2 was hospitalized for malnutrition. Findings Include: Center for Medicare & Medicaid Services (CMS) considers weight loss ‘significant' if it exceeds 5 percent (%) within one month, 7.5% within three months, or 10% within six months. R2's admission Minimum Data Set (MDS) assessment dated [DATE], identified an admission date of 3/13/25, indicated R2 was severely cognitively impaired and had diagnoses of cerebral palsy, depression, and enlarged prostate know as benign prostatic hyperplasia (BPH), obstructive uropathy (blockage hindering urine flow), and Rhabdomyolysis (muscle breakdown). R2 weighed 147 pounds, received a mechanically altered diet, was not on a weight prescribed regimen, and a box was marked yes for weight loss of 5% or more in the last month or loss of 10% or more in the last six months. The MDS documented R2 had no issues with swallowing, was dependent on staff for all cares including eating, hygiene, and mobility. Care Areas triggered were cognitive loss, visual function, communication, urinary catheter, psychosocial well-being, mood, behavior, falls, nutritional status, pressure ulcer, and psychotropic drug use. R2 received antipsychotics, antidepressants, and antianxiety medications. R2's Nutrition Care Area assessment dated [DATE], was triggered due to significant weight loss and altered diet. It lacked identification of care plan considerations and included a note to refer to nutrition evaluation for additional information. R2's Clinical Nutritional Evaluation dated 3/15/25, identified R2's weight as 147.8 pounds with a usual weight of 160 pounds, no weight loss or gain of 5 percent (%) or more in the last month, body mass index (BMI) as greater than 30 indicating obese, had a regular diet, difficulty chewing, intake at 26-50%, took supplements twice a day, and required staff assistance with feeding. A report titled IDT Care Conference dated 3/26/25 identified nutrition concerns as low/sporadic meal consumption.R2 was on a regular diet with modified thick liquids and weighed 143 pounds.The note identified R2 was totally dependent on staff for all needs.R2's record lacked documentation for additional quarterly care conferences. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R2 used a wheelchair, was dependent on staff for all mobility, cares and eating, weighed 138 pounds, and required a mechanical and therapeutic diet. R2's provider orders included a house supplement (magic cup) twice a day from 3/15/25-7/6/25 and were documented as given 17 times out of 226 opportunities. R2's provider orders also identified weekly weights were ordered 3/17/25-3/24/25. R2 was weighed one time out of two opportunities during this period.R2's provider orders identified weekly weighs were ordered 3/26/25-4/16/25.R2 was weighed one time out of four opportunities during this period.R2's provider orders identified weekly weights were ordered 4/23/25-7/19/25.R2 was weighed five times out of fifteen opportunities. R2's medical record identified the following weights (in pounds): 3/15/2025 14:21147.8 3/16/2025 13:10147.8 3/20/2025 15:45143.0 3/31/2025 09:21141.0 4/17/2025 13:15139.0 4/23/2025 10:54136.4 5/1/2025 12:55135.2 5/28/2025 14:37138.0 6/12/2025 14:38132.2 6/25/2025 15:41128.2 7/23/2025 14:44127.6 7/24/2025 14:44126.0 R2's was seen by the medical director on 4/6/25, 5/14/25, and 6/18/25, and the provider visit notes described R2 as pleasantly confused with no distress a satisfactory appetite.The record lacked documentation related to weight loss. An Associated Clinic of Psychology (ACP) note dated 6/18/25, identified R2 as calm and relaxed throughout the session.R2 reported frequent hunger and consumed a snack during the session.R2 denied any stressors outside of feeling hungry. R2's nutrition care plan focus dated of 6/19/25, identified a nutritional risk due to dysphagia and hot liquids.Goals included weight gain, intake greater than 50%, and no adverse incident related to hot liquids.The interventions included total assist of one with eating and drinking, obtain weights weekly and as needed, offer adequate fluids at and between meals, supplements per MD order, provide assist with meal intake, and speech therapy to consult as needed. A report titled Clinical Nutritional Evaluation dated 7/6/25, identified R2's weight as 128.2 pounds and height as 65 inches tall, with a usual weight of 160 pounds, no weight loss or gain of 5% or more in the last month, BMI greater than 30 indicating obese, regular diet, difficulty chewing, intake at 26-50%, took supplements, and required staff assistance with feeding. R2's progress note dated 7/6/25, indicated a weight warning was triggered and weight was 128.2 pounds, and the registered dietician increased supplements from twice per day to three times per day. R2's orders to give supplements three times a day from 7/6/25-7/12/25, were documented as given three times out of 21 opportunities.Documentation indicated R2 refused three times during this period. R2's Census information identified he was in the hospital from [DATE] to 7/19/25. R2's Transfer Information document dated 7/19/25, indicated R2 was admitted to Methodist hospital on 7/12/25 for malnutrition and failure to thrive and treated for a urinary tract infection (UTI) and weakness.During the hospital stay R2 was given antibiotics and referred to a dietician.The hospital note identified R2 as a patient with moderate malnutrition in context of acute illness/injury.The results of abdominal imaging dated 7/13/25, revealed no medical reason for weight loss, no evidence for occult malignancy or CT findings to explain the patient's symptoms or weight loss.The document indicated R2 required additional resources due to the degree of malnutrition during the hospital stay.The hospital dietitian recommended in discharge orders for strawberry boost in the morning and at night with daily snacks, updated food preferences, and high calorie- high protein eating. R2's hospital weight on 7/13/25 was recorded as 115 pounds and 11.9 ounces, which was a 21.7% weight loss from R2's admission to the long-term care facility and indicated severe weight loss. R2's Census information indicated he returned to the facility on 7/19/25 and discharged on 7/30/25 to another care setting. During an interview on 8/4/25 at 12:03 p.m., dietary aid (DA)-A stated nutrition supplements were brought up from the kitchen and passed to the residents by the nursing assistants with meals if the dining ticket had a supplement ordered. Extra supplements were brought up from the kitchen and given to the nurses to store at the nurse's station for snacks in between meals. During an interview on 8/4/25 at 12:08 p.m., nursing assistant (NA)-B stated if a resident needed a nutritional supplement it was printed on the dining ticket, and nursing assistants passed the supplements along with the meal tray.If a resident was allergic or refused the supplement the nurse would be notified. During an interview on 8/4/25 at 12:20 p.m., registered nurse (RN)-B stated ‘mighty shakes' were liquid and ‘magic cups' were frozen, and both came up from the kitchen and were served with meals.If the supplement was ordered to be given between meals, the kitchen sent up the supplements, but no labels identified who the supplements were for, and the nurses knew who was supposed to receive them.RN-B stated a provider would be notified of weight loss only if there was a three-to-five-pound loss.The nursing assistants were responsible for weighing residents and recording the weights in a binder located at the nurse station.RN-B stated the nurses reviewed the logs daily for weight loss; however, no parameters were printed on the logs to instruct staff regarding when to notify the manager or provider.RN-B confirmed if a resident was losing weight month after month the nurse would be aware but couldn't confirm if the dieticians reviewed the weight logs or used the recorded weights in the medical records to discuss at care conferences. During an interview on 8/4/25 at 12:27 p.m., RN-C confirmed when a resident returned from a hospitalization and their discharge orders recommended nutritional supplements or other interventions the dietician would get involved.All supplements were documented on the treatment assessment record (TAR) and the nurse manager would be informed if a resident consistently refused.RN-C stated If a resident refused meals or consumed less than 50% of their meal the chart was flagged, and the entire team would monitor for weight loss.The provider was notified if there was a significant decrease in weight by the dietician or nurse manager. RN-C stated the resident should be weighed at the same time and in the same manner each time, and the entire team monitored for weight discrepancies. During an interview on 8/4/25 at 1:00 p.m., registered dietician (RD)-C stated if nutrition supplements were ordered with meals they were served with the meal tray, but supplements were also stocked on the floor and served as a snack.The supplement would be labeled with the resident's name.RD-C stated preferences were discussed at care conferences and if a resident didn't like the supplement or if they refused the supplement many alternatives were offered including snacks.RD-C indicated if a resident was losing weight, a weight warning would be triggered in the electronic health record when they lost 5% or greater.The team would discuss the weight loss, and the nurse manager would notify the provider. A nutritional assessment was completed for R2 on 3/15/25 & 7/6/25.RN-C confirmed the weight warning triggered on 7/6/25 and indicated a 5% decrease over 30 days.R2's record lacked additional interventions implemented until 7/23/25, when another weight warning was identified.RD-C confirmed a high calorie supplement was ordered for R2 after the hospital stay dated 7/12/25-7/19/25, but confirmed the record did not reflect R2 received the additional supplements. During an interview on 8/5/25 at 9:04 a.m., registered nurse (RN)-A stated it was the NA's responsibility to pass the supplements.RN-A stated weights were documented, and if weight was triggered for significant weight loss the provider was notified.The nurse manager was responsible for notifying the provider who would consult with the dietician and order labs to rule out illness and would then identify likes and dislikes with food or the root cause for the appetite being down.The family was notified only if there was a definite decline in weight.RN-A stated when residents returned from the hospital the discharge summary was reviewed, and any provider orders were implemented.RN-A stated R2 had weight loss, the family was consulted, and the family offered ideas to stimulate appetite such as finger foods but confirmed R2's record lacked documentation of these interventions. RN-A confirmed R2's weight loss was documented, and the care plan was not updated to implement personalized interventions but would expect nutrition interventions should have been implemented with continued weight loss.RN-A confirmed the provider was never notified of R2's weight loss. During an interview on 8/5/25 at 9:54 a.m., family member (FM)-A, FM-B, and FM-C, FM-A stated R2 was 165 pounds while living at home in March of 2025.During a care conference on 3/26/25, R2 was 145 pounds. FM-B stated the primary discussion during the care conference was about R2's weight loss and approximately 90-120 minutes was spent discussing interventions.FM-B stated the social worker confirmed to them R2 received a nutritional supplement, Ensure, and when the family requested additional Ensures, they were told, well he gets one.FM-B denied the nurse manager discussed any type of personalized interventions such as finger foods.FM-C stated they visited approximately five weeks later in 6/4/25, and R2 weighed approximately 135 pounds, was alarmingly thin, and cognitively altered.FM-C stated the facility notified R2's wife on 7/11/25, R2 hadn't eaten for the past two days and wasn't taking any medications. They stated when they visited at 4:00 p.m. on 7/12/25, R2 was lying in bed and appeared to have lost 30 pounds, was massively dehydrated, and cognitively altered.They stated staff were unable to tell the family R2's current weight, and indicated staff were directed to push fluids, but were unable identify or locate any protocol, and unable to determine if they had pushed any fluids.FM-C stated given R2's altered behavior, how staff couldn't determine a current weight, or if orders were followed, family called 911.They stated R2 was admitted to Methodist hospital from [DATE] to 7/19/24, for malnutrition, failure to thrive, and dehydration, and was treated for a urinary tract infection (UTI).FM-C stated after 24 hours of antibiotics the infection started to clear, R2 was hungry and began eating and drinking. FM-A stated the family was aware R2 had lost weight but didn't know the extent until the day they called emergency services on 7/12/25. During an interview on 8/5/25 at 10:58 a.m., nurse practitioner (NP)-B stated the facility would notify them of resident concerns by phone or leave a post it notes if they were onsite, and stated notifications were not always documented in a progress note.NP-B could not recall meeting with R2 regarding weight loss or whether staff notified them specifically about weight loss but was aware sometimes R2 would indicate he was hungry, but when food was offered continued refusing.After reviewing R2's medical record, NP-B confirmed there should have been a notification if there was a ten-pound weight loss and NP-B would have implemented interventions such as labs to rule out illness or decreased renal function, prescribed appetite stimulants, or referred R2 to ACP. NP-B confirmed staff first notified the on-call nurse practitioner on 7/11/25, when R2 wasn't eating or taking medication.NP-B stated other interventions for weight loss could have been implemented sooner, including neuro-psych testing and medications, hospice, or feeding tubes, though not ideal, but in hindsight additional interventions should have been applied due to the weight loss. During an interview on 8/5/25 at 11:12 a.m., LPN-A stated the provider, or family would be notified if weight triggered a warning for significant weight loss of 5% or more.LPN-A stated weekly weights were the standard and should be done on bath day.LPN-A confirmed R2 had an order, but R2's record lacked documentation of weekly weights.LPN-A stated R2 transferred to the unit in April 2025, and no interventions for weight loss would be implemented until a weight warning was triggered.LPN-A indicated R2 first triggered for weight loss on 7/24/25.LPN-A stated there was not a concern for the other weights in R2's medical chart because they were not triggered in the electronic record for significant weight loss, but LPN-A had noticed a downward trend.LPN-A would not notify the provider unless it met the weight loss parameter of three pounds per day or five pounds per week but could not identify what document was used for that guidance.LPN-A recalled feeding R2 breakfast three to five times per week and recognized there were times R2 wouldn't eat breakfast but did finish all lunches.LPN-A had no other concerns after the hospitalization in July because R2 was eating on and off.LPN-A stated R2 only had one care conference during the thirteen-week stay at the facility and confirmed the care plan lacked personalized interventions due to the system not triggering weight loss until July. During an interview on 8/5/25 at 12:00 p.m., the DON stated staff should review all weekly weights, identify any decrease in weight, and any resident with weight loss should be discussed at the daily meeting.The provider should be notified, interventions for nutrition such as supplements or offering extra snacks should be implemented, and staff would document this in a progress note.DON indicated some residents refused everything offered but were encouraged with more snacks depending on their diet, however staff should monitor consumed meals and notice if a resident wasn't eating and if their weight had decreased.DON stated they had witnessed R2 tell staff he was hungry and then refuse to eat when staff attempted feeding, but could not identify what, if any, interventions were attempted relating to this behavior. The DON stated R2's weight was discussed during their initial care conference, however the record lacked documentation of that discussion. The DON confirmed R2 had an order for weekly weights and stated staff should have recognized R2's gradual 20-pound weight decrease even without the triggered warnings in the electronic health record. DON stated staff should have added new individualized interventions to the care plan to increase R2's weight upon identification of the weight loss and/or during quarterly care conferences, but no quarterly care conference took place. Staff also should have updated the provider, and DON verified there were no provider notifications regarding weight loss, nutrition, or refusing to eat or take medications until 7/11/25, prior to the hospitalization at Methodist Hospital.The DON stated R2's weight loss was a combination of deconditioning and a UTI that led to the hospitalization on 7/12/25. The facility Weight Policy dated 5/1/24, identified the registered dietitian (RD) and or responsible party shall be notified of weight changes at the discretion of the IDT. The RD shall review residents who trigger for significant weight gain or loss. Significant is defined as a person with 5% weight change over 30 days, 7.5% weight change over 90 days, or 10% weight change over 180 days. The IDT and or facility designee shall review weights for significant weight changes and will be discussed to determine individualized care plan interventions and documented in the electronic medical record. Facility policy, Notification of Change dated 3/24, identified nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the residents and or their representative and the resident's physician to ensure best outcomes of care for residents.Significant change in status-deterioration in health, mental or psychosocial status in life threatening conditions or clinical complications.

Based on interview and record review, the facility failed to monitor and notify the physician following a change in condition for one of three residents, (R1) who had multiple episodes of vomiting that began on [DATE] and continued through [DATE] when R1 died . This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE] when R1's had a change in condition was not monitored, nor was the physician notified of R1's change in condition that started on the evening of [DATE] and continued through the morning of [DATE] when R1 passed away. The IJ was identified on [DATE]. The administrator and the director of nursing were notified of the immediate jeopardy at 10:47 a.m. on [DATE]. The immediate jeopardy was removed on [DATE] and the deficient practice was corrected on [DATE], prior to the start of the survey and was therefore past non-compliance. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder. R1's additional diagnoses included esophageal varies with bleeding, dysphagia, cognitive communication deficit, schizophrenia, peptic ulcer without hemorrhage or perforation, and personal history of a traumatic brain injury. R1's care plan dated [DATE] did not indicate R1 had a history of gastrointestinal (GI) bleeding, history of vomiting, or concerns with stomach problems. R1's minimum data set (MDS) dated [DATE] indicated R1 required substantial/maximal assistance with dressing and transfers, dependent upon staff for bathing and hygiene, and partial/moderate assistance with oral hygiene. MDS indicated R1 did not experience vomiting. MDS indicated R1 did not reject evaluation or care. R1's provider orders for life-sustaining treatment (POLST) dated [DATE] indicated R1 did not want resuscitation (DNR) if she did not have a pulse and was not breathing. The POLST indicated R1 wanted comfort-focused treatment and to allow natural death. R1's brief interview for mental status (BIMS) assessment dated [DATE] indicated R1 had a score of fourteen, which indicated R1 was cognitively intact. R1's vital sign documentation indicated licensed practical nurse (LPN)-C took R1's vital signs on [DATE] at 9:40 p.m. Those readings included blood pressure was ,d+[DATE], oxygen was 97% on room air, pulse was 88, respirations were 18, temperature was 97.8 on the forehead. Normal blood pressure is ,d+[DATE] to ,d+[DATE]. Normal temperature is 97.8 to 99.1. Normal Pulse is 60 to 100. Normal respirations are 12 to 18. Normal oxygen is 95% to 100%. R1's medical record indicated no nursing progress notes for [DATE]. R1's progress note dated [DATE] at 9:02 p.m. indicated R1 stated she did not feel well, had an upset stomach, and refused to eat dinner. R1 had two episodes of vomiting and her abdomen was slightly distended. R1 had a large bowel movement and stated she felt better. The progress note indicated the licensed nurse heard bowel sounds in all four quadrants, blood pressure was ,d+[DATE] temperature was 97.8 degrees Fahrenheit, pulse was 85, respirations were 18, and oxygen was at 92% on two liters of oxygen. The note indicated licensed nurses would continue to monitor R1. R1's medical record indicated no nursing progress notes for the remainder of [DATE] nor the morning of [DATE] until 6:17 a.m. R1's electronic medication administration record (eMAR) dated [DATE] at 5:22 a.m. indicated R1 was vomiting. R1's medication administration record (MAR) dated [DATE], indicated R1 was to receive omeprazole at 6:00 a.m. but LPN-A documented 9 which meant other-see nursing note. R1's progress note dated [DATE] at 6:17 a.m. indicated R1 refused to have her incontinent brief changed. R1's progress note dated [DATE] at 10:24 a.m. indicated the director of nursing (DON) arrived and checked on R1, noting black emesis after postmortem care was completed. The DON swabbed R1's mouth, washed her face, helped the nursing assistants (NA) change her bedding, and notified the funeral home that R1 was ready to be transferred to the funeral home. R1 left the facility at 12:30 p.m. R1's progress note dated [DATE] at 2:42 p.m. indicated a NA reported to the licensed nurse at 7:30 a.m. that R1 had vomited when the NA was getting her up for the morning. The licensed nurse responded immediately and found R1 in her wheelchair and leaning forward with a NA supporting R1's back. The vomit looked coffee in color and smelled metallic. The licensed nurse asked NAs to put R1 back to bed for a better assessment. R1's vital signs were checked but were not reading and the licensed nurse placed a call to emergency services regarding R1's condition. The paramedics arrived around 8:30 a.m. and they pronounced R1 deceased . R1's emergency medical services (EMS) report dated [DATE] indicated EMS received a call at 8:07 a.m. indicating EMS staff was called for someone who was vomiting. The report indicated EMS arrived at the facility at 8:14 a.m. and got to R1 at 8:20 a.m. Upon arrival, EMS noted R1 was in her bed in her room with a towel tucked in her shirt and had black emesis on the towel and on her shirt. Facility staff stated that a nurse went to check on R1 and was found that she was not speaking when she usually spoke. The facility staff reported R1 had been vomiting. The report indicated facility staff gave EMS staff paperwork, including R1's POLST form. The last time facility staff checked on R1 was at 7:30 a.m. and had not spoken since that time. EMS staff noted R1 to be pale, cold to the touch, did not find a radial or carotid pulse, and was not breathing. Rigor had not set in yet as R1's jaw was malleable. EMS staff noted R1 to be a DNR and therefore had not started cardiopulmonary resuscitation (CPR). EMS placed a four-lead electrocardiogram (ECG) on R1 at 8:26 a.m. to assess R1's cardiac rhythm and determined R1 deceased . During an interview on [DATE] at 8:49 a.m., NA-C stated he worked with R1 on [DATE]. He asked R1 if she wanted to get up for the day and she verbally said yes. He asked R1 if she could grab the grab bars on her bed to assist herself in turning over so that NA-C could change her incontinent brief and she did. R1 usually said more in the mornings and could usually verbalize what she wanted. Once he got R1 in her wheelchair, she began vomiting black coffee stuff and he reported R1's vomiting episode to LPN-E. NA-C stated LPN-E went to R1's room and then she called EMS. When LPN-E called EMS, trained medication assistant (TMA)-A attempted to take R1's vital signs. Once paramedics got to the facility, they had pronounced her deceased . During an interview on [DATE] at 10:49 a.m., nurse manager (NM)-A stated her expectation is licensed nurses would notify the physician after every change in condition episode. She would be concerned about a change in condition when R1 was not feeling good on [DATE], she was vomiting on [DATE], and then died . She was unsure whether the licensed nurses notified the physician about R1's episode of vomiting overnight on [DATE] into [DATE]. NM-A stated she would expect the licensed nurse to notify the physician about a change in condition when the change in condition happens. She considered episodes of vomiting on and off for months a change in condition and the physician should be notified. NM-A stated she did not get a report on [DATE], [DATE] or [DATE] that R1 had been vomiting. NM-A stated she usually received a report about the residents when a change in condition happened. During an interview on [DATE] at 11:16 a.m., LPN-A stated she worked the overnight hours on [DATE] into [DATE]. She received report from LPN-D that R1 had vomited on the evening shift. She requested for NA-A to clean R1 up and after that, R1 had been resting. LPN-A stated she only saw R1 twice that shift. At 5:22 a.m. R1 had an order for omeprazole to be given at 6:00 a.m., but LPN-A had held it from R1 due to the report LPN-D had given her about R1 vomiting on the evening shift. LPN-A stated she wrote an eMAR note stating R1 had been vomiting. She did not notify the physician about R1 vomiting because she was told LPN-D had already notified the physician. She wrote a progress note at 6:18 a.m. on [DATE] that R1 had refused to have her incontinent brief changed but it did not concern LPN-A because R1 was able to make her needs known. She did not assess R1 after she had vomited throughout her shift because she was really busy with other residents yelling at each other and a phone call. LPN-A stated R1's episodes were out of her baseline and thought it was a change in condition. During an interview on [DATE] at 11:22 a.m., nurse practitioner (NP)-A stated R1 had an extensive history with GI bleeds. She was notified that R1 had been vomiting only after R1 had died . Last time she was updated about R1 was on [DATE], and that was about R1 being constipated. She is usually notified from the facility via phone, but the facility also had her pager in case of an emergency. She was concerned that the facility had not notified her about R1's vomiting. NP-A stated if she would have been notified about R1's episodes of vomiting on [DATE], she would have recommended R1 go to the hospital immediately. During an interview on [DATE] at 12:07 p.m., DON stated she received a phone call after R1 had passed on [DATE] and after EMS had left the facility. She did not recall what time she received the phone call. She arrived at the facility to assist with postmortem care. The DON further stated R1's first episode of vomiting, should have warranted a change in condition. Her expectations with a change in condition would be to assess vital signs at a minimum, assess the resident, notify the physician, and notify the family. Her expectation was that after every episode of change in condition, the physician would be notified, and those orders and recommendations would be followed. Her expectation was when the licensed nurses talk with family about the residents change in condition, the licensed nurse would give their recommendations if they were waiting for a physician to call back or state the recommendations from the physician. Licensed nurses would also ask the family their preferences about the resident being sent to the hospital and if they are ok with that. DON stated her expectation was after every change in condition, the licensed nurses would put a nursing order in for licensed nurses to check vital signs every four hours for the next twenty-four hours. Any of the licensed nurses could enter those orders since it is a nursing order. Her expectation was the licensed nurse would round on the resident at least every two hours. DON stated she found it concerning when the licensed nurses did not notify the physician after each episode of vomiting. During an interview on [DATE] at 1:00 p.m., LPN-D stated she worked the evening of [DATE]. R1 was at her baseline prior to dinner. At dinner, R1 refused to eat dinner, had an upset stomach, and stated she wanted to go to bed. R1 had vomited around 7:00 p.m. R1's vomit was brown in color but could not describe any more. LPN-D stated we cleaned R1 up after she vomited. This was not unusual for R1 to vomit. NA-C reported to her that R1 had a large bowel movement and had felt better. LPN-D stated R1 had vomited again around 8:00 p.m. LPN-D stated R1's vomit was brown in color but could not describe any more. She took R1's vital signs and they read within normal limits. She also assessed R1's bowel sounds because she had thought R1 was constipated. She did not notify the physician about R1's vomiting on [DATE] because it was not unusual for her to vomit. LPN-D stated after she took R1's vital signs at 8:00 p.m. she did not continue to monitor R1 because she got too busy. During a subsequent interview on [DATE] at 1:07 p.m., DON stated LPN-D had assessed R1 on the evening shift on [DATE] but she would have liked to have known what color the emesis was. She would have liked to see the licensed nurses assess R1 more. If the licensed nurses had continued to monitor R1, they would have put in nursing orders to take vital signs every four hours for the first twenty-four hours. The licensed nurses should have laid eyes on R1 at least every four hours. During an interview on [DATE] at 1:35 p.m., the administrator stated when a resident had a change in condition her expectation was the licensed nurse would monitor the resident, put monitoring nursing orders in, put a progress note in, and state what change of condition occurred. The administrator stated the physician would be notified of a change in condition along with the on-call supervisor, DON, and herself. During a subsequent interview on [DATE] at 2:40 p.m., LPN-A stated she did not recall what times R1 had vomited on her overnight shift on [DATE] to [DATE]. She held R1's 6:00 a.m. omeprazole dose due to the report she received about R1 vomiting during dinner time on the evening shift on [DATE]. LPN-D reported to LPN-A she had called the physician to report R1's vomiting episodes and the physician had recommended R1 to be monitored overnight. She would have expected LPN-D to put a progress note in the medical record about her conversation with the physician but did not look to see whether there was a progress note entered or not. She trusted LPN-D when she said she had notified the physician. She checked on R1 twice on the overnight shift on [DATE] to [DATE] but could not recall the times she checked on her. She checked on R1, when she was giving medications to other residents by slowly walking past R1's room. LPN-A stated both times she walked past R1's room, she had been sleeping. LPN-A stated she never went in R1's room during her shift. At 5:22 a.m. when she wrote the eMAR note about R1 vomiting, LPN-A stated she never attempted to give R1 her omeprazole dose because LPN-D recommended not to give R1 any medications. After her shift ended on the morning of [DATE], she gave report to LPN-E that R1 had vomited twice during her shift and LPN-D had reported R1's episodes of vomiting on the evening shift on [DATE]. LPN-A stated she was terminated from the facility two hours prior to this interview. She was terminated from the facility due to not following the charting procedures. LPN-A stated the last day she worked at the facility was on [DATE]. During a subsequent interview on [DATE] at 3:00 p.m., the administrator stated the facility investigated R1's death and concluded the licensed nurses did not assess or document the change in condition. The administrator stated LPN-A was placed on a leave during the investigation and was terminated from her position. During an interview on [DATE] at 9:56 a.m., LPN-E stated when she got to the facility on [DATE] at 6:30 a.m., she worked on a different unit. She was transferred to R1's floor around 7:15 a.m. where she received report from LPN-A that R1 had been vomiting all night. She asked LPN-A how she monitored R1 throughout the night and LPN-A did not respond. After she received report, and she started passing medications to residents. NA-C reported to her around 7:30 a.m. stated R1 had been vomiting and she was not looking good. She stopped passing medications and went to R1's room where she found R1 sitting in her wheelchair and was vomiting. R1's vomit looked like black coffee grounds. NA-D was supporting her back while she was vomiting. She requested to NA-C and NA-D to put R1 back in her bed so that she could assess her. Instead of assessing R1, she called EMS immediately. While she was calling EMS, she had instructed TMA-A to take R1's vital signs. After she got off the phone with EMS, LPN-E went to R1's room and attempted to take her vital signs but they did not read. R1 did not have a pulse but she was still breathing. R1 was not responding to her. Once EMS arrived around 8:00 a.m. they had pronounced her deceased . During an interview on [DATE] at 10:14 a.m., NA-A stated she was new to the facility and was still getting to know the residents. She worked with R1 during her overnight shift [DATE] into [DATE]. When she started her overnight shift on [DATE], she noted R1's call light was on. She went to R1's room where R1 stated she was not feeling well. She asked R1 if she wanted her to get LPN-A and R1 stated no. NA-A stated even though R1 had said she did not want NA-A telling LPN-A, NA-A told LPN-A that R1 was not feeling well. NA-A stated LPN-A stated R1 was not taking Zofran anymore, so she could not give it to R1. NA-A stated throughout the night during rounds, she would check on R1 to see if she had vomited. She had vomited several times throughout the night. NA-A stated the vomit was small and dark in color. R1 had vomited on her nightgown, so NA-A would have to assist R1 in changing her nightgown. NA-A stated she would give R1 a towel to vomit on. When she came back for the next round to check on R1, she would need to change her nightgown again and give her a new towel because she had vomited again. She told LPN-A throughout the night that she was concerned about R1 vomiting and didn't look good. NA-A stated she knew that the facility has sent other residents to the emergency department before, so NA-A knew that would be an option. Before the end of her shift on the morning of [DATE], she made sure R1 had a clean gown on. She worked directly with R1 overnight on [DATE] into [DATE]. When she started her overnight shift on [DATE], R1 did not have her call light on but NA-A had checked on her. R1 looked worse than she did on [DATE]. She told LPN-A again that R1 seemed to be worse than the night before and that is when LPN-A stated again that she could not give her anything because she was not prescribed Zofran. R1 had vomited several times during her shift. NA-A stated R1 would vomit on her blanket and pillow. The vomit was black in color. NA-A stated she brought R1 new sheets and new towels. During the last rounds of her shift, she had noted R1 looked way worse than she did earlier in the night. Before the end of her shift on the morning of [DATE], R1 was still vomiting. R1 was still able to talk and move. NA-A asked R1 if she wanted her to change her nightgown and R1 would take off her nightgown for her. She changed R1's incontinent brief throughout the night except when she refused once. R1 did not state why she refused to have her incontinent brief changed but noted she looked very uncomfortable. She reported R1's condition to the oncoming licensed nurse about R1's condition but could not recall the licensed nurse's name. NA-A stated she reported to the oncoming NA's about R1's condition but could not recall the NA's names. During a follow up interview on [DATE] at 11:38 a.m., LPN-A stated she remembered during her overnight shift on [DATE] into [DATE] that NA-A had told her something but she had forgot about it. She did not remember exactly what NA-A told her but R1 had not been feeling good. She was too busy working with other residents that she did not go into R1's room and assess her during her shift. LPN-A stated she did not recall if she told the oncoming morning shift on [DATE] about R1's condition. During an interview on [DATE] at 8:50 a.m., NA-A stated R1 started vomiting on [DATE] at 10:30 p.m. NA-A stated she was unsure whether R1 had been vomiting during the day on [DATE] but as soon as she got to the facility for her overnight shift on [DATE], R1 had already been vomiting. During an interview on [DATE] at 10:12 a.m., TMA-A stated on the morning of [DATE] he received report from LPN-A that R1 had been vomiting overnight. NA-C was getting R1 up for the day and once NA-C got her in her wheelchair, she began vomiting. He attempted to get R1's blood pressure and it could not read it. He could not find a pulse on R1. He did get an oxygen reading and that reading read sixty-two percent while on two liters of air. LPN-E instructed him to turn R1's air flow to four liters. TMA-A stated LPN-E called EMS. When EMS arrived, they pronounced her deceased . The facility's notification of changes policy and procedure dated ,d+[DATE] indicated changes in a resident' condition or treatment be shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The policy stated, nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: provided education to the licensed nurses from [DATE] through [DATE] on NA's charting needs to be done prior to the end of their shift, report to the nurse if NA's feel as though there is a change in the resident, and the NA feels as though something is not being addressed by the licensed nurse, to follow up with the NM or DON. Education was provided to the licensed nurses indicating nurse's assessments needing to be completed and physician notification needs to be done immediately. The audit indicated there was no orders for monitoring, the Physician was notified, a progress note was completed, and resident assessments were completed.

Based on observation, interview and document review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 residents (R1) reviewed for missing person/elopement. This resulted in immediate jeopardy when R1 exited the facility and was found on the ground on near a street intersection on the sidewalk by law enforcement (LE)-A, late at night. The facility was unaware of R1's absence from 11:20 p.m. until 11:47 p.m. which placed him at risk for serious harm, impairment, or death. The immediate jeopardy began on 4/29/23 at 11:20 p.m., when R1 left the facility unsupervised and was found at 11:47 p.m., outside the facility on the on the ground by law enforcement (LE)-A. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 5/16/23, at 4:41 p.m. The facility immediately implemented corrective action on 5/1/23 prior to the survey and was issued at Past Noncompliance. Findings include: R1's progress note dated 5/23/22, indicated staff met with R1 about a recent self harm incident over the weekend. R1 reported that he self-harmed because he spaced out after trying to remove the wander guard. The note included, the need for a wanderguard as resident has a history of going outside in the evening without (appropriate) clothing. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses of nontraumatic intracerebral hemorrhage of the brain stem, seizure disorder, difficulty walking, agnosia (loss of the ability to identify objects using one or more senses), generalized muscle weakness, cerebral infarction (stroke), and psychiatric disorder. R1 is not cognitively impaired, independent with activities of daily living (ADLs), used a walker for mobility, was occasionally incontinent of urine, and had two falls without injury since the previous assessment. Further identified R1 was administered antipsychotic medication. R1's ADL care plan dated 11/20/20, identified R1 was ambulatory with four wheeled walker. R1's fall care plan dated 11/20/20, identified R1 was at risk for falls related to seizures and stroke. Further identified R1 had three falls since 2/21/23. R1's care plan dated 12/14/20, informed staff R1 had impaired thought process related to unspecified mental disorder to known physiological condition R1's communication care plan dated 1/21/21, identified R1 had hearing impairment. He required communication through writing and directed staff to use ADL cards, approach resident face to face, and provide white board or note pad. R1's activity care plan dated 5/13/21, informed staff R1 had weakened muscles with some paralysis and also had neurological neglect of one side of his body. R1's behavior care plan dated 12/16/21, indicated R1 needed frequent checks to determine resident needs and offer assistance if needed (12/30/21). Monitor/assess for delusional thinking, paranoia, and inform nurse manager/social services of changes to mood behavior (2/6/23). R1's care plan dated 3/14/23, indicated R1 refused assistance for cares, yelled at staff, and setting self down on the floor. R1's wandering care plan dated 4/18/23 identified R1 had a history of wandering due to episodic confusion/impaired cognitive function related to history of organic mood disorder and paranoia. Corresponding interventions included complete wander/elopement risk assessment quarterly/as needed to assess risk and assist resident to exercise regimen per physical/occupational therapy. R1's psychotropic medication care plan dated 12/14/23, identified R1's target behaviors as confusion, irritability, and agitation. R1's physician order dated 2/14/23, included R1's Wanderguard to be removed and document any behaviors in a nurse progress note every shift for 7 days; end date of 2/21/23. R1's Elopement Risk Evaluation dated 2/15/23, identified R1 had a habit/history of wandering or attempts to leave the building, was ambulatory, had diagnoses of a cognitive disorder. R1's antipsychotic medications, history of calling the police, somatic complaints, and history of self-harm was not identified as a risk factor on the assessment. The evaluation indicated R1 had a risk score of '3'. The evaluation tool directed if the score was 4 or greater include elopement plan. R1's progress note dated 2/15/23, indicated interdisciplinary team (IDT) met to review current status and elopement risk. Elopement risk assessment indicated R1 was low risk for elopement. R1 had not exhibited behaviors indicating risk since last quarter. IDT concluded trial removal of wanderguard at this time. Monitoring would be completed for seven days. There was no indication an assessment for on-going interventions was developed or implemented after the seven day monitoring had ended. R1's Elopement Risk Evaluation dated 3/4/23, was inconsistent with the evaluation dated 2/15/23. Indicated R1 did not have a habit/history of wandering or attempts to leave the building and identified R1 currently taking medications that caused confusion. The evaluation did not identify a history of somatic complaints or self-harm. The section labeled additional considerations was blank. R1's elopement risk was scored as a level '3'. R1's elopement care plan dated 4/18/22, indicated R1 was at risk for elopement related to impaired cognition, episodic confusion, and independently mobile with interventions to reduce the risk of elopement with a wander alert attached to right side of walker was discontinued on 3/14/23. R1's Wander/Elopement Risk Evaluation dated 4/10/23, indicated R1 was physically able to leave the building and was ambulatory with a walker. R1 was a risk for wandering/elopement however the section labeled Summary was blank. R1's evaluation lacked evidence staff included interventions or had revised the care plan to address R1's risk for wandering/elopement. R1's psychology visit note dated 4/24/23, indicated the physician had made the decision to increase R1's Zyprexa (antipsychotic medication) to 20 milligrams (mg) due to his delusional thinking that is somatic in nature. R1 reported his mood was stable and was strong on his feet. R1 was getting out of bed and walking again. This is a very positive change. A police report, dated 4/30/2023 at 12:53 a.m., included law enforcement (LE)-A was completing a routine patrol of the area surrounding the facility. On 4/29/23 at 11:47 p.m. LE-A observed a male (R1) on the ground with his walker and was at the corner of a street intersection. The male appeared in distress and was waving LE-A over. A nurse saw LE-A's squad emergency lights and came out (of the facility). She (nurse) stated [R1] is a resident there and he must have snuck out. The report indicated R1 had requested to go to the hospital for unknown an medical reason and complained his bed linens were always soiled. R1 was walked back into the facility to wait for emergency medical services (EMS). Once inside the facility LE-A asked the facility supervisor how it was possible [R1] who could barely walk was able to make it out of his room in Unit [unit number specified] on the second floor and walk out to the location that he was found. The supervisor stated he must have not locked the front door. LE-A took pictures of R1's room which appeared filthy. There were ants on the floor along with feces stains, his bed was soiled, and the room smelled of feces. On 4/29/2023, the temperature in St. Louis Park, MN was 45 degrees Fahrenheit (F) at 11:53 p.m. per the national weather service. On 5/15/2023, the surveyor observed the distance between the point R1 was found by Law Enforcement (LE)-A and the facility main entrance which was approximately 80 yards. R1's progress note dated 4/30/2023 at 2:45 a.m., Licensed Practical Nurse (LPN)-A indicated R1 had become agitated at an unspecified time and requested facility staff contact 911. R1's vital signs were stable. R1 started yelling at LPN-A to leave his room after she informed R1 he seemed to be okay and would need a reason to call an ambulance. LPN-A stated she intercepted R1 in the facility parking lot, where he fell on to his bottom and police happened to be driving by. The progress note indicated LE-A contacted paramedics and R1 was subsequently transported to the hospital for further evaluation. R1's representative was contacted who requested he resumed wearing his wanderguard. R1's Elopement Risk Evaluation dated 4/30/23, identified a risk score of 7 which directed staff to include an elopement care plan. Documentation indicated R1 was at risk for elopement, goals included, R1 will not leave the building, and family will be kept informed. The section Wander guard in place was not documented, however in the Additional Comments sections documentation included, Resident to resume use of wander guard. R1's Readmit Data Collection dated 5/1/23, indicated R1 was readmitted from the hospital with a closed non-displaced fracture of anterior process of right calcaneus (prominence on the heel bone). R1's progress note dated 5/2/23, included IDT met to review resident fall outside facility. Resident was sent to acute care hospital after being found. Team met to review R1's behavior of exiting the facility. After communication with power of attorney, it was determined that R1 would be more appropriate on a secure unit. R1's progress note dated 5/9/23, included R1 continues to have sporadic episodes of requesting to go to the hospital. Elopement risk completed with a score of 4.0. physician was notified of the same with orders received and a wander guard applied to resident's walker. Staff will continue to monitor and initiate frequent check with rounds at nigh and as needed. R1's revised care plan for wandering on 5/9/23, indicated the following interventions: Monitor R1's whereabouts every 2 hours. Document any noticed wandering behavior and attempted diversional interventions. R1's trigger for wandering/eloping were needing to go to the hospital. R1 behaviors can be de-escalated by offering coffee/snacks of choice, and getting family involved. During an interview on 5/12/2023 at 10:52 a.m., LE-A stated he had been patrolling the area on the night of 4/29/2023 at approximately 11:45 p.m. and was waved over by R1 who was sitting on the ground. LE-A stated R1 was located on the sidewalk of the northeast corner of Texas Ave S and 28th St W, before the entrance of the facility parking lot. LE-A stated there were several bystanders from the neighborhood, but no facility staff present. LE-A indicated he exited his squad car, helped R1 to stand, then returned to his squad car to turn on his emergency lights. LE-A stated he was with R1 for approximately 30-60 seconds before he noted LPN-A exiting the facility front doors. LE-A indicated when he spoke to LPN-A, she had stated they knew R1 had left his unit but were unaware R1 had left the facility. LE-A stated he does not know how long R1 had been outside the facility without supervision. R1's psychiatric visit note dated 5/8/23, indicated staff reported R1 left the building at night, wanting to go to the hospital, and fell while outside. He is currently on a secured unit pending cognitive screenings. R1 displayed some challenges with recall regarding hospitalization . During an interview on 5/15/2023, at 11:07 a.m., NA-C stated R1 had been agitated since approximately 10:00 p.m. on 4/29/2023, and had been using his call light to request assistance and contacting the police with unspecified concerns. NA-C notified LPN-A about R1's concerns. NA-C stated NA-E had told LPN-A R1 was not allowed outside the facility without supervision. NA-C stated neither she nor NA-E were made aware of any issues with R1 until LE-A arrived on the unit. During an interview on 5/9/23 at 3:07 p.m., and 5/15/23 at 1:18 p.m., LPN-A indicated on 4/29/23, R1's agitation and behavioral disturbances began around 10:00 p.m. LPN-A stated R1 was insistent on contacting the police but would not provide a medical concern for her to assess. LPN-A indicated R1 walked past the nurses station and got on an elevator shortly after midnight. R1 was wearing a long-sleeved collared shirt and shorts. LPN-A stated she was unaware R1 could not be in the community by himself. During an interview on 5/10/2023 at 9:46 a.m., the Director of Nursing (DON) stated R1 needed to be accompanied to all appointments by a family member or staff. The DON stated R1 was not safe to leave the facility independently. A facility policy titled Elopement Guideline, dated 2/27/2023, stated documentation of an elopement event must include all attempts to locate the resident and time specific entries detailing the initiation and results of these efforts. The policy states there should be a unit-wide search for the resident and the Administrator should be notified of the elopement. The policy indicates a facility-wide search should be completed, followed by a thorough search of the facility grounds involving all available facility staff. The immediate jeopardy that began on 4/29/23, was removed on 5/1/23 before the survey and was issued at Past Non-Compliance when the facility implemented the following: Completed an assessment of R1 for wandering, confusion, anxiety, paranoia, and behaviors that increased R1's risk for elopement. The facility updated R1 care plan to include a wanderguard on R1's walker, frequent checks, and identified triggers and intervention to decrease R1's behaviors associated with leaving the facility, and placed in a secure unit. All staff were educated on elopement policy, and code white missing person procedures. Licensed nursing staff were educated on how to complete a comprehensive assessment and care plan interventions for resident at risk for elopement.

Based on observations, interview, and document review, the facility failed to provide supervision and implement timely interventions for safety for 2 of 4 residents (R1, R7) reviewed for accidents. This resulted in harm to R1 who was known to smoke with oxygen running and sustained facial burns, and R7 with a history of substance abuse had a change in behavior, barricaded himself in his room for many hours without staff intervention and was hospitalized related to a drug overdose. Findings include: R1's face sheet dated 2/11/19, indicated [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], indicated R1 had moderately impaired cognition. An admission progress note dated 1/27/19, at 9:52 p.m. indicated R1 was noted to be a smoker and was on oxygen at 2 liters with a portable tank. The referring paperwork from the hospital dated 1/27/19, indicated R1 was a smoker of several packs a day. A smoking assessment dated [DATE], at 7:20 a.m. indicated R1 had skills to be an independent smoker, and followed the smoking rules. There was no additional assessment for smoking completed until 2/4/19. On 1/29/19, at 10:00 a.m. a progress note by licensed practical nurse (LPN)-A indicated R1 was found outside smoking with oxygen running, a wanderguard for the portable oxygen tank was indicated as an intervention, but was not able to be located. No other interventions were implemented. On 1/29/19, at 2:00 p.m. LPN-A documented in a progress note R1 continued to go outside and smoke with portable oxygen tank on. LPN-A educated R1 of the danger and again noted no wanderguard was available. No other supervision was implemented. The initial care plan dated 1/30/19, indicated R1 was at risk for smoking related to oxygen use, the interventions were for oxygen off while smoking and 30 minute checks due to non-compliance with smoking rules. The care plan did not include any direct supervision of R1 related to smoking. The care plan did not indicate that cigarettes and lighter were to be kept at nurse's station until 2/4/19. During observations on R1's unit on 2/11/19, at 11:00 a.m. the roommate of R1 had cigarettes and lighter on his table and stated there were no restrictions on where cigarettes and lighters were kept. At the time of the complaint investigation R1 had been discharged from the facility. A progress note dated 2/3/19, at 9:50 p.m. by LPN-A indicated the roommate of R1 ran to the nurse's station and stated there was a fire in their bathroom. R1 was in the bathroom, LPN-A documented there was a smell of burnt hair and apparently R1 had lit a cigarette with his oxygen running in the bathroom and caused a fire. The progress note indicated R1 was transferred to the hospital emergency department via ambulance. The medical record indicated R1 had returned to the facility after treatment for [REDACTED]. LPN-A was interviewed on 2/11/19, at 2:30 p.m. and stated R1 was confused and was angry, and did not want to be at the facility. LPN-A stated R1 was a smoker and had no cigarettes on admission. LPN-A stated that R1 had picked up butts in the smoking area and borrowed cigarettes from other residents which was against the rules for smoking. LPN-A stated education had been done on the danger of smoking with oxygen but R1 did not agree that there was a danger. LPN-A stated when R1 had been smoking with oxygen on, he thought it was a good idea to place a wanderguard on the oxygen tank but there was no wanderguard available. Management was aware of the incident. LPN-A stated on 2/3/19, at about 10:00 p.m. R1 was found smoking in the bathroom with oxygen on and R1 had sustained [MEDICAL CONDITION] his beard had burned. The oxygen tubing was observed to be smoking and the oxygen was turned on. The cigarette butt was taken from R1 and stomped out on the floor. LPN-A stated R1 was angry, resisted and stated his face was in pain. LPN-A stated first aide was done and 911 was called, R1 was taken to the emergency department and returned the next day. During an interview with the director of social services (SW)-A on 2/12/19, at 10:45 a.m. he stated R1 had been dismissive of the smoking rules and he had met with R1 on 1/30/19, to review the rules, taken cigarettes and placed at nurse's station. He stated the smoking area was not supervised by staff, and residents were assessed to be able to smoke independently. He further stated residents borrowed cigarettes and there was a new rule on 2/5/19, to prohibit borrowing. During an interview with the acting administrator on 2/11/19 at 3:40 p.m., she stated the incident had occurred before her time at the facility. She stated there were several new rules and residents had been informed. The facility policy for smoking (undated and reviewed on 2/4/19) indicated a resident would be assessed and informed of the safe smoking policy on admission. The policy indicated the approved smoking area and that resident(s) who ignore the safe smoking policy would receive a verbal warning then a written contract. In addition, the policy indicated persistent violations of the policy would result in the resident losing their smoking privileges. R7's face sheet dated 2/12/19, identified [DIAGNOSES REDACTED]. An assessment by the attending physician dated 1/16/19, indicated R7 had a past medical history of [REDACTED]. R7's admission MDS dated [DATE], indicated R7 had no confusion and had intact cognition. In addition, the MDS indicated R7 had no changes in mental status assessed, however, had moderate depression. The behavior Care Area Assessment (CAA) indicated R7 was hospitalized for [REDACTED]. Also the mood CAA indicated R7 endorsed mood symptoms related to history of substance abuse and behaviors. R7's care plan dated 1/4/19, indicated R7 had a history of [REDACTED]. The care plan interventions included to provide education on medication interactions with substance abuse and to notify the physician if R7 appeared impaired. During a review of the physician orders [REDACTED]. In addition, the undated nursing assistant care sheet indicated R7 had a history of [REDACTED]. A review of the progress notes revealed the following: A progress note dated 2/2/19, at 10:10 p.m. indicated R7 had behavior that was a danger to himself. The note indicated R7 had reported seeing bugs crawling on his hands and had broken into the ceiling panels trying to hide from the police when the police were not present. The note indicated R7 had barricaded the room door with a wheelchair and tied the locks with ace wraps. It was noted R7 had a history of [REDACTED]. The director of nursing was notified and 911 called following the incident. The progress note did not indicate the police intervention. A progress note dated 2/2/19, at 10:41 p.m. indicated R7 had been found smoking in his room with oxygen on. A progress note dated 2/3/19, at 10:38 a.m. indicated R7 had been barricaded in the bathroom since 2:00 a.m., the writer LPN-A forced the door open and R7 was hallucinating, and 5 insulin syringes were found. R7 stated the substance was [MEDICATION NAME]. Another progress note at 2:49 p.m. by the charge nurse indicated R7 had been barricaded in the bathroom since 2:00 a.m. and refused to have staff enter. When staff went into the bathroom found R7 trying to inject a syringe in R7's arm. The police were called and R7 was transported to the hospital. The hospital admission history and physical dated 2/3/19, at 7:30 p.m. indicated R7 was admitted to the hospital for an intentional drug overdose on illegal substance. LPN-A was interviewed on 2/12/19, at 2:20 p.m. regarding R7. LPN-A stated he had called the police on 2/2/19, at 11:00 p.m. due to a change in behavior and smoking in the bedroom. He stated the police did not take R7 to the hospital at that time. When LPN-A returned to the unit on 2/3/19, at 7:00 a.m. the trained medication aide (TMA) that had worked the night shift reported R7 was barricaded in the bathroom since 2:00 a.m. and refused to have staff enter. LPN-A had notified the day charge nurse and the bathroom door was forced open. R7 was found with multiple syringes and powdered substance. The police were called and R7 was admitted to the hospital and had not returned to the facility. During an interview on 2/12/19, at 2:45 p.m. with the acting administrator, stated if staff suspected drug use a room search should be conducted and the supervisor should be notified. During an interview with the nurse manager registered nurse (RN)-A on 2/12/19 at 2:00 p.m. she indicated if staff suspected drug use the policy was to remove, destroy and call police if illegal substance. She stated the staff would conduct room searches but the searches were not documented. The director of nursing (DON) was interviewed on 2/13/19, at 11:00 a.m. and stated typically there was a night nurse on the unit, but on 2/2/19, and 2/3/19, there was a TMA and 2 aides assigned to the unit. There was an RN supervisor, but the DON was not sure if the RN was notified until the day shift on 2/3/19. The DON did not have an incident report available for review. The DON verified he was notified on the evening shift on 2/2/19, and the day shift on 2/3/19 of incidents with R7. The facility policy titled High Risk Communication Guide(undated) indicated an event was an occurrence that resulted in or has the potential to result in harm to a resident. All events were to be tracked and trended for quality assurance.

Based on interview and document review, the facility failed to provide language-impaired residents with necessary care that addressed a resident's acute injury, for 1 of 7 residents reviewed (R1), who fell and sustained a [MEDICAL CONDITION], was not assessed by nurses at the time of the fall, was not subsequently monitored by nurses for any fall-related symptoms, and was not assessed when fall-related symptoms occurred. Eighteen hours after the fall, the resident was transferred to the hospital, per family request, where it was determined that the resident was not a surgical candidate for repair of the [MEDICAL CONDITION]. The resident died five days later. R1's medical record was reviewed. R1's care plan, dated [DATE], indicated that R1 had dementia with severe cognitive impairment and poor judgment. R1 did not understand English because R1 spoke another primary language. Staff communicated with R1 by using a picture board, gestures, several staff who spoke R1's primary language, an interpreter, or R1's family member. R1's primary means of mobility was independent ambulation with a wheeled walker. R1 independently ambulated all around the facility unit. R1 ambulated to the dining room for all meals. R1 could independently toilet herself. R1 sometimes forgot to use the walker when ambulating and had to be re-directed by staff to use the walker. R1 walked with a shuffled, unsteady gait due to [MEDICAL CONDITION]. For all these reasons, R1 was at risk for falls. The physician progress notes [REDACTED]. R1 had [MEDICAL CONDITION]. R1 had no recent falls. All of R1's routine medical evaluations were effectuated with R1's family member in attendance as R1 had no English comprehension.The nursing progress notes, dated [DATE] at 8:40 a.m., indicated that R1 refused to get out of bed that morning. LPN/E gave R1 Tylenol for pain, but there was no information about the location of R1's pain or any assessment data pertaining to R1. Thirty minutes after R1 took the Tylenol, staff assisted R1 into a wheelchair and R1 went to the dining room for breakfast by wheelchair. R1 had to be assisted by staff with 50% of the morning meal and then assisted by staff to use the toilet. Staff then assisted R1 back to bed. The nursing progress notes, dated [DATE] at 11:50 a.m., indicated that family member (FM)/H had arrived, approached LPN/E, and reported that R1 was having pain from a fall R1 said she had. R1 was unable to provide any information about the time or place of the fall. R1 was transferred to the hospital for further evaluation. There was no evidence that nursing staff assessed R1 at any time on [DATE], even though R1's abilities had changed from normal that morning and R1 was reporting pain. The nursing progress notes from [DATE] - [DATE] provided no evidence of any event or fall involving R1. The facility's incident reports from [DATE] - [DATE] provided no evidence that R1 had any falls during this period of time. The hospital record indicated that R1 was evaluated in the Emergency Department at 1:32 p.m. on [DATE]. R1's right hip was tender to palpation, with circular bruising observed on the right hip. R1 had pain with minimal rotation of the right extremity and hip. Hospital staff spoke with RN/B, by telephone, who said that R1 had an unwitnessed fall at the skilled care facility on [DATE]. X-rays revealed that R1's right hip was broken. Orthopedic and Surgical services were consulted. Due to R1's multiple medical co-morbidities, there were no interventions that could change R1's risk profile for anesthesia. R1 was not a surgical candidate. The only option was comfort care and pain management. Hospice care was initiated. R1 was discharged to a hospice house on [DATE], with death anticipated in a short time. R1's death certificate indicated that R1 died on [DATE] from Complications of Right [MEDICAL CONDITION] (Non-Operated), due to a Fall. An interview with Family member (FM)/H was conducted on [DATE] at 8:40 a.m. FM/H stated she visited R1 daily for two to three hours. FM/H visited R1 on [DATE] around 11:00 a.m. R1 had no problems,was feeling good, and was her usual self. FM/H again visited R1 on [DATE] around 11:00 a.m. R1 was in intense pain and was rubbing her right hip. R1 couldn't walk. R1 couldn't sit without crying. FM/H removed R1's clothing to look at R1's right hip. R1 had a large purple bruise on the right hip, approximately 5 cm x 5 cm, which FM/H photographed. R1 told FM/H that she fell , but R1 couldn't remember when or where she fell . FM/H asked LPN/E about the big bruise on R1's hip. LPN/E wasn't aware R1 had a bruise on her hip. LPN/E didn't know anything about R1 falling. FM/H wanted R1 transferred to the hospital for further evaluation. The hospital did x-rays and found that R1's right hip was broken. The hospital doctors told FM/H that R1 couldn't survive surgical repair of the hip, due to R1's multiple health problems. Palliative care was recommended. R1 was made comfortable with narcotic pain medication. R1 was kept in the hospital several days until hospital staff found a hospice house for R1. R1 was discharged to a hospice house on [DATE], where R1 died peacefully on [DATE]. An interview with Nursing Assistant (NA)/F was conducted on [DATE] at 2:37 p.m. NA/F stated she was familiar with R1 and had assisted R1 many times with care needs. R1 sometimes forgot to use her walker when she wandered all around the unit. NA/F would find R1's walker and bring it to R1. R1 did not speak any English. NA/F did not know there was a picture board to communicate with R1. R1 often pointed to things or showed NA/F what she wanted. R1's family member visited frequently and would tell the staff what R1 needed. NA/F was working during the evening of [DATE] when R1 fell . NA/F and other staff were preparing supper in the dining room around 5:30 p.m. when another resident came to the dining room and said that R1 was on the floor in her room. NA/F, LPN/D, and two other NAs (unidentified) went immediately to R1's room. R1 was sitting on the floor in the doorway to her room. R1 was speaking very rapidly in another language. No one could understand what R1 was saying. LPN/D directed the NAs to put R1 in a wheelchair. NA/F got the wheelchair while LPN/D and another NA (unidentified) stood R1 up with a gait belt. R1 was placed in the wheelchair and went by wheelchair to the dining room for supper. R1 sat in the wheelchair the rest of the shift. R1 did not walk after the fall occurred. When NA/F left duty at 9:00 p.m., R1 was in bed. NA/F did not know who assisted R1 to bed that evening. Normally, R1 could independently get herself in bed. An interview with LPN/D was conducted on [DATE] at 1:10 p.m. LPN/D stated he was R1's assigned nurse during the evening shift of [DATE]. LPN/D normally works on another unit and picks up extra shifts once or twice a month on R1's unit. LPN/D is familiar with all the residents on R1's unit, including R1. R1 was generally independent with care. R1 ambulated with a walker. R1 did not normally use a wheelchair on the unit. Communication with R1 was poor because R1 did not speak any English. LPN/D was unaware if there was a picture board or some other means to facilitate communication with R1. The facility does not have an interpreter. R1's family member came often and would tell the staff what R1 needed. On [DATE], R1 fell in the doorway of her room, shortly before supper around 6:00 p.m. LPN/D did not see R1 fall but was alerted that R1 was on the floor in her room. LPN/D went to check on R1 and observed that R1's walker was several feet away from where R1 was sitting on her buttocks in the doorway to her room. LPN/D moved R1's legs a bit to check for any pain with motion. R1's facial expression didn't seem to show pain but R1 could not understand any of LPN/D's questions and LPN/D could not understand R1's responses. R1 was speaking another language. LPN/D did not seek interpretive assistance from R1's family member about what R1 was trying to communicate. LPN/D and a Nursing Assistant (unidentified) stood R1 up from the floor and placed R1 in a wheelchair. Other than the brief movement of R1's legs, LPN/D did no further assessment of R1's status or check R1's body for potential injuries from the fall. LPN/D did not notify R1's medical provider or family member about R1's fall. LPN/D did not complete an incident report, document the event in R1's progress notes, or document on the shift communication board, which initiates nursing follow-up of a resident's fall for 72 hours. LPN/D's explanation was he forgot to follow the facility protocol for resident falls. LPN/D did not assess or attempt to communicate with R1 at any time after R1 was transferred to a wheelchair as the result of a fall. Although R1 came to supper in the wheelchair, did not ambulate after the fall, and stayed in the wheelchair the remainder of the shift, LPN/D did not perceive this as a change in condition from R1's normal status. An interview with LPN/E was conducted on [DATE] at 3:15 p.m. LPN/E stated she was familiar with R1's needs and was routinely R1's assigned unit nurse. R1 was pleasantly forgetful. R1 ambulated with a walker all over the unit. R1 spoke another primary language. R1's English was limited to yes, no, and toast. R1 had a communication picture board that was kept on the dresser in her room to help bridge the language barrier. If LPN/E could not resolve the language barrier by using the picture board to communicate with R1, LPN/E contacted R1's family member who would translate what R1 was saying. LPN/E was R1's assigned unit nurse during the day shift of [DATE]. Early in the morning (exact time not recalled), the NA (unidentified) assigned to R1's care told LPN/E that R1 was holding her left side and didn't want to get out of bed . LPN/E went to R1's room around 8:30 a.m. to administer R1's routine dose of Tylenol that R1 takes for arthritic pain. R1 was holding her abdomen and it appeared R1 was having pain. LPN/E did not use R1's picture board as a means to gain more information from R1 to further assess R1's pain. LPN/E told the NA (unidentified) to wait a half hour until the Tylenol took effect, then get R1 up in the wheelchair. LPN/E later observed that R1 was in the dining room in the wheelchair for breakfast. R1 looked like she didn't feel good. R1 wasn't as alert as usual and R1 needed help to eat. LPN/E did not assess R1, attempt to communicate with R1, or contact R1's family member as a means to ascertain more information about R1's change in condition. LPN/E told the NA (unidentified) to lay R1 back down in bed after breakfast. R1 slept until FM/H came to visit, shortly before noon. FM/H came to the nurse's desk and told LPN/E that R1 was in intense pain and had a bruise on her hip from a fall R1 said she had. LPN/E was unaware of R1's fall, which angered FM/H. There was no information communicated during shift report about R1 having a fall and no documentation about R1 having a fall. LPN/E offered to get an x-ray of R1's hip but FM/H wanted R1 sent to the hospital for evaluation, which LPN/E facilitated. The facility's policy Fall/Injury Management - Post Fall or Injury, dated [DATE], indicated that proper action following a fall includes: ascertaining if there were injuries and providing treatment as necessary .assess the resident and implement appropriate measures to provide immediate care after fall/injury using a mechanical lift for all clinically appropriate residents who have fallen to the floor and cannot get up independently .communicating the fall to the physician and responsible party in a timely manner initiate and complete the accident/incident process .communicate interventions during shift report and daily clinical rounds .communicate interventions to the staff using the nursing assistant assignment sheet .continue documentation each shift for 72 hours.

Based on interview and document review, the facility failed to notify the resident's physician and family member of an accident involving the resident, for 1 of 7 residents reviewed (R1), who fell , sustained a right [MEDICAL CONDITION], and went without any medical intervention or evaluation for 18 hours. Findings include: R1's medical record was reviewed. R1's care plan, dated [DATE], indicated that R1 had dementia with severe cognitive impairment and poor judgment. R1 did not understand English because R1 spoke another primary language. Staff communicated with R1 by using a picture board, gestures, several staff who spoke R1's primary language, an interpreter, or R1's family member. R1's primary means of mobility was independent ambulation with a wheeled walker. R1 sometimes forgot to use the walker when ambulating and had to be re-directed by staff to use the walker. R1 walked with a shuffled, unsteady gait due to [MEDICAL CONDITION]. For all these reasons, R1 was at risk for falls. The physician progress notes [REDACTED]. R1 had [MEDICAL CONDITION]. R1 had no recent falls. All of R1's routine medical evaluations were effectuated with R1's family member in attendance as R1 had no English comprehension. The facility's incident reports from [DATE] - [DATE] provided no evidence that R1 had any falls during this period of time. The nursing progress notes, dated [DATE] at 8:40 a.m., indicated that R1 refused to get out of bed that morning. LPN/E gave R1 Tylenol for pain, but there was no information about the location of R1's pain or any assessment data pertaining to R1. The nursing progress notes, dated [DATE] at 11:50 a.m., indicated that family member (FM)/H had arrived, approached LPN/E, and reported that R1 was having pain from a fall R1 said she had. R1 was unable to provide any information about the time or place of the fall. R1 was transferred to the hospital for further evaluation. The hospital record indicated that R1 was evaluated in the Emergency Department at 1:32 p.m. on [DATE]. R1's right hip was tender to palpation, with circular bruising observed on the right hip. R1 had pain with minimal rotation of the right extremity and hip. Hospital staff spoke with RN/B, by telephone, who said that R1 had an unwitnessed fall at the skilled care facility on [DATE]. X-rays revealed that R1's right hip was broken. Orthopedic and Surgical services were consulted. Due to R1's multiple medical co-morbidities, there were no interventions that could change R1's risk profile for anesthesia. R1 was not a surgical candidate. The only option was comfort care and pain management. Hospice care was initiated. R1 was discharged to a hospice house on [DATE], with death anticipated shortly. R1's death certificate indicated that R1 died on [DATE] from Complications of Right [MEDICAL CONDITION] (Non-Operated), due to a Fall. An interview with Family member (FM)/H was conducted on [DATE] at 8:40 a.m. FM/H stated she visited R1 daily for two to three hours. FM/H visited R1 on [DATE] around 11:00 a.m. R1 had no problems,was feeling good, and was her usual self. FM/H again visited R1 on [DATE] around 11:00 a.m. R1 was in intense pain and was rubbing her right hip. R1 couldn't walk. R1 couldn't sit without crying. FM/H removed R1's clothing to look at R1's right hip. R1 had a large purple bruise on the right hip, approximately 5 cm x 5 cm, which FM/H photographed. R1 told FM/H that she fell , but R1 couldn't remember when or where she fell . FM/H was surprised by R1's statement because no one from the facility had called FM/H to report that R1 had a fall. FM/H asked LPN/E about the big bruise on R1's hip. LPN/E wasn't aware R1 had a bruise on her hip. LPN/E didn't know anything about R1 falling. FM/H wanted R1 transferred to the hospital for further evaluation. The hospital did x-rays and found that R1's right hip was broken. An interview with LPN/D was conducted on [DATE] at 1:10 p.m. LPN/D stated he was R1's assigned nurse during the evening shift of [DATE]. LPN/D was familiar with all the residents on R1's unit, including R1. Communication with R1 was poor because R1 did not speak any English. LPN/D was unaware if there was a picture board or some other means to facilitate communication with R1. The facility does not have an interpreter. R1's family member came often and would tell the staff what R1 needed. On [DATE], R1 fell to the floor in her room, shortly before supper around 6:00 p.m. LPN/D checked on R1 and observed that R1's walker was several feet away from where R1 was sitting on her buttocks in the doorway to her room. LPN/D moved R1's legs a bit to check for any pain with motion. R1's facial expression didn't seem to show pain but R1 could not understand any of LPN/D's questions and LPN/D could not understand R1's responses. R1 was speaking another language. LPN/D did not notify R1's family member about R1's fall or attempt to seek interpretive assistance from R1's family member about what R1 was trying to communicate at the time of the fall. LPN/D and a Nursing Assistant (unidentified) stood R1 up from the floor and placed R1 in a wheelchair. Although R1 remained in the wheelchair all shift and didn't ambulate after the fall, LPN/D did not notify R1's medical provider about R1's fall and change in status.An interview with LPN/E was conducted on [DATE] at 3:15 p.m. LPN/E stated she was familiar with R1's needs and was routinely R1's assigned unit nurse. R1 spoke another primary language. R1's English was limited to yes, no, and toast. R1 had a communication picture board that was kept on the dresser in her room to help bridge the language barrier. If LPN/E could not resolve the language barrier by using the picture board to communicate with R1, LPN/E contacted R1's family member who would translate what R1 was saying. LPN/E was R1's assigned unit nurse during the day shift of [DATE]. Early in the morning (exact time not recalled), the NA (unidentified) assigned to R1's care told LPN/E that R1 was holding her left side and didn't want to get out of bed . LPN/E went to R1's room around 8:30 a.m. to administer R1's routine dose of Tylenol that R1 takes for arthritic pain. R1 was holding her abdomen and it appeared R1 was having pain. LPN/E did not use R1's picture board as a means to gain more information from R1 to further assess R1's pain. LPN/E told the NA (unidentified) to wait a half hour until the Tylenol took effect, then get R1 up in the wheelchair. LPN/E later observed that R1 was in the dining room in the wheelchair for breakfast. R1 looked like she didn't feel good. R1 wasn't as alert as usual and R1 needed help to eat. LPN/E did not assess R1, attempt to communicate with R1, or contact R1's family member as a means to ascertain more information about R1's change in condition. LPN/E did not notify R1's medical provider of R1's change in status. An interview with MD/G was conducted on [DATE] at 12:56 p.m. MD/G stated that facility practice is for staff to immediately notify a resident's medical provider when a resident has a fall with injury or a change in condition. The resident's primary medical provider is available weekdays from 8:00 a.m. to 4:30 p.m. An on-call medical provider is available to meet resident needs from 4:30 p.m. on Fridays through 8:00 a.m. on Mondays. MD/G could not recall who R1 was, but MD/G had R1's clinic chart in front of him during the interview. Facility staff did not notify MD/G about R1's fall on [DATE] until noon on [DATE], at which time staff were directed to send R1 to the hospital for evaluation of what was reported as being a bruised hip following a fall with intense hip pain. MD/G did not know the circumstances of the fall or whether earlier intervention would have resulted in a different outcome. If R1 had pain or any signs of injury at the time of the fall on [DATE], MD/G would have ordered an x-ray. MD/G felt the facility nurses were diligent about calling the medical provider when residents had a sudden decline or change in status, if the staff recognized the resident's change in condition. The facility's policy Fall/Injury Management - Post Fall or Injury, dated [DATE], indicated that proper action following a fall includes: ascertaining if there were injuries and providing treatment as necessary .assess the resident and implement appropriate measures to provide immediate care after fall/injury using a mechanical lift for all clinically appropriate residents who have fallen to the floor and cannot get up independently .communicating the fall to the physician and responsible party in a timely manner.