Every finding on record at Aurora on France

Based on observation, interview and document review, the facility failed to provide pharmaceutical services that ensured medications were available to meet residents' needs for 2 of 5 residents reviewed for medication administration (R29 and R57). This deficient practice resulted in multiple prescribed medications being unavailable for administration and created the potential for residents to miss ordered medications or receive doses that differed from the physician's prescribed regimen. Findings include: R29's admission Minimum Data Set (MDS), dated [DATE], indicated he was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R57's admission Minimum Data Set (MDS), dated [DATE], indicated he was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. During observation and interview on 05/27/2026 at 8:01 a.m., RN-E conducted a medication pass for R29 and identified four medications that were unavailable for administration, including ginkgo biloba, a multivitamin with minerals, vitamin B12, and vitamin E. RN-E checked the medication cart and available house stock but was unable to locate the medications. RN-E stated she would need to fax and call the pharmacy to ensure the medications were delivered that day and reported medications generally should be reordered when the supply reached the last row of a medication card or when there was still a few days of the medication left giving time for the medication to be delivered before it ran out. RN-E stated the assistant administrator, who was also filling the supplier role, reordered house stock medications. RN-E further stated she would need to notify the provider regarding the unavailable medications because they were vitamins and not considered urgent. RN-E stated, So I am missing 4 different med, that's a lot. During observation and interview on 05/28/2026 at 7:51 a.m., LPN-C conducted a medication pass for R57 and was unable to locate cyclosporine ophthalmic drops ordered for administration. LPN-C stated the medication should have been reordered when the supply reached the last package of eye drops and reported she would administer the resident's other medications and continue searching because mornings were busy. During the same medication pass, LPN-C identified that the resident's ordered losartan 75 mg was unavailable and only losartan 50 mg was present. LPN-C stated the resident should have had one 50 mg tablet and one 25 mg tablet available for administration and reported she had called the pharmacy twice during her previous shift on Tuesday regarding the missing medication.During a follow-up interview on 05/28/2026 at 9:50 a.m., LPN-C stated she obtained a one-time order from the nurse practitioner to administer losartan 50 mg in place of the prescribed losartan 75 mg because the ordered dose was unavailable. LPN-C stated staff were not permitted to split tablets to achieve the ordered dose.During interview on 05/28/2026 at 8:18 a.m., the nurse manager and RN-F stated the expectation was for the nurse administering the medication to reorder it when approximately seven days of supply remained. RN-F stated staff were expected to fax refill requests to the pharmacy and follow up by telephone to confirm receipt of the fax. RN-F stated pharmacy staff sometimes responded that refill requests were submitted too early and at other times reported they had not received the faxed request. RN-F stated nurses did not always have time to call the pharmacy to verify receipt of refill requests and acknowledged, it should not be that way, but life happens.A pharmacy policy titled Ordering and Receiving Medication from the Dispensing Pharmacy, dated 9/10/24, indicated refill request of current medications should be placed 5-7 days before the current supply runs out to ensure to gaps in medication administration.

Based on interview and document review, the facility failed to implement hospital discharge recommendations and facility standing orders for daily weight monitoring for a resident with a primary diagnosis of congestive heart failure (CHF). The facility also failed to assess and implement a low-sodium diet recommendation, failed to monitor for weight changes indicative of fluid retention, and failed to develop a care plan addressing CHF management after the resident's diuretic therapy was placed on hold pending further clinical evaluation for 1 of 1 residents (R84) reviewed for quality of care.Findings include: Findings include:R84's admission Minimum Data Set (MDS) assessment, dated 5/5/26, identified R84 had mild cognitive impairment and a primary diagnosis of chronic congestive heart failure (CHF - a condition where the heart cannot pump blood well often resulting in excess fluid buildup in the body).R84's electronic medical record (EMR) revealed a documented weight of 270 pounds on 5/4/26.R84's hospital Interagency Transfer Form - Physician Orders discharge paperwork dated 5/21/26 indicated R84 was admitted to the hospital on [DATE] with a weight of 210 pounds and diagnosis of edema of left upper extremity.R84's Discharge summary dated [DATE] indicated R84 received IV Lasix (furosemide, a medication used to treat fluid retention) during the hospital stay and transitioned to oral Lasix for edema, however, the orders directed R84 should pause taking it until your doctor or other care provider tells you to start again. The discharge paperwork included signed orders for daily weights, provider notification for a weight gain of 2 pounds in one day and/or 5 pounds in one week, and a low sodium diet. R84's weight at discharge on [DATE] was 169 pounds.R84's facility Orders included Ok for Standing House Orders starting 5/21/26.The facility Standing Orders for Nursing Facilities and Skilled Nursing Facilities 2026 signed 2/3/26, included Daily weights for patients with Heart Failure and call for > 3lb weight gain in 24 hours or 5lbs in one week unless otherwise ordered.R84's weight was documented at 153 pounds on 5/23/36.R84's medical record lacked evidence of daily weight monitoring, instructions for provider notification, and ordered diet following re-admission to the facility.R84's comprehensive care plan failed to identify congestive heart failure as a focus area and lacked interventions related to CHF management, daily weight monitoring, fluid status monitoring, sodium restriction, or monitoring for signs and symptoms of worsening heart failure. During interview on 5/27/26 at 1:03 p.m., nursing assistant (NA)-B stated staff learned how to care for residents through the Kardex, (which was based off the comprehensive care plan), the nurse, or the manager. NA-B was unable to provide insight regarding specific care provided to R84. During interview on 5/28/26 at 7:51 a.m., licensed practical nurse (LPN)-C stated daily weights would be documented in the Medication Administration Record (MAR). LPN-C stated residents generally received monthly, weekly, or daily weights depending on medications or clinical needs and stated nursing assistants completed weights through nurse delegation.During interview on 5/28/26 at 8:18 a.m., nurse manager and registered nurse (RN)-F stated the hospital discharge recommendations for daily weights and a low-sodium diet should have been followed. RN-F stated daily weights would normally be documented on the Treatment Administration Record (TAR) and stated the dietitian would review dietary recommendations and place them on the resident's meal ticket. When asked how staff would determine when to restart furosemide without daily weight monitoring, RN-F stated the provider would monitor laboratory values and staff would observe the resident. RN-F acknowledged staff had not routinely monitored R84's weight as directed by the discharge paperwork. RN-F later stated a diagnosis of CHF would not necessarily require daily weights and stated staff would instead monitor vital signs daily. During interview on 5/28/26 at 9:54 a.m., the Director of Nursing (DON) stated the facility's standing orders included daily weights for residents with CHF; however, not every resident required implementation of those orders. The DON stated nurse managers were responsible for determining which recommendations and interventions should be initiated following admission. The DON further stated unit health coordinators would not necessarily review discharge recommendations unless a specific physician order had been entered and stated nurse managers were responsible for determining which discharge recommendations were most important for each resident.During interview on 5/28/26 at 10:23 a.m., the dietitian stated the facility provided low-sodium diets and followed physician orders for dietary restrictions.A facility policy on Heart Failure monitoring was requested; however, the facility did not have this specific policy.

Based on interview and document review, the facility failed to ensure a level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 1 of 1 residents (R45) reviewed for PAS.Findings include: R45's admission Minimum Data Set (MDS) dated [DATE], indicated R45 was admitted to the facility on [DATE] and had intact cognition. The MDS indicated R45 was diagnosed with anxiety and bipolar disorder. R45's PAS notice dated 4/22/26, indicated a copy of the PAS was included with this notice, but the PAS was not final until the lead agency sent a final determination to the nursing facility. R45's medical record was reviewed and lacked evidence that a final determination from the lead agency had been received. During an interview on 5/27/26 at 2:13 p.m., the admissions coordinator (AC) stated that when a resident was admitted from the hospital, the hospital would complete a PAS, and the screening would then be sent to them. The AC stated that generally she would reach out to the lead agency, and they would sometimes send the final PAS. The AC confirmed that they did see the final PAS from the lead agency, which was Medica, after reviewing R45's medical record. The AC stated she did not keep documentation on any attempts to reach out to the lead agency for the final PAS. During an interview on 5/28/26 at 9:50 a.m., the administrator stated that admissions was in charge of receiving the PAS and then following up as needed to obtain the final PAS. The facility's PASARR Level I & II policy dated 10/2017, indicated that prior to a resident's admission, the admissions coordinator or designee would ensure the PASARR Level I screening was completed and received. The admissions coordinator or designee would then work with the appropriate community provider to ensure completion of the PASARR level I screening form and verification was received. The policy indicated that the PASARR Level I would be scanned into the resident's medical record.

Based on interview and document review, the facility failed to ensure a discharge return anticipated (DRA) Minimum Data Set (MDS) was transmitted for 1 of 3 residents (R42) and a discharge return not anticipated (DRNA) MDS was transmitted for 1 of 1 residents (R8), to the Centers for Medicare and Medicaid (CMS) reviewed for no MDS record in 120 days.Findings include: R42's admission MDS dated [DATE], indicated R42 had a discharge- return anticipated and it was unplanned. The MDS indicated the assessment was completed but did not indicate the assessment was submitted to CMS. The MDS included under the submit section, do not submit to CMS. R42's Census listing dated 12/11/25, indicated R42 admitted to the nursing home on [DATE], and their status changed to STOP BILLING on 12/11/25. R42's progress note dated 12/11/25 at 2:56 a.m., indicated R42 was discharged to the emergency department due to a fall. R8's DRNA MDS dated [DATE], indicated R8 had a discharge- return not anticipated and it was planned. The MDS indicated the assessment was completed but did not indicate the assessment was submitted to CMS. The MDS included under the submit section, do not submit to CMS. R8's Census listing dated 1/6/26, indicated R8 admitted to the nursing home on [DATE], and their status changed to STOP BILLING on 1/6/26. R8's progress note dated 1/6/26 at 12:57 p.m., indicated R8 was discharged with family to an ILF. During an interview on 5/27/26 at 12:36 p.m., registered nurse (RN)-D, an MDS coordinator, confirmed she had reviewed R42's record and stated that it looked like a DRA assessment had been completed but never sent to CMS. RN-D confirmed she had reviewed R8's record and stated that a DRNA assessment had been completed but also had never been sent to CMS. The facilities MDS/Care Plan Process/Resident Assessment policy dated 10/21/25, indicated that when MDS forms are completed directly on the facility's computer, each assessor signs and dates it, after it is reviewed for accuracy. The policy did not include the expected time frame for submitting DRA/DRNA MDS's to CMS.

Based on interview and record review, the facility failed to offer a written notice of transfer which included a statement of the resident's appeal rights and the contact information of the Office of the State Long-Term Care Ombudsman. In addition, the facility failed to provide written information on the duration of the bed-hold, and reserve bed payment for 2 of 3 residents (R51, R69) reviewed for hospitalizations. Findings include: R51 R51's admissions Minimum Data Set, dated [DATE] identified R51 with intact cognition, had no functional impairment, required assistance with toileting, dressing, and showering. In addition, R51 had diagnoses of congestive heart failure, heart disease, arthritis, depression, and chronic lung disease. During record review of R51's electronic medical record (EMR) R51 was hospitalized on [DATE] following a fall in his room. He was sent to the hospital and remained until 5/18/26 when he was transferred back to the facility. During interview with registered nurse (RN)-A on 5/28/26 at 6:58 a.m., RN-A stated expectation of staff to print out a face sheet, orders, and medication list to transfer resident to hospital. RN-A stated she was unaware of providing a written transfer and bed hold form. During interview with RN-B on 5/28/26 at 7:09 a.m., RN-B stated expectation of staff to print out a face sheet, orders, and medication list to transfer resident to hospital. RN-B stated nothing was written or signed by the resident on transfer. During interview with R51 on 5/28/26 7:19 a.m., R51 stated he was not offered or provided a verbal or written transfer or bed hold form. During interview with licensed practical nurse (LPN)-A on 5/28/26 at 7:22 a.m., LPN-A stated expectation of staff to print out a face sheet, orders, and medication list to transfer resident to hospital. We do not have them sign the bedhold or transfer form. R69 R69's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R69 had intact cognition with no hallucinations, delusions, or behaviors. R69's progress note dated 3/16/26 at 3:15 p.m., indicated R69 was transferred to the emergency department by ambulance, as R69 had said she was now ready to go. R69's medical record was reviewed, and an indication that a written transfer notice, which included information such as the ombudsman information and the resident's appeal rights, was given on transfer to the hospital was not found. Indication that R69 had been given a written bed-hold notice that included information such as the duration of the state bed-hold policy, the reserve bed payment policy, or the nursing facility's policy regarding bed-hold periods, on transfer to the hospital was not found. During an interview on 5/27/26 at 12:15 p.m., registered nurse (RN)-E stated she sent documents such as the order summary, medication administration record, etc., but did not give a written transfer notice, which included information like ombudsman information and appeal rights, or a written bed hold notice. RN-E stated she believed that social services would follow up with the resident later to see if they would like to hold their bed. During an interview on 5/27/26 at 1:15 p.m., RN-F, the nurse manager for the unit, stated she did not believe they had a process in place to give residents a written notice of transfer, which included information like ombudsman information and appeal rights, or bed hold on transfer to the hospital, although social services did follow up with residents after transfer to see if they would like to hold their bed. During an interview on 5/28/26 at 9:44 a.m., the director of nursing (DON) deferred questions regarding written transfer and bed-hold notices to the assistant administrator (AA). During an interview on 5/28/26 at 9:53 a.m., the AA stated that staff might go through a written bed hold notice with the resident before transfer to the hospital, depending on their responsiveness status. The AA stated otherwise, the social services department would contact the resident or representative at a later time to determine if they would like their bed hold. The AA stated the expected process would be for these conversations to be documented in a progress note, but he wasn't sure how often this was happening. The AA stated he believed the facility had a form that could be given on transfer that included things such as the ombudsman and appeal information but was not sure if staff were giving out this form on transfer to the hospital. The AA stated that if this form was given, he would expect it to be scanned into the electronic medical record, but he did not see it for R69. The facility's Transfer and Discharge from the Facility policy dated 1/22/25, indicated that the Notice of Transfer or Therapeutic Leave would be given to the resident or representative at the time of transfer. The policy indicated this would be documented in the resident's record. The policy indicated that if the resident representative was not present at the time of transfer, nursing staff would contact them and notify them of the transfer and clarify the status of the bed hold. The policy indicated that on the first business day following the resident's transfer, social services staff should continue to attempt to reach the representative to clarify the bed-hold status. The policy indicated that social services staff should document the resident's bed hold status in the electronic medical record and should send the notice of transfer, along with the bed hold notice, to the representative for signature. The policy indicated social services would then scan these notices into the electronic health record.

Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow resident to safely administer own medications for 1 of 1 (R1) resident observed with medications at bedside. Findings include:R1's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, needed substantial/maximal assistance with toileting hygiene, upper/lower body dressings, bed mobility, transfers, and needed moderate assistance with oral and personal hygiene. R1 was dependent on staff for bathing. R1's diagnosis report dated 5/28/26, indicated diagnosis of pneumonia, acute respiratory failure with hypoxia, hypertensive heart failure, diabetes, anxiety disorder, and chronic low back pain. R1's physician orders dated 5/28/26 included orders for clobetasol propionate external ointment 0.05% (a topical steroid) with directions to apply to labia, distal left wall topically in the evening every Monday, Wednesday, Friday for Lichen Planus (chronic non-contagious inflammatory condition where the immune system mistakenly attacks cells in the skin, hair, nails or genital mucosa). Apply a pea sized amount 3 times weekly. Apply to the inside of the labia and distal left wall of vagina. R1's Medication Administration Record (MAR) dated May 2026, indicated the cream was administered by the staff as ordered. R1's nursing admission assessment dated [DATE], included a question about self-administration of medication and the answer was documented as not applicable.During interview on 5/26/26 at 4:35 p.m., R1 stated she had a vaginal rash, and over a week ago the staff lost her medicated cream (clobetasol). R1 stated first they lost the cream's labeled plastic bag, then they couldn't find the cream. R1 said her husband brought her the clobetasol cream she had at home. During the interview, the clobetasol cream was on top of her nightstand. The clobetasol's box was labeled by a local pharmacy with R1's information. R1 stated she had been applying the cream every day to the affected area, and as needed. During interview on 5/27/26 at 12:41 p.m., registered nurse (RN)-E stated residents can self- administer medications if they are alert and oriented, and after a self-administration of medication (SAM) assessment was completed. RN-E added, the facility also needed a doctor's order.During interview on 5/27/26 at 12:51 p.m., RN-H stated she was not aware R1 had a medicated cream in her room. RN-H looked in the medication cart for the cream and was not there. RN-H retrieved the cream from R1's room and stated she will need a SAM assessment and provider's order to self-administer the medicated cream, and they would need to re-order the medicated cream from our pharmacy. During interview on 5/27/26 at 1:00 p.m., nurse manager RN-F stated before a resident was allowed to self-administer a medication a procedure needed to be followed. RN-F stated a SAM assessment needed to be completed, and the staff needed to obtain a doctor's order for SAM and to be okay to leave medication at bedside. During interview on 5/28/26 at 10:32 a.m., the director of nursing (DON) stated staff needed to screen the resident's cognition, complete a SAM, and contact the provider to obtain an order. DON stated the expectation was no medications will be left at bedside without proper assessment and orders. Facility's policy titled Self Administration of Medications dated 9/2024, indicated the policy of this facility was to establish uniform guidelines concerning the self-administration of drugs in compliance with federal regulations. The policy's procedure indicated a SAM will be completed for any resident requesting to administer any medication without the direct supervision of a nurse. The attending physician's order will be signed and dated prior to self-administration and left at bedside. The medication kept at bedside must be stored in a locked box, attached to something that can't be easily moved. Nurses will educate the resident on the proper use of medications.

Based on interview and record review, the facility failed to promote and maintain dignity for 1 of 3 residents reviewed for dignity (R29) when staff directed a continent resident to roll over and have a bowel movement in his brief rather than assessing and implementing toileting interventions consistent with his needs, preferences, and dignity. The facility failed to ensure assessments, care plans, and staff practices provided clear direction regarding R29's toileting status and preferences, despite documentation identifying him as continent of bowel and bladder and his expressed distress regarding having bowel movements in bed. This had the potential to cause psychosocial harm, loss of dignity, and diminished quality of life by failing to respect the resident's autonomy, preferences, and right to receive care in a dignified manner. Findings include: R29's admission Minimum Data Set (MDS), dated [DATE], indicated he was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R29's toileting care plan, initiated 4/24/26 and revised 4/27/26, identified him as totally dependent and directed staff to use a bedpan and/or brief for toileting, clothing management, and hygiene. Additional care plan interventions directed staff to toilet him as requested and as needed and noted he needed assistance with a urinal. A separate incontinence care plan, initiated 4/28/26, directed staff to provide incontinence care according to the bowel and bladder assessments and after incontinence episodes. However, review of a bowel and bladder assessment dated [DATE] identified R29 as continent of both bowel and bladder. The assessment contained no documented bowel habits. R29's transferring care plan, initiated 4/24/26 and revised 4/29/26, indicated R28 was totally dependent on staff and using a full body mechanical lift for all transfers. R29's Kardex continued to direct staff to provide incontinent care following episodes of incontinence despite the bowel and bladder assessment identifying him as continent. The conflicting assessments and care planning failed to provide clear direction regarding whether R29 was continent and should be assisted to toilet or incontinent and managed through routine brief changes. During interview on 5/26/26 at 2:52 PM, R29 reported he used a urinal but required staff assistance. He stated he had experienced accidents while waiting for staff to respond. He described having a bowel movement in bed as the most demoralizing part of my whole life. R29 stated staff had never offered or discussed transferring him to a toilet using a mechanical lift despite his awareness and continence. During interview on 5/27/26 at 1:03 PM, nursing assistant (NA)-B stated R29 previously requested a bedpan but currently used a brief and urinal. NA-B stated that on the day of the interview, R29 had a bowel movement in his brief and called for assistance. NA-B stated she told him he would have an easier time having a bowel movement if he rolled onto his side in bed. NA-B further stated he transferred with a mechanical lift and did not transfer to the toilet. During interview on 5/27/26 at 1:58 PM, registered nurse (RN)-E stated R29 was continent and called staff when he needed a bedpan or urinal. RN-E stated staff positioned the urinal, covered him for privacy, and left the room. RN-E further stated therapy had been completing bathroom transfer training using pivot transfers. RN-E acknowledged a specialty toileting sling was available and could be used to transfer residents to a toilet but stated R29 did not use the sling. The nurse's description of R29 as continent and capable of participating in toileting activities conflicted with care plan and Kardex directions identifying him as incontinent and directing staff to provide routine brief care.During interview on 5/28/26 at 8:18 AM, nurse manager and registered nurse (RN)-F stated that toileting expectations for a continent resident who required a mechanical lift depended on the resident's preferences. RN-F stated residents could use a bedpan or be assisted to a toilet if they wished to get out of bed and staff attempted to respect resident choices. Regarding R29, RN-F stated he preferred a bedpan for bowel movements and a urinal for bladder needs and would use the call light to request assistance. RN-F stated she had offered to assist R29 to the toilet; however, he expressed concerns about safety and believed he needed to improve further before attempting toilet transfers. When informed that a nursing assistant reported telling R29 to roll onto his side and have a bowel movement in his brief, RN-F stated, We would not say that and indicated such a statement would be a coachable moment. During interview on 5/28/26 at 9:54 AM, the director of nursing (DON) stated dignified toileting practices included use of a bedpan when needed. The DON stated it was not the standard of care expected by the facility to tell a resident to roll over and have a bowel movement in bed. The DON's statement supported that directing R29 to have a bowel movement in his brief did not align with facility expectations for preserving resident dignity. A facility policy titled Dignity, dated 3/2025, indicated the facility promoted care for residents in a manner that enhanced each resident's dignity and respect in full recognition of their individuality.

Based on observation, interview, and document review, the facility failed to ensure routine/as-needed nail trimming and cleaning was completed for 1 of 1 residents (R13) reviewed for nail care who required staff assistance with their activities of daily living (ADLs).Findings include: R13's admission Minimum Data Set (MDS) 4/10/26, indicated R13 had intact cognition and was diagnosed with paraplegia (the partial or complete paralysis of the lower half of the body) and not diabetes. The MDS indicated R13 required setup/clean-up assistance with eating, supervision or touching assistance with oral hygiene and personal hygiene, and was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. R13's care plan dated 4/6/26, indicated a weekly body audit was to be performed. The care plan indicated R13 required setup/clean-up assistance with eating, supervision or touching assistance with oral hygiene and personal hygiene, and was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. R13's Weekly Bath and Skin Sheet dated 5/9/26, 5/17/26, and 5/23/26, included a section titled Nail Care with a box checked indicating R13's fingernails were short and smooth and did not need trimming. No further completed Weekly Bath and Skin Sheets were found. After reviewing R13's medical record, documentation indicating R13 had received nail care while at the facility before the survey start was not found. During an interview and observation on 5/26/26 at 11:59 a.m., R13 was observed in bed with his fingernails over 1/4 of an inch beyond the end of his fingertip with a brown substance underneath the tips of his fingernails. R28 stated he did not have a fingernail clipper and was unsure if he would be able to cut them by himself anyway. R28 stated he had wanted his nails trimmed for a while, but the staff had not offered to assist him with trimming them. During an observation and interview on 5/27/26 at 10:09 a.m., R13 was observed with fingernails over 1/4 of an inch beyond the end of his fingertip with a brown substance underneath the tips of his fingernails. R13 stated that no one had offered to help him cut or clean his fingernails. During an interview and observation on 5/27/26 at 1:42 p.m., nursing assistant (NA)-A confirmed he was the aide assisting R13 during the day shift. NA-A stated that R13 required assistance with his activities of daily living, and he did not think R13 would be able to cut his nails by himself. When asked about the appearance of R13's nails, NA-A was unsure. NA-A was observed to enter R13's room and stated R13's nails looked pretty long, and he thought it was not likely they were short on 5/23/26. NA-A confirmed he had not offered to help R13 complete nail care. During an interview on 5/28/26 at 7:41 a.m., registered nurse (RN)-G stated that the aides should assist the residents with trimming and cleaning their nails on shower days and as needed. RN-G stated that generally, nails would be something the aides would look at, but if the nurse notices that they were long or dirty, they could then delegate nail care to the aide. RN-G stated that if the nurse happened to notice the nail status, they would document this on the weekly bath sheet, but usually the aides would look at a resident's nail status and relay that to the nurse to document. During an interview on 5/28/26 at 9:42 a.m., the director of nursing (DON) stated that nursing staff should be checking resident nail status and trimming and cleaning as needed and on bath days, if indicated. The DON stated that the nurses should be assessing the resident's nail status themselves on bath days to ensure it is accurate. The facility's Care of Nails policy dated 6/20/25, indicated nail care should be completed on bath days and as needed.

Based on observation, interview, and record review, the facility failed to ensure food was properly stored in refrigeration units. In addition the facility failed to ensure dishes were properly air dried prior to stacking for storage. These deficient practices had the potential to impact all residents who consumed facility prepared food. Findings include: During a kitchen tour on 5/19/25 at 2:27 p.m., led by the culinary manager (CM) the following were noted: ---The bottom 3 racks on the right of the walk-in freezer were less than 6 inches from the floor of the freezer and held food. The middle rack bottom shelf touched the floor. There was a prep pan of raw whole turkeys on it. The prep pan had a brownish red substance on the bottom of the pan. ---The first-floor fridge had a stack of boxes sitting directly on the fridge floor. The CM stated they had just got a shipment, and the boxes were still being put away. ---On the clean side of dish room there were 18 stacks of plastic glasses that had visible moisture between and in the glasses. The CM stated the glasses had been stacked wet instead of being completely air dried before they were stacked. ---The first-floor food prep area contained several shelves of food storage containers and metal prep table pans. There were multiple stacked 8-quart, 4-quart, and 2-quart food storage containers that appeared to be wet with visible moisture between items. The DM confirmed there was visible moisture inside the storage containers and stated they should not have been stacked until they were completely dry. During an interview on 5/19/25 at 2:46 p.m., dietary aide (DA-A) stated they had stacked the glasses after they came out of the dishwasher to air dry. The CM instructed DA-A not to stack the glasses until they were completely dry. The CM stated letting the glasses air dry was important for infection prevention reasons. During an observation of the walk-in freezer on the first floor on 5/21/25 at 8:34 a.m., it was noted the bottom food shelves on the 3 storage racks on the right of the freezer were about an inch off the floor, with the second rack's bottom shelf touching the floor on two corners. Two of the bottom shelves contained food. During an interview on 5/21/25 at 8:43 a.m., the CM confirmed three of the rack's shelves in the walk-in freezer were not greater than 6 inches from the bottom of the freezer floor. The DM indicated the racks should not be that close to the floor. The boxes of chicken should not be on the floor of the freezer, they should have been put on a shelf. Ideally when food is delivered it should be put on the shelf by the person that received it. The DM stated pans that held food should be clean and indicated pans in the freezer would be replaced with clean ones. During an observation on 5/21/25 at 8:55 a.m., the in the second-floor dish area there were stack of glasses with visible moisture on both the inside and outside surface areas. In addition, there were cold and hot food storage containers stacked with visible moisture on them. The CM confirmed the glasses and food containers were stacked and wet. The CM stated this was not acceptable, the items needed to air dry before they were stacked for infection control reasons. During a follow-up on 5/21/25 at 9:14 a.m., the CM stated the chicken stacked in the freezer had been there since last evening when it was delivered. The food on the lower shelves in the freezer had all been moved to higher shelves. The facility policy Food Storage dated 2/2024, directed food should be stored at a minimum of six inches off of the floor. The facility policy Cleaning Dishes dated 7/2022, directed dishes should be air dried on racks and should not stacked until they were completely dry.

Based on observation and interview, the facility failed to ensure staff adhered to infection control standards including the use of personal protective equipment (PPE) in enhanced barrier precaution (EBP) and contact precaution rooms, as well as failing to properly perform hand washing and gloving for 3 of 3 residents (R208, R23, R259) reviewed for infection prevention and control. Findings include: R208: R208's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses including non-pressure chronic ulcer of other part of the right foot with necrosis of muscle, gangrene, cellulitis of right lower limb, osteomyelitis, diabetes mellitus, peripheral vascular disease (PVD), chronic kidney disease. The MDS indicated R208 needed moderate assistance of one person for transfers, was taking antibiotics, and had been participating in occupational and physical therapy. R208's provider order dated 5/9/25 included an order for wound care to her right foot. And on 5/6/25, an order for physical and occupational therapy to evaluate and treat as clinically indicated due to an infection on the right foot. R208's care plan dated 5/7/25, identified a problem statement for EBP indefinitely due to right heel diabetic ulcer chronic wound. Interventions included required personal protective equipment (PPE) of gloves and gown prior to the high-contact care activity. High contact care activities included, but were not limited to, dressing, grooming, bathing, transferring, personal hygiene, changing linens, changing briefs or and assisting with toileting. During an observation on 5/20/25 from about 2:30 p.m., to 3:20 p.m. therapy assistant (TA)-E made a few trips from R208's room, with gloves on, down the hall away from R208's room, and then walk back to her room with different items including some free weights, and still wearing gloves. From the hallway, TA-E was observed in the doorway of R208's bathroom, back and forth to her bedroom area, and then transferring R208 out of the bathroom and to her room. TA-E was wearing gloves during these contacts but was not wearing a gown. During an interview on 5/20/25 at 3:28 p.m., TA-E stated he had infection prevention training, through online orientation. TA-E explained he looked at the signs outside the doors to know what kind of precautions were in place, and stated EBP was an infection control measure to keep things from spreading from one person to another. TA-E stated PPE for EBP should be used any time he was touching the person, for activities of daily living, (ADLs), transfers, or bed mobility. TA-E confirmed he was working with R208 today and had transferred her, including in the bathroom after she had gone to the bathroom, and helped her to brush her teeth. TA-E acknowledged he shouldn't be wearing gloves in the hallway unless he was cleaning something up. R23: R23's admission MDS dated [DATE], indicated resident was cognitively intact with diagnoses that included recurrent enterocolitis due to Clostridium difficile (bacterial infection that can cause diarrhea), thrombocytopenia (low blood platelet count), sleep apnea, history of falling, and malaise. R23 required a moderate level of assistance for ADLs and was frequently incontinent of bowels. During observation on 5/19/25 at 2:39 p.m., physical therapy aide (PTA)-A entered R23's room. PTA-A was wearing gloves but was not wearing a personal protective gown. PTA-A adjusted R23's shirt collar and left the room. Signs posted in the hallway outside R23's room indicated resident was on contact precautions. Also observed outside resident room was a small cart containing yellow personal protective gowns, bleach based cleaning wipes, and alcohol based hand sanitizer. During interview on 5/19/25 at 2:40 p.m., PTA-A stated being aware of contact precautions for R23. PTA-A explained being in a hurry and was helping a coworker before the end of the shift. PTA-A did not complete hand washing after leaving R23's room. During observation on 5/19/25 at 2:53 p.m., nursing assistant (NA)-B in R23's room taking resident's breakfast order for 5/20/25. NA-B observed not wearing PPE while in R23's room. NA-B did not complete hand washing after leaving resident's room. During observation on 5/20/25 at 9:19 a.m., NA-A entered R23's room carrying tablet computer. NA-A did not put on any PPE before entering R23's room. NA-A exited resident room and did not do hand hygiene before walking away. During interview on 5/20/25 at 9:20 a.m., NA-A stated R23 was on contact precautions due to having C. diff (Clostridium difficile). NA-A explained going into resident room without personal protective equipment was okay since she did not touch the resident. NA-A did not complete hand washing after leaving R23's room. R259: R259's diagnoses list included aftercare following a joint replacement surgery, right artificial knee, heart failure, hypertension, hyperlipidemia, type 2 diabetes, asthma, obstructive sleep apnea, depression, anxiety, and insomnia. During observation on 5/20/25 at 10:06 a.m., signs indicating R259 was on EBP displayed on resident's door observed. NA-C put on gloves and entered R259's room. NA-C changed R259's brief, completed perineal care, and helped resident wash his face and hair. During interview after NA-C left R259's room, NA-C stated not knowing why resident was on EBP. NA-C acknowledged understanding EBP and the need to wear gown and gloves for certain cares. NA-C confirmed wearing gloves and no gown during cares. NA-C further stated he should have worn a gown while giving cares. During an interview on 5/22/25 at 12:39 p.m., the director of nursing (DON) stated she would not expect staff to wear gloves in the hallway unless they were using a hazardous product to clean something. The DON stated this situation was not acceptable, and she also expects staff to wear PPE when precautions are posted. The DON added they have done education to employees on-the-spot regarding precaution types and gloves in the hall. A policy, Hand Hygiene/Glove Use dated 11/8/24, identified: 1. Hand hygiene could be performed with soap and water or alcohol-based hand rub. When hands were not visibly dirty, AHBR would be the preferred method for hand hygiene in the healthcare setting. The policy gave guidelines when soap and water would be used. 2. Steps for glove use: 3. Don gloves before touching non-intact skin, open wounds or mucus membranes. 4. Change gloves during patient care if the hands will move from a contaminated body site to a clean body site. 5. Perform hand hygiene after doffing gloves and donning a new pair. 6. Remove gloves after contact with a patient and/or the surrounding environment using proper technique to prevent hand contamination. 7. Perform hand hygiene after removing gloves. 8. Do not wear the same pair of gloves for the care of more than one patient. 9. Do not double glove. 10. Do not reuse gloves. 11. Do not wear gloves in the hallway. A policy, Enhanced Barrier Precautions (EBP) dated 1/22/25, identified its purpose was to reduce the risk of infectious agent transmission in healthcare settings. EBP, including gowns and gloves, would be used for chronic wounds, including pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers, indwelling medical devices (catheters, tubes, lines, ostomies). To be used when providing high contact resident care such as dressing, bathing, transferring, changing linens, changing briefs, assisting to the toilet, device care or wound care. A policy, Transmission/Isolation Precautions dated 1/1/25, identified transmission-based precautions were actions implemented in addition to standard precautions based on the means of transmission. Contact precautions included gown (impermeable to fluid) gloves, and face mask or shield if splashing was likely. These precautions would be used for things such as clostridium difficile. After performing hand hygiene don gown and gloves prior to entering the room. Remove PPE and dispose of in the appropriate container before leaving the resident room. Perform hand hygiene.

Based on interview, observation, and document review, the facility failed to ensure care was provided to preserve dignity for 2 of 2 residents (R20, R307) who were reviewed for dignity. Findings include: R20: R20's quarterly Minimum Data Set (MDS) dated [DATE], indicated R20 was moderately cognitively impaired with the diagnoses of hyperlipidemia, asthma, depression, anxiety, and diabetes. R20's care plan last revised 5/21/25, indicated R20 required an assist of one personal hygiene. The care plan also indicated R20 had impaired vision and instructed staff to make sure R20's glasses were clean and to remind R20 to wear their glasses. During an observation on 5/20/25 at 9:10 a.m., R20 was noted to have several long hairs on their chin. R20 stated they had not noticed they had chin hairs, and stated if they had known they would want the hairs pulled out. R20 stated staff had not asked if the chin hairs bothered them or offered to assist with removing them. During an observation at 5/21/25 on 9:28 a.m., R20 was noted to have several visible chin hairs. During an interview on 5/21/25 at 2:24 p.m., NA-D stated they would not ask a female resident if they wanted their chin hairs removed. Plucking chin hair was not something they did for residents. During an interview on 5/22/25 at 10:40 a.m., NA-E stated they had not had a situation where they identified a female resident with chin hairs, and didn't think offering to pluck chin hairs was something they would do. During an interview on 5/22/25 at 10:42 a.m., NA-F stated it was a personal thing, some women were embarrassed by chin hairs. If they saw a resident with chin hairs, they would ask the resident if they wanted the hairs plucked. During an interview on 5/22/25 at 11:46 a.m., RN-D stated they would expect their staff would offer to take care of chin hair if they noticed a resident had chin hairs growing. It can be embarrassing for some women to have long facial hairs and not know it. Staff should offer to assist residents with chin hairs removal. During an interview on 5/22/25 at 12:31 p.m., the director of nursing (DON) stated dignity is important, and having unwanted facial hair can be a dignity issue for some residents. To be sensitive to all, we have discussed reviewing and putting facial hair preferences on the care plan at the time residents are admitted to the facility. R307: R307's admission Minimum Data Assessment (MDS), dated [DATE], indicated R307 had intact cognition, diagnosis for fractures, and needed partial to moderate assistance with personal hygiene. Further, the MDS indicated R307 rated the highest importance to clothing choices, bathing preferences and personal belongings. R307's care plan, dated 5/6/2025, indicated personal preferences for facial hair to be removed to maintain dignity. R307 needed assist of one with bathing, transfers, dressing, and personal hygiene. During an observation and interview on 5/19/25 at 4:19 p.m., R307 had white facial hair covering the entire chin area approximately ¼ inch long. In addition, the area under the nose and above the lip were covered with white hairs approximately ¼ long. R307 stated after a fall at home an ambulance transported her to the hospital, she caught a glimpse facial hair in the mirror and felt embarrassed, would not leave home with facial hair, and stated clearly that facial hair bothered her. During an observation on 5/20/25 at 3:41 p.m., facial hair was still present on R307. During an interview on 5/21/25 at 9:40 a.m., R307 stated facial hair bothers me and asked if it could be seen. If I was at home I would pluck them, I have some tweezers at home. There are a lot of things I don't have here. During an interview on 5/21/25 at 11:55 p.m., registered nurse (RN)-A was unaware of R307's facial hair and would take care of it. During an interview on 5/21/25 at 11:55 a.m., the director of nursing (DON) stated the facility needs to find a way to address this topic during admission concern over asking female residents about facial hair. The DON was unaware of R307's concerns of facial hair and how it made her feel and suggested possibly getting an electric razor. During an interview on 5/22/25 at 12:15 p.m., the DON stated staff assisted R307 with a disposable razor, R307 told her she had never been shaved before, but it made her feel better. Facility policy, Dignity dated 3/25, identified residents groomed as they wish. Facility policy, AM Cares dated 4/25, identified shaving women and men's facial hair.

Based on observation, interview, and document review, the facility failed to implement new orders for 1 of 1 resident (R26) with fluid retention and failed to recognize hypertensive blood pressure readings and follow provider orders for as-needed (PRN) blood pressure medication for 1 of 1 resident (R307) reviewed with hypertension. Findings Include: R26: R26's admission MDS (Minimum Data Assessment) dated 5/12/25, indicated R26 was cognitively intact and had diagnoses of cardiorespiratory (heart & lung) conditions, coronary artery disease, heart failure, hypertension, diabetes mellitus, and respiratory failure. R26's care plan dated 5/16/25, indicated diuretic therapy, congestive heart failure intervention such as assessments, monitored labs, documented weights, recorded fluid amounts, and administered cardiac medications. R26's provider orders identified the following: -5/7/25 give furosemide (a medication used to rid the body of excess fluid) 80 milligrams (mg) in the morning, and 40 mg later in the day for heart failure. The order was discontinued on 5/19/25. -5/15/25 a faxed medication order indicated to increase furosemide to 80 mg twice a day (8 a.m. and 4 p.m.). Hold for dizziness/lightheadedness or diarrhea and give furosemide 40 mg instead. R26's medication administration record (MAR) for May 2025, indicated furosemide 80 mg was given in the morning, and furosemide 40 mg was given at 12 p.m. from the 15th through the 18th. Progress notes for R26 identified the following: -5/15/25 at 10:02 a.m., indicated the provider was made aware of R26's weight gain and would start R26 on 80 mg of furosemide twice a day (BID). -5/21/25 at 4:45 a.m., indicated R26 complained of chest pain and was transported by emergency medical services (EMS) to the hospital. Facility-provided emails dated 5/15/25, identified medical doctor (MD)-A and registered nurse (RN)-A discussed new order for R26. A follow-up email was sent on 5/19/25 at 11:39 a.m., RN-A stated the order sent over on 5/15/25 was missed. During an interview on 5/19/25 at 5:37 p.m., family member (FM)-A stated the provider increased an order for furosemide last week, the order was sent to RN-A, and labs would be checked on Monday, 5/19/25. FM-A stated after the care conference on 5/19/25, MD-A called FM-A back and explained the facility staff didn't enter the new orders for furosemide from last week. During an interview on 5/21/25 at 1:11 p.m., RN-A stated the provider would either give a verbal order or send an email because providers at the hospital use a different computer system. The facility nurses would then enter the order into the electronic medical record (EMR). The main source of communication was through email or verbal communication. The faxed orders went into the resident's paper chart. RN-A confirmed a fax was received on 5/15/25 for R26 to increase the dose of furosemide to 80 mg twice a day and to hold for dizziness, light headiness, or diarrhea and to give furosemide 40 mg instead. During an interview on 5/21/25 at 1:21 p.m., the director of nursing (DON) verified there was no order in R26's EMR updating the furosemide order of 5/15/25. At 3:43 p.m., the DON confirmed the facility did not follow up with the provider on Friday, 5/16/25, for clarification of the medication order received on 5/15/25. During an interview on 5/21/25 at 6:31 p.m., MD-A stated she saw R26 on 5/15/25, and wrote and faxed a new order for furosemide to be increased to 80 mg twice a day. MD-A stated they didn't hear anything back after the original email was sent, so on Monday 5/19/25, after reviewing R26's chart, she emailed RN-A and increased the furosemide orders. MD-A confirmed RN-A didn't attempt to clarify the medication orders on Friday, 5/16/25 or at any time over the weekend. MD-A stated the facility could contact her directly by phone or contact triage regarding order clarification. MD-A stated the furosemide order did delay R26's progress but didn't directly cause harm. MD-A stated the facility had notified her R26 was sent to the hospital with chest pain this morning, and didn't believe the missed medication order and the chest pain were related. A facility policy, Order Transcription dated 10/24, identified verification and communication of orders/transcription and verification: HUC/nurse reviews chart after provider visit to check for any new orders. Orders must be transcribed into the EHR. A second licensed staff member must confirm the order placed in the EHR. Double verification by another nurse is required for medications or critical treatments. Order is faxed to the pharmacy. Schedule labs or special supplies as needed. Staff uploads any paper copies of order(s) into EHR. Examples: telephone orders, physician written order(s), referral forms, etc. Communication to the care team. R307: R307's admission MDS dated [DATE], identified intact cognition and diagnoses of renal insufficiency and hypertension. R307's MDS also indicated a fall prior to admission that resulted in a fracture. R307's care plan dated 5/7/25, identified a problem statement for hypertension and included interventions to administer anti-hypertensive medications, monitor blood pressure readings and any side effects and report these to the provider. R307's medication order dated 5/9/25, identified hydralazine hydrochloride (HCL) oral tablet 25 mg with directions to give as needed for hypertension three times a day as need for blood pressures with the top number (systolic) above 160 and the bottom number (diastolic) over 110. R307's MAR dated May 2025, identified hydralazine HCL 25 mg tablet had never been administered. From 5/9/25 through 5/19/25, R307's blood pressure summary report indicated 10 incidents where the blood pressure readings met criteria to report to the provider and to administer hydralazine HCL 25 mg. R307's progress notes for May 2025 failed to document provider notification of elevated blood pressures or that anti-hypertensive medications were given. During interview on 5/21/25 at 9:47 a.m., RN-C stated the process for an abnormal blood pressure would be to first check if there was a PRN medication for pain and elevated blood pressures, for example hydralazine. Then her skill set would be used through assessment and reviewed vital signs to determine interventions. The EMR would be reviewed, PRNs could be given, the provider and the nurse manager would be notified and then reassess the patient. During an interview on 5/21/25 at 11:21 a.m., RN-B stated the nurses completed vital signs for their own residents, and if an abnormal vital sign was received, they would use their assessment skills, check the PRN medications, notify the provider and the nurse manager by phone or email. RN-B stated most residents with blood pressure management have PRN orders for hydralazine, it was a very common medication given in the facility. RN-B added once the resident was treated and the plan was completed, a progress note was placed in the residents' chart showing the nurses had followed up on the order with either medication or a different plan the provider wanted to follow. RN-B confirmed nursing assistants didn't check vital signs in this facility, so if there was an elevated blood pressure that was not reported to a provider or medication was not given, then a nurse didn't use their assessment skills. RN-B stated the importance of giving anti-hypertensive medications was elevated blood pressures could result in stroke. During an interview on 5/21/25 at 2:55 p.m., the DON confirmed the completed neurological sheet completed on 5/19/25 documenting the elevated blood pressures after R307's fall. The DON confirmed the elevated blood pressures should have been documented into the EMR, but confirmed the provider was notified of the fall. The DON stated the RNs involved with caring for R307 at the time of the fall felt the blood pressure and the fall could have been related because medication was not given to reduce the blood pressure. The nurse continued to monitor the blood pressures as they decreased and never administered any medications. The provider agreed with this plan and the details of this conversation were documented. The DON confirmed it would be a medication error for missed doses every time R307 had an elevated blood pressure and there was no provider notification or no anti-hypertensive medication administered. Further, the DON stated her expectation would be if a nurse received an abnormal vital sign, they would notify the provider, provide interventions, and check the PRN orders. During an interview on 5/21/25 at 6:56 p.m., MD-A stated she was notified R307 had a fall on 5/19/25, but staff failed to clarify R307's blood pressure was elevated prior to the fall and was unaware of any other instances of elevated blood pressures prior to 5/19/25 when MD-A assumed R307's care. MD-A confirmed elevated blood pressures could cause headaches, stroke, chest pain, congestive heart failure, but didn't feel the elevated blood pressure and the fall were related in this scenario. Facility policy, Change of Condition/Notification dated 3/25, identified attending physicians/nurse practitioner were to be contacted of all health status changes immediately. Facility policy, Medication Administration dated 3/10/23, identified medications were administered as prescribed in accordance with good nursing principles and practices.

Based on interview and document review, the facility failed to report immediately, no later than 2 hours, to the State Agency (SA), in accordance with established policies and procedures, an allegation of staff to resident abuse for 1 of 3 residents (R5) who were reviewed for allegations of abuse. Findings include: R5's admission Minimum Data Set (MDS) assessment dated [DATE], identified R5's cognitive status was unable to be determined and had diagnoses which included stroke, hypertension (elevated blood pressure), and aphasia (a language disorder that affects a person's ability to understand and communicate language.) Identified R5 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R5's care plan revised 9/16/24, identified R5 was at risk for vulnerability related to recent placement and R5 would remain free from any physical, mental and emotional harm. Care plan directed staff to cue and intervene as needed for safety. During an interview on 9/23/24 at 11:52 a.m., family member (FM)-A stated on 8/8/24, R5 called her and was very upset and crying. However, due to R5's aphasia, FM-A stated she was not able to understand R5 over the phone so she went to the facility the next morning to discuss with R5 in person. FM-A stated on 8/9/24, R5 informed her that a staff member made a gesture by putting their middle finger up and directed it at R5 during cares. FM-A stated R5 was visibly upset as they talked about it. During the interview, R5 put her middle finger up as an example of what had happened to her. FM-A stated both she and R5 felt that what the staff member did was an abusive gesture toward R5. FM-A stated she had notified the social worker (SW) on 8/9/24, regarding the allegation of abuse toward R5. Review of facility reported incidents to the SA lacked documentation of the SA being notified of the allegation of abuse toward R5. During an interview on 9/23/24 at 3:11 p.m., SW stated FM-A had informed her R5 reported a staff member put up their middle finger towards R5. SW stated she attempted to talk with R5 however, because of R5's aphasia, SW was not able to completely understand what R5 was attempting to say. SW reported the allegation of abuse to the director of nursing (DON). SW stated she did not feel the incident was reportable to the SA since SW had not heard the allegation of abuse directly from R5 therefore, the allegation of abuse was only FM-A's interpretation and may not have actually happened. During an interview on 9/24/24 at 8:50 a.m., DON stated he spoke with R5 on 8/9/24, after he was made aware R5 was upset. DON stated after talking with R5, he had assumed R5 was upset with the hospital she had been at prior to being admitted to the facility. DON verified the allegation of abuse had not been reported to the SA since he was not aware of the allegation of abuse. DON stated if he had been informed of the allegation of abuse, he felt that was a reportable event and his expectation would have been that it would have been reported immediately but no more than two hours after forming the suspicion of abuse. During an interview on 9/24/24 at 9:40 a.m., administrator stated on 8/9/24 , FM-A had called her and stated R5 was very upset and someone should check on R5. Administrator stated she had not been told why R5 was upset however, had told DON that R5 was upset and asked DON to go and visit with R5. Administrator stated at that time, DON had felt R5 was in her normal state. Administrator stated since DON had not determined any allegation of abuse had occurred after visiting with R5, she did not feel it was a reportable event. Administrator indicated if DON had determined there had been an allegation of abuse, it would have been a reportable event. Review of a facility policy titled Vulnerable Adult - Abuse Prohibition Plan (Preventing,Screening, Identifying, Preventing, Training, Protecting, Reporting and Response, Investigating, to Maltreatment, Accidents and Unusual Occurrences) revised 10/6/22, identified mandated reporters in skilled nursing facilities ensured that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, and a report made immediately, but not later than 2 hours after the allegation made was identified. Policy defined verbal abuse as use of oral, written or gestured language which willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance regardless to their age, ability to comprehend or disability. Speaking to the resident in a derogatory manner or using profanity against them.

Based on interview and document review, the facility failed to complete an investigation and ensure protection for residents following an allegation of a staff to resident abuse for 1 of 3 residents (R5) investigated for abuse. Findings include: R5's admission Minimum Data Set (MDS) assessment dated [DATE], identified R5's cognitive status was unable to be determined and had diagnoses which included stroke, hypertension (elevated blood pressure), and aphasia (a language disorder that affects a person's ability to understand and communicate language.) Identified R5 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R5's care plan revised 9/16/24, identified R5 was at risk for vulnerability related to recent placement and R5 would remain free from any physical, mental and emotional harm. Care plan directed staff to cue and intervene as needed for safety. During an interview on 9/23/24 at 11:52 a.m., family member (FM)-A stated on 8/8/24, R5 called her and was very upset and crying. However, due to R5's aphasia, FM-A stated she was not able to understand R5 over the phone so she went to the facility the next morning to discuss with R5 in person. FM-A stated on 8/9/24, R5 informed her a staff member made a gesture by putting their middle finger up and directed it at R5 during cares. FM-A stated R5 was visibly upset as they talked about it. During the interview, R5 put her middle finger up to show what happened to her. FM-A stated both she and R5 felt that what the staff member did was an abusive gesture toward R5. FM-A stated she had contacted the social worker (SW) on 8/9/24, and reported the allegation of abuse toward R5. Review of facility reported incidents to the SA lacked documentation of an investigation report being submitted to the SA. During an interview on 9/23/24 at 3:11 p.m., SW stated FM-A had informed her R5 reported a staff member had made a gesture towards her with her middle finger. SW stated she attempted to discuss with R5 and because of R5's aphasia, SW was not able to understand what R5 was trying to say. SW reported the allegation of abuse to the director of nursing (DON). SW stated she had not completed any further investigation regarding the allegation of abuse since she was unable to determine if the abuse had actually occurred. During an interview on 9/24/24 at 8:50 a.m., DON stated he was made aware that R5 had been upset and talked with R5 on 8/9/24,,about it. DON stated after talking to R5, he had assumed R5 was upset with the hospital she had been at prior to being admitted to the facility. DON stated he was not aware of the allegation of abuse and as a result an investigation of the allegation had not been completed. DON verified the unidentified alleged perpetrator (AP) would have had continued access to R5 and other vulnerable residents as a result of not completing an investigation. DON stated if he had known about the allegation of abuse, an investigation would have been completed and the AP would have been removed from the schedule during the investigation. During an interview on 9/24/24 at 9:40 a.m., administrator verified no investigation had been completed regarding the allegation of abuse of a staff member towards R5. As a result, the unidentified AP would have had continued access to R5 and other vulnerable residents. Administrator stated had the allegation of abuse been verified, the facility would have immediately initiated an investigation and removed any AP's from the schedule pending the investigation. Review of a facility policy titled Vulnerable Adult - Abuse Prohibition Plan (Preventing,Screening, Identifying, Preventing, Training, Protecting, Reporting and Response, Investigating, to Maltreatment, Accidents and Unusual Occurrences) revised 10/6/22, identified during the shift that the alleged abuse/neglect, unexplained injury or suspected crime was first observed, a mandated reporter/covered individual would immediately make an initial report to their supervisor, after securing the resident's safety. Steps would be taken to ensure that no resident in the facility remained in danger of maltreatment, including medical intervention if needed. Further identified immediate steps were taken to protect the vulnerable adult from harm while the situation was being investigated and the original reporter was assured that retaliation was not tolerated. Upon report to a supervisor of the suspected abuse, the employee in question would be interviewed, and suspended pending investigation. This was for the protection of the resident.

The facility failed to ensure dishware was cleaned and sanitized in a manner to reduce the risk of foodborne illness. This had potential to affect all 42 residents. Findings include: During observation and interview on 6/17/24 at 6:36 p.m., dietary (DA)-A loaded silverware, forks, and spoons in the dish washer. The dish washer temperature was 142 for wash cycle and 188 for rinse. Trays went through the washer, and the wash temperature was 142 and rinse temperature was 188. Plates went through the washer, and the washer temperature was 140 and the rinse temperature was 190. Items washed were being placed or stacked for later use. DA-B and DA-A referred to director of culinary (CD) and dining room coordinator (DRC) when asked about the dish washer temperatures. During subsequent observation and interview, CD stated the dish machine was a heat machine and a chemical rep comes out once a month. Dish detergent and dish rinse aid were observed to be attached to the dish machine. DRC stated they regularly put silverware, glasses, and other items through the dish washer multiple times as a standard practice. DA-B was stacking dishes and placing away from clean area of dish washer, and DRC directed DA-B to bring silverware to be washed through the dish machine again. CD reviewed the temperature log where dish washer temperatures were recorded, and the log indicated for the wash temperature to be 150 to 165 and the rinse temperature to be at least 180. The log directed staff to notify supervisor and/or maintenance immediately if temps not as specified. The log indicated wash temperatures between 140 to 174 and rinse temperatures between 165 to 192, and the dish washer temperatures for dinner had not been recorded yet. CD stated the timing of checking the dish washer temperatures surrounding meals varied but usually was done prior to washing dishes to ensure the dish washer was running correctly. More dishes ran through the dish washer, and DRC verified the wash temperature at 142 and rinse at 190. DRC pointed to a stick on the front of the machine which indicated 140 was the low temperature and 150 the high temperature. DRC pointed to different setting which may be used to wash heavier More dishes were washed, and CD verified wash temperature of 144 and rinse temperature of 190. CD expected staff to tell them when the dish machine was not getting to the correct temperatures, and then CD contacted maintenance who fixed immediately. DRC stated if they could not use the dish washer, they used plasticware until fixed again. During observation on 6/18/24 at 10:06 a.m., the dish machine had a manufacturer sticker which identified the minimum wash temperature as 150 and the minimum rinse temperature as 180. During interview on 6/20/24 at 12:39 p.m., DA-C stated they checked dish washer temperatures after breakfast, lunch, and dinner meal. DA-C stated the wash temperature either needed to be 140 or 150 and higher and 180 for the final rinse temperature. DA-C stated they would let senior chef or CD know if the dish washer was not getting up to appropriate temperature. During follow up interview on 6/20/24 at 1:38 p.m., CD verified the dish machine in the transitional care unit kitchen was a high temperature dish washer and stated they wanted to provide safe food service and did not want residents to get sick from the food service. The facility provided [NAME] TempStar manual dated 8/31/23, directed operators to refer to the machine data plate for specific water requirements. The facility policy Cleaning Dishes with Dish Machine dated 2/19, indicated the wash temperature must reach temperatures between 140 to 160 degrees and rinse temperature must reach 180 degrees or higher. The policy and procedure directed staff to monitor temperatures throughout the dish washing process and record one set of temperature for each meal service.

Based on interview and document review the facility failed to ensure comprehensive care plans were developed for montioring side effects in 2 of 5 residents (R4, R147) reviewed for antipsychotic drug use. Findings include: R147 had a diagnosis of dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R147's physician's orders dated 6/12/24, indicated quetiapine fumarate (Seroquel) oral tablet 25 milligrams (mg). Give 12.5 mg by mouth as needed for anxiety twice a day. R127's care plan lacked any indication of side effect montioring for antipsychotic medications. During interview on 6/20/24 at 9:50 a.m., the director of nursing stated residents who were taking an antipsychotic medication should also be monitored for side effects (on the care plan). During interview on 6/20/24 at 10:57 a.m. the Pharmacist stated she had made a recommendation on 6/18/24 to monitor for side effects, add non pharmacological interventions for psychotropics and monthly orthostatic blood pressure for R147 since she was taking an antipsychotic medication. The pharmacist also stated these recommendations should have been started at the time the antipsychotic was prescribed and while developing the care plan 46885 R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 admitted to the facility on [DATE], had intact cognition, did not have behaviors, did not reject care, had depression, and took an antidepressant 7 out of 7 days. R4's Care Area Assessment (CAA) dated 5/20/24, indicated R4 had depression and took fluoxetine 40 mg every day and had an order for trazodone for insomnia and had not used the medication. Further, the CAA indicated, adverse consequences of antidepressants exhibited by R4 included an increased risk for falling and depression. R4's care plan dated 5/23/24, indicated R4 would remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood through the review date and interventions indicated to monitor, document, and report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. The care plan lacked interventions for monitoring for side effects. R4's Physician's Orders form indicated the following orders: 5/14/24, trazodone HCl Oral Tablet (trazodone HCl) Give 50 milligrams (mg) by mouth as needed for Sleep. 5/14/24, fluoxetine HCl Oral Capsule 40 MG (Fluoxetine HCl) Give 40 mg orally one time a day for depression. The Physician's Orders form was reviewed and lacked any monitoring for side effects. R4's Consultant Pharmacist's Medication Regimen Review form dated 5/21/24, indicated to update the care plan and kardex to include behavior, intervention and side effect monitoring for continued fluoxetine, trazodone, and atarax as needed use. During interview on 6/20/24 at 10:39 a.m., the pharmacist consultant (PC)-D stated she completed a medication review on 5/21/24 and recommended indications for medications along with updating the care plan to include behavior monitoring, non pharmacological interventions, and side effect monitoring for psychotropic medications. PC-D stated she expected staff should have already address the care plan interventions by now. During interview on 6/20/24 at 1:41 p.m., the director of nursing stated each area nurse manager printed off recommendations and gave them to the nurse practitioner and stated since the facility was a transitional care unit (TCU), they try to turn around the recommendations quickly and expected the nurse's to follow up within 5 business days. DON further stated R4 had a depression care plan to monitor for harm but stated R4 did not have anything regarding nonpharmacologic interventions and side effect monitoring for the psychotropics and stated it should be in the care plan but did not see anything in R4's care plan.

Based on interview, observation, and document review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) for 1 of 3 (R4) residents who had a Foley catheter reviewed for infection prevention and control. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, was dependent on staff for toileting hygiene, toileting transfers, had an indwelling catheter. R4's Medical Diagnoses form indicated under a heading, Special Instructions, EBP-Foley. Additionally, R4's diagnoses included: unspecified fracture of the lower end of the left femur (thigh bone), periprosthetic fracture (fracture around a joint replacement prostheses) around unspecified internal prosthetic joint, and retention of urine. R4's Physician Orders form lacked information under the heading Special Instructions. Additionally, an order dated 6/10/24, indicated the following: Change catheter and overnight bag every month and as needed unless otherwise directed. R4's care plan provided on 6/20/24 at 11:45 a.m., indicated under a heading, Special Instructions, EBP-Foley. The information under the heading, Special Instructions, was undated. Additionally, R4's care plan dated 5/23/24, indicated R4 had an indwelling catheter for urinary retention and interventions lacked instructions for EBP. R4's care sheet lacked information R4 was on EBP. R4's hospital encounter summary dated 5/14/24, indicated R4 had postoperative urinary retention and a history of urinary incontinence and failed a voiding trial on 5/9/24 and a catheter was replaced on 5/10/24. Further, discharge orders indicated a trial of voiding at the transitional care unit (TCU) in 5 days, and if R4 failed, can consider a urology evaluation as an outpatient. During observation on 6/17/24 at 1:55 p.m., nursing assistant (NA)-B was wearing gloves, but no gown and drained urine from R4's catheter into a cylinder and then poured it down the toilet. No signs were located on R4's door for EBP and no carts were located outside R4's door. During interview and observation on 6/17/24, at 2:09 p.m., R4 had a Foley catheter and stated she had the catheter because she could not get up to go to the bathroom and had the catheter since she was in the hospital. There was no EBP signage. During interview and observation on 6/18/24 at 11:57 a.m., NA-C was in R4's room and donned gloves and had a cylinder with urine and brought the cylinder into the bathroom. NA-C did not have a gown on. NA-C wiped up a spill on the floor below where R4's catheter was located. NA-C stated she emptied R4's catheter and verified she wore gloves but did not wear a gown and stated anyone who was on precautions had signage inside the doorway and verified R4's room lacked any signage and stated R4 did not have any precautions. NA-C further stated the infection control nurse put signage up for residents on precautions and NA-C went by the signage to know if anyone was on precautions. During interview on 6/18/24 at 12:10 p.m., trained medication aide (TMA)-A stated the signage on doors let staff know what type of precautions a resident was on. TMA-A further stated she had education on EBP and thought residents with catheters should be on EBP and staff should wear a gown, mask, and gloves. During interview on 6/18/24 at 12:14 p.m., licensed practical nurse (LPN)-A stated residents on EBP had signage posted and residents who had a catheters, wounds, or IV's, were on EBP and verified R4's doorway lacked signage and stated staff would not know R4 was on EBP and would let the infection preventionist know there was no signage. During interview on 6/18/24 between 1:14 p.m., and 1:17 p.m., LPN-A stated she had the isolation cart ready and planned to add signage for R4. At 1:17 p.m., LPN-A stated she explained to R4 she needed EBP because of the catheter. During interview on 6/18/24 at 2:48 p.m., NA-D stated R4 was alert and oriented and able to report reliable information. During interview on 6/20/24 at 9:32 a.m., the director of nursing (DON) stated staff were alerted to EBP because there would be an isolation cart and signage to indicate what isolation precautions someone was on, and it would also indicate what kind of personal protective equipment (PPE) to donn when going into the room. Further, the DON stated he expected EBP to be in place to prevent infection. A policy, Enhanced Barrier Precautions, dated 4/1/24, indicated EBP expanded the use of PPE beyond situations in which exposure to blood and body fluids was anticipated and referred to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multi drug resistant organisms (MDROs) to staff hands and clothing. EBP are indicated for residents with an infection or colonization with a CDC (Centers for Disease Control) targeted MDRO when contact precautions do not otherwise apply, or wounds and or indwelling medical devices. The policy lacked information on where staff look to know whether a resident was on EBP.

Based on interview, and document review, the facility failed to ensure residents that were prescribed psychotropic medications were monitored for side effects, for 2 of 5 residents (R4, R147) reviewed for unnecessary medications and the facility failed to ensure non pharmacologic interventions were in place for R4 who had psychotropic medications ordered. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 admitted to the facility on [DATE], had intact cognition, did not have behaviors, did not reject care, had depression, and took an antidepressant 7 out of 7 days. R4's Care Area Assessment (CAA) dated 5/20/24, indicated R4 had depression and took fluoxetine 40 mg every day and had an order for trazodone for insomnia and had not used the medication. Further, the CAA indicated, adverse consequences of antidepressants exhibited by R4 included an increased risk for falling and depression. R4's care plan dated 5/23/24, indicated R4 would remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood through the review date and interventions indicated to monitor, document, and report as needed any risk for harm to self, suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. The care plan lacked interventions for monitoring for side effects. R4's Physician's Orders form indicated the following orders: 5/14/24, trazodone HCl Oral Tablet (trazodone HCl) Give 50 milligrams (mg) by mouth as needed for Sleep. 5/14/24, fluoxetine HCl Oral Capsule 40 MG (Fluoxetine HCl) Give 40 mg orally one time a day for depression. The Physician's Orders form was reviewed and lacked any monitoring for side effects. R4's Consultant Pharmacist's Medication Regimen Review form dated 5/21/24, indicated to update the care plan and kardex to include behavior, intervention and side effect monitoring for continued fluoxetine, trazodone, and atarax as needed use. During interview on 6/20/24 at 10:39 a.m., the pharmacist consultant (PC)-D stated she completed a medication review on 5/21/24 and recommended indications for medications along with updating the care plan to include behavior monitoring, non pharmacological interventions, and side effect monitoring for psychotropic medications. PC-D stated she expected staff should have already address the care plan interventions by now. During interview on 6/20/24 at 1:41 p.m., the director of nursing stated each area nurse manager printed off recommendations and gave them to the nurse practitioner and stated since the facility was a transitional care unit (TCU), they try to turn around the recommendations quickly and expected the nurse's to follow up within 5 business days. DON further stated R4 had a depression care plan to monitor for harm but stated R4 did not have anything regarding nonpharmacologic interventions and side effect monitoring for the psychotropics and stated it should be in the care plan but did not see anything in R4's care plan. 42586 R147 had a diagnosis of dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R147's physician's orders dated 6/12/24, indicated quetiapine fumarate (Seroquel) oral tablet 25 milligrams (mg). Give 12.5 mg by mouth as needed for anxiety twice a day. R147's medication administration and treatment administration record (MAR/TAR) for June of 2024 lacked any indication of side effect monitoring for antipsychotic medications. R127's care plan lacked any indication of side effect montioring for antipsychotic medications. During interview on 6/20/24 at 8:38 a.m., licensed practical nurse (LPN)-B stated when a resident takes an antipsychotic medication, side effect monitoring should be done. LPN-B further stated the nurse manager and the health unit coordinator (HUC) were responsible for putting in those orders and the nurses were responsible for making sure it was completed by documenting side effects on the medication administration and treatment administration records (MAR/TAR). LPN-B verified R147 was taking Seroquel and had no side effect monitoring. During interview on 6/20/24 at approxiately 8:45 a.m., the nurse manager registered nurse (RN)-A stated she would expect a resident who was taking an antipsychotic medication to also be monitored for side effects. RN- verified R147 was taking an antipsychotic and had no antipsychotic montioring in place. During interview on 6/20/24 at 9:50 a.m., the director of nursing stated residents who were taking an antipsychotic medication should also be monitored for side effects (on the care plan). During interview on 6/20/24 at 10:57 a.m. the Pharmacist stated she had made a recommendation on 6/18/24 to monitor for side effects, add non pharmacological interventions for psychotropics and monthly orthostatic blood pressure for R147 since she was taking an antipsychotic medication. The pharmacist also stated these recommendations should have been started at the time the antipsychotic was prescribed and while developing the care plan. The facility's policy regarding psychopharmacological drug use last revised on 10/6/22, indicated the resident will be monitored for the effectiveness of the medication or possible adverse consequences. Results will be documented in the resident's active record. It further indicated behavioral interventions means modification of the residents behavior or environment, including staff approaches to care, to the largest degree possible to accommodate the resdient's behavioral symptoms. Nursing services, social services and other members of the interdisciplinary team will address the behavior in progress notes, care plans, on the nursing assistant care sheets/kardex, treatment medication sheets or other forms per facility behavior monitoring program. Medication use is not the sole approach for behavioral interventions. Other interventions will be identified in the care plan.

Based on observation, interview, and document review, the facility failed to ensure a Foley catheter was removed according to physician orders for 1 of 1 resident (R4) who was admitted to the facility with an indwelling Foley catheter. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, was dependent on staff for toileting hygiene, toileting transfers, had an indwelling catheter. R4's Medical Diagnoses form indicated the following: unspecified fracture of the lower end of the left femur (thigh bone), periprosthetic fracture (fracture around a joint replacement prostheses) around unspecified internal prosthetic joint, and retention of urine. R4's hospital encounter summary dated 5/14/24, indicated R4 had postoperative urinary retention and a history of urinary incontinence and failed a voiding trial on 5/9/24, and a catheter was replaced on 5/10/24. Further, the hospital discharge orders indicated a trial of voiding at the transitional care unit (TCU) in 5 days, and if R4 failed, could consider a urology evaluation as an outpatient. R4's Care Area Assessment (CAA) dated 5/14/24, indicated R4 had a diagnosis of urinary retention and admitted with a Foley catheter and all catheter cares were by nursing. Additionally, the CAA indicated there was no order for a voiding trial and R4 was assisted with the bedpan for bowel movements upon request. R4's Physician Orders form indicated the following orders 5/19/24, monitor/record/report to the medical doctor signs and symptoms of a urinary tract infection, pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Make sure output is recorded in point of care. 5/19/24, catheter care every shift. Document on characteristics of urine and output, make sure the urine bag is hanging below the level of your waist and check for kinks. 6/10/24, Change catheter and overnight bag every month and as needed unless otherwise directed. R4's Physician Orders form was reviewed and lacked the order for a trial of voiding at the transitional care unit (TCU) in 5 days and if R4 failed, can consider a urology evaluation as an outpatient. R4's medication administration record (MAR) and treatment administration record (TAR) was reviewed for May 2024, and June 2024, and lacked information a voiding trial was completed. R4's care plan dated 5/23/24, and revised on 6/6/24, indicated R4 had an indwelling catheter for a diagnosis of urinary retention and the goal was to remain free from catheter related trauma through the review date. Interventions indicated R4 required catheter care every shift and as needed, the catheter bag and tubing should be positioned below the level of the bladder and away from the entrance room door, the tubing should be checked for kinks, monitor intake and output as per facility policy, monitor for signs and symptoms of discomfort on urination and frequency, monitor, record, report to medical doctor signs and symptoms of a urinary tract infection, and observe and document pain and discomfort due to the catheter. R4's care sheet indicated R4 was incontinent of bowel and bladder. During interview and observation on 6/17/24, at 2:09 p.m., R4 had a Foley catheter and stated she had the catheter because she could not get up to go to the bathroom and had the catheter since she was in the hospital. During interview on 6/18/24 at 1:19 p.m., licensed practical nurse (LPN)-A stated she was not aware of any trial for removing R4's catheter and stated R4 had been at the facility a few times and could not recall R4 having a catheter on previous admissions to the facility and stated she would have to look in R4's chart to see why R4 had a catheter. During interview on 6/18/24 between 1:50 p.m., and 2:09 p.m. registered nurse (RN)-A stated if a resident had a catheter, they discussed with the provider and voiding trials were documented in the orders and they documented a bladder scan and how much resident was going and how much residual was documented in the treatment administration record (TAR). RN-A stated admission orders were located in the document tab and verified in the orders that R4 was to have a voiding trial with in 5 days of admission and stated she did not think R4 had a trial and would have expected R4 to have a trial. RN-A further stated the admission orders were supposed to be located in the computer and in the resident's hard chart. RN-A viewed R4's medication administration record (MAR) and TAR and verified there was no documentation of a voiding trial. RN-A further viewed R4's progress notes and verified there was no documentation a voiding trial was completed. RN-A stated it was important to complete a voiding trial because of the risk of infection and stated the longer a catheter was in, the longer it took to recover and stated she did not know how the order was missed and stated generally they had a health unit coordinator (HUC) and another nurse check the orders. At 2:09 p.m., RN-A viewed the hard chart and verified the order for the trial of voiding and stated the order had been missed. During interview on 6/18/24 at 2:48 p.m., NA-D stated R4 was alert and oriented and able to report reliable information. During interview on 6/20/24 at 8:40 a.m., R4 stated she just had the catheter removed. During interview on 6/20/24 at 9:29 a.m., the director of nursing, (DON) stated orders were placed in the electronic medical record (EMR) for catheter cares. During interview on 6/20/24 at 9:31 a.m., RN-B stated they completed a comprehensive bowel and bladder assessment and look for the reason for the catheter and then document in the EMR. During interview on 6/20/24 at 9:32 a.m., DON stated there may be an order on admission to remove a catheter and they would ask the nurse practitioner about a voiding trial and if a resident failed a voiding trial, they referred out. DON further stated if a resident had a voiding trial he expected the trial to be documented and stated R4 did not have parameters for the voiding trial and expected the nurse practitioner to provide parameters and further expected staff to clarify the orders and expected staff to document if they sought clarification. DON stated it was important to complete a voiding trial to make sure a resident was not retaining urine. A policy, Catheter Care, dated 9/2023, indicated it was the policy of the facility to provide care to the individual who must use an indwelling catheter with care that meets the necessary standards of infection control and dignity. An indwelling catheter will only be used after all other alternatives have been explored to minimize the risk of infection and GU (genitourinary) trauma. The catheter will be removed as soon as possible after the risks and benefits have been evaluated.

Based on observation, interview, and document review the facility failed to develop and implement interventions to prevent pressure ulcers. The facility further failed to ensure residents with current pressure ulcers were turned and repositioned timely for 1 of 2 residents (R13) reviewed for pressure ulcers. Findings include: R13's admission Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and a diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, chronic pain, and polyneuropathy. It further indicated R13 had impairment on both sides of upper and lower extremities, required substantial/maximal assistance with bed mobility, and was at risk for and had (1) unstageable facility acquired (not present on admission) deep tissue injury. R13's care area assessment (CAA) for skin was triggered and indicated the following: -at risk for skin breakdown due to decreased mobility, decreased range of motion (ROM) to upper/lower extremities, residual right hemiparesis, bowel incontinence, use of Foley catheter, and use of Apixaban 5 milligrams (mg) twice a day which may cause easy bruising. -admitted with a PICC line in his right upper arm with catheter checked for length, peripherally inserted central catheter (PICC) line dressing change per order. -deep tissue injury (DTI) to his right heel. Orders for heel protectors, barrier film twice a day with army battle dressing (ABD) and wrapped in Kerlix per order. He will be seen by wound physician's assistant on 6-6-2024. -requires assistance with bed mobility and transfers, using an alternating pressure mattress (APM) and needs assistance with turning/repositioning/offloading every 2 hours and as needed. -all catheter cares done by nursing, checked/changed and offered bedpan for bowel movements, assisted with pericare, incontinent pad change, and wears an incontinent pad for his comfort. -receiving physical and occupational therapy (PT/OT) and expected to improve in some of his activiites of daily living (ADL). -Braden score is 10 and again 15, at risk, weekly skin audits. R13's admission assessment dated [DATE] indicated, no skin issues. R13's physician's orders dated 6/8/24 indicated, reposition every 2 hours and as needed. R13's comprehensive skin assessment dated [DATE] indicated, a Braden score of 10, high risk, no pressure reducing device in bed/chair, risk factors-cognitively impaired, requires assistance with ADL's, bowel incontinence, no pedal pulses, no interventions. Patient is a two assist with all ADL's and is incontinent of bowel. Nursing staff will check on the patient every hour and offer assistance with all ADL's as needed. R13's care plan dated 5/26/24 indicated, R13 had an ADL self-care performance deficit related to physical deconditioning/acute cystitis with an intervention of asssistance of (2) staff for repositioning and turning in bed. R13's care plan dated 5/31/24, further indicated R13 had an actual impairment to skin integrity and potential for further impairment to skin with an intervention to turn and reposition every 2 hours in bed and/or chair. R13's progress note dated 5/29/2024, indicated pressure wound found on right heel today. See wound notes for measurements. New orders from physician's assistant which include heel protectors at all times, APM, barrier film x2 to area, allow to dry, cover with ABD and Kerlex twice daily. Message left to update son. During continuous observation and interview on 6/18/24 from 10:15 a.m. to 1:00 p.m. the following was observed/occurred: -10:15 a.m. occupational therapist (OT)-A was leaving R13's room and stated R13 required assistance to reposition and was unable to do so by himself due to severe back pain. OT-A further stated during therapy R13 had been repositioned. -10:18 a.m. R13 was laying in bed on his back with the head of bed (HOB) slightly elevated and a pillow between his right arm and the bed rail. -10:25 a.m. licensed practical nurse (LPN)-A enterd R13's room and asked what his pain level was. -10:35 a.m. LPN-A exited the room and stated while in the room, she had applied R13's pain patch to his neck, looked at/assessed his feet, fixed his watch so it wasn't pinching his skin, checked his PICC line dressing and assessed his pain level. LPN-A did not repostion R13. -10:40 a.m. speech therapist (SLP)-A entered the room -10:53 a.m. nursing assistant (NA)-A entered the room and asked R13 what he would like for lunch. -10:54 a.m. SLP-A exited the room and stated she was talking to him about the difficulty of eating certain foods and liquids. SLP-A also stated she didn't do any cares with R13. -10:55 a.m. NA-A exited room. -11:08 a.m. R13 was in the same position. -11:18 a.m. R13 put on the call light, NA-A entered room, asked How can I help you? and then stated Oh, you want some more water. -11:19 a.m. NA-A exited the room. -11:21 a.m. NA-A entered the room with a glass of water. -11:24 a.m. NA exited the room and stated she brought the resident some water and had to thicken it. R13 was in the same position. -11:54 a.m. R13 was in the same position. -12:04 p.m. NA-A entered room with R13's lunch tray, set it up for him, and exited at 12:05 p.m. -12:07 p.m. NA-A R13 was in the same position except the HOB was elevated to a sitting position. -12:17 p.m. same position, no staff have entered the room. -12:28 p.m. NA-A removed R13's meal tray from his room, R13 was in the same position. -12:50 p.m. R13 was in the same position, no staff have entered the room. -1:01 p.m. NA-A stated the last time R13 was repositioned was about an hour or two ago then she stated Well actually I put the head of his bead back down about a half hour ago and asked him if he was comfortable, but the last time I actually turned him on his side was about two hours ago. During interview on 6/20/24 at 11:26 a.m., NA-A stated the NA's complete rounds every 2 hours which included checking/changing briefs and re-positioning, also as needed. NA-A further stated if a resident refused to have their brief changed or to re-position they try to reapproach them later and if they still refuse, they should let the nurse know and document it. During a follow up interview on 6/20/24 at 1:01 p.m., NA-A stated the last time R13 was repositioned was about an hour or two ago then she stated Well actually I put the head of his bead back down about a half hour ago and asked him if he was comfortable, but the last time I actually turned him on his side was about two hours ago. During interview on 6/20/24 at 7:25 a.m. LPN-B stated nurses were responsible for completing skin assessments twice a week on bath days. If they observe a new skin concern they are required to fill out a skin check form, if there are no new skin concerns they can just check it off on the treatment administration record (TAR) that it was completed. When a resident was admitted to the facility the receiving nurse was responsible for documenting if a resident was at risk for or had any skin alterations and then the nurse manager was responsible for adding interventions. It was the nurse managers responsiblity to follow up and make sure it was care planned. LPN-B further stated NA's were responsible for completing rounds every 2-3 hours which included checking/changing briefs, repositioning, and seeing if the resident needed anything. Repositioning would be considered to be when a resident was laying on their back and then would be repositioned on their side or using pillows to relieve pressure on one area of the body. Raising/lowering the HOB by itself would not be considered repsotioning a resident. NA's should report refusals by resident to reposition and the nurses should document it. During interview on 6/20/24 at 7:38 a.m., NA-E stated NA's should complete rounds every 2-3 hours and included checking/changing brieds and repositioning. NA's generally reposition residents from side to side, or onto their back if they are on their side and raising/lowering the HOB would not be considered repositioning a resident. During interview on 6/20/24 at 8:20 a.m., the nurse manager registered nurse (RN)-A stated nurses and managers were expected to put in interventions on the admission assessment depending on what the receiving nurse triggered and she would expect skin interventions to be added right away upon admission, if the resident was at risk for skin breakdown. RN-A further stated re-positioning a resident would be considered side to side, onto their back, or raising the HOB and the feet, not just raising the HOB by itself. Also, asking a resident if they are comfortable dosen't mean they shouldn't be offered to be reprositioned. we want to prevent those skin breakdown. Usually in a TCU the residents need help to do those things and staff should encourage them. We want to prevent skin breakdown. RN-A also verified R13 didn't have any skin interventions added upon admission (before 5/29/24 when a pressure ulcer was noted on his heel). During interview 6/20/24 at 8:40 a.m., the director of nursing (DON) stated nurses were responsible for completing skin checks once a week on bath day and documenting it in the medical record. THe DON further stated interventions should be added right away on admission when a resident was at risk for skin breakdown. The DON would not consider raising/lowering the HOB of a resident to be repositioning. The facility's policy on the management of skin alterations dated 5/24/24, indicated on admission, readmission, quarterly, and significant change in condition, each resident will have a skin risk assessmentt and Braden assessment for determination of risk. Appropriate interventions will be implemented based on assessment and will be placed on resident care plan.

Based on observation, interview, and document review, the facility failed to provide interventions to prevent elopement of 1 of 3 residents (R1) reviewed for elopement. This resulted in an immediate jeopardy (IJ) for R1 who eloped after making repeated attempts to leave the facility. Findings include: The IJ began on 1/5/22, when R1 eloped from the facility. R1 was found five blocks from the facility walking along a high traffic street and R1 had crossed over a freeway overpass. R1 was carrying his continuous positive airway pressure ([CONDITION(S)]) machine, and was wearing only a long-sleeved shirt, pajama pants, and shoes in subzero wind chill temperatures. The administrator and director of nursing (DON) were notified of the IJ at 3:50 p.m. on 1/11/22. The facility implemented corrective action to prevent recurrence by 1/7/22, so F689 was issued at past non-compliance. R1's Face Sheet printed on 1/12/22, indicated R1's diagnosis included cerebral infarction (stroke) dementia, dysphagia, and [CONDITION(S)]. R1's admission Cognitive Assessment conducted on 1/4/22, indicated R1 was oriented to person, had confusion and was severely cognitively impaired. R1's admission Elopement Risk Assessment on 1/4/22, indicated he was a new admission, and was not a known elopement risk. On 1/5/22, at 11:42 p.m. a progress note written by registered nurse (RN)-A indicated R1 spent the entire day in his room with his wife and son. At around 8:30 p.m. RN-A overheard another nurse talking with R1, asking R1 where his room was. RN-A went and took R1 back to his room, and R1 stated he was going home. The progress note indicated RN-A told R1 maybe he could return home the following day, but R1 insisted he was going home. The progress note indicated R1 kept going to the exit, and required redirection back to his room. RN-A called R1's wife and had R1 talk to her for a couple of minutes. R1 kept telling his wife he was in a motel, and was ready to come home. The progress note indicated R1 argued with his wife on the phone for a while, and then told her he would see her that evening. R1 immediately left his room and RN-A continued to follow R1 redirecting him. R1 kept seeking the exit, and RN-A redirected him with the help of nursing assistant (NA)-A. The progress note indicated R1 had his [CONDITION(S)] machine in hand. During this time, RN-A had a call from the emergency room (ER) regarding another resident. RN-A documented he saw NA-A holding R1's hand and walking towards his room. At 9:20 p.m. RN-A sat down to print the paperwork which needed to be faxed to the ER. RN-B passed by and asked how RN-A's day was, and RN-A stated it was stressful due to a patient exit seeking. RN-B asked if it was the resident who was newly admitted . The progress note indicated RN-A immediately ran towards R1's room and asked NA-A where R1 was, and NA-A replied he was in his room in bed. RN-A ran to R1's room to check, but R1 was nowhere to be found. RN-A immediately initiated an alarm, and everyone went looking for R1. R1 was not located, and RN-A called 911 at exactly 9:40 p.m. and requested help. Staff continued their search throughout the facility. At exactly 9:56 p.m. RN-A was notified R1 had been found by the police. R1 was assessed, and paramedics arrived and took R1 to the hospital. On 1/6/22, at 12:09 p.m. a progress note written by the DON indicated R1 had gone down the elevator near the and staff were looking for him. 911 was immediately called and the administrator was informed. Police located R1 several blocks away and returned him to the facility. R1 was sent to the hospital for evaluation, and preliminary contact with the hospital indicated R1 was uninjured. The progress note incorrectly indicated nursing staff indicated R1 was not showing any elopement tendencies prior to the incident. On 1/11/22, at 9:37 a.m. R1's family member (FM)-A was interviewed and stated she left around 7:30 p.m. on 1/5/22, and R1 had expressed he wanted to go home. Later in the evening, R1 called her at home and stated he was leaving the facility to go home; he believed he was staying in a motel. FM-A stated she told R1 he needed to stay at the facility. FM-A stated she was notified by the DON shortly after the elopement, and was told R1 was found wearing only a long-sleeved sleeping shirt and lounge pants. FM-A stated R1 was a little unsteady on his feet and usually ambulated with a cane or walker. FM-A stated she was told the nurse working with R1 was called away to take a call from the hospital when the elopement occurred. On 1/11/22, at 10:31 a.m. NA-A was interviewed and stated he was the NA who was assigned to work with R1 on 1/5/22. NA-A stated R1's family was there most of the evening, and left at approximately 9:00 p.m. NA-A stated R1 tried to leave, and said multiple times he wanted to go home. NA-A stated R1 required redirection back to his room multiple times. NA-A stated he saw RN-A redirecting R1 to his room, away from exits, and away from the elevators. NA-A stated R1 was wearing a white long sleeve T-shirt, pajama pants, and socks and shoes. On 1/11/22, at 10:52 a.m. RN-A was interviewed and stated he was the nurse assigned to work with R1 on 1/5/22. RN-A stated R1 did not show signs of exit seeking until after his family left at approximately 7:30 p.m. RN-A stated at approximately 9:00 p.m. he talked to R1, who stated he was at a motel and wanted to go home. RN-A stated R1 began going towards the exit signs, and seemed like he was trying to leave. RN-A stated the exit signs did not point directly to the exits, so R1 was trying to go through doorways of other residents' rooms, which required repeated redirection away from these rooms. RN-A stated he followed R1 around for a period observing his behavior. RN-A stated he was going to look through R1's chart to try and find out more about his history, when he received an urgent phone call and request for another resident's medical record to be faxed to hospital staff. RN-A stated he walked R1 back to his room, and returned to the nursing station to address the hospital's request. RN-A stated R1 came right back out of his room and told RN-A he wanted to go home. RN-A stated he had R1 call his wife to talk to her to see if it would help convince him he was not at a motel and needed to stay here, but it was not effective. RN-A stated R1 required continuous redirection, but eventually he had to leave R1 alone and attend to the medical record request. RN-A stated he observed NA-A holding R1's hand and walking with him while he completed the medical record request. RN-A stated he spoke to NA-A after he finished and asked where R1 was, and NA-A stated he put R1 to bed his room. RN-A stated he was not concerned of R1's wherabouts after that conversation. RN-A stated RN-B walked by and asked him how his night was. RN-A stated it was a difficult night as R1 was continually trying to elope. RN-B stated she had just pointed a man in the direction of the unit elevators, but he just looked like a regular guy. RN-A stated he became concerned and immediately went to check on R1, but R1 was not in his room. RN-A stated he gathered staff and all began a search for R1. RN-A stated he called 911 providing a description of R1 as wearing a light top, pajama pants, with socks and shoes. RN-B stated he immediately contacted the DON, and staff searched every floor for R1. RN-A stated eventually a call came in R1 had been located a few blocks away, and was being returned to the facility by police. RN-A stated he covered R1 with warm blankets, began checking his vital signs (VS) and was completing a full assessment when paramedics arrived and took over. RN-A stated even though R1 was exit seeking, and telling staff he wanted to go home, R1 was not put on any type of checks or increased supervision prior to the elopement. On 1/11/22, at 11:33 a.m. RN-B was interviewed and stated she was working on 1/5/22. RN-B described the evening of 1/5/22. RN-B stated she was talking to RN-A, and he stated it had been a difficult night due to R1's attempts to elope. RN-B stated she returned to her unit, and few minutes later NA-A approached her looking for R1. RN-B stated there was a man looking for the elevator not long ago, and she pointed the elevator out for him. RN-B stated she did not know what R1 looked like but believed it was not R1 as he was wearing a brown jacket, yellow mask over his mouth, and was fully clothed. RN-B stated she had to ask the man to put his mask up over his nose and he complied. RN-B stated she and NA-A left to search for R1. RN-B stated RN-A called 911 and gave a description of R1, while she called the DON and administrator to update them of the situation. All floors were notified R1 was missing, and all floors were searched. Approximately 7-10 minutes after the search began, they received a call from the police stating they found R1. RN-B stated when R1 returned, they began an assessment and got warm blankets to cover him with. RN-B stated someone contacted the doctor, she was not sure of what was said as she had to leave as her shift had ended at 10:00 p.m. RN-B stated she was not sure of what interventions were implemented prior to the elopement. On 1/11/22, at 12:14 p.m. the DON was interviewed. The DON stated the facility does not have a secure (locked) unit, and they were careful to screen residents prior to admission. The DON stated they will not admit residents if there is a concern they will elope. The DON stated they did serve residents with memory loss, but not those who wander. The DON stated they did not find concerns with R1 with his preadmission screening. The DON stated she worked late on 1/5/22, and was out on the units dealing with a variety of things that day. The DON stated she left the building at approximately 9:00 p.m. and elopement concerns with R1 were not brought to her attention. The DON stated RN-B called her just as she was arriving home. The DON stated RN-B thought she may have seen R1 get on the elevator. The DON stated on her way back to the facility at 9:50 p.m. RN-B called her again stating R1 was found by the police. The DON arrived back at the facility, and the police told her he was found on [NAME] Ave and 62, she was unsure if it was highway 62 or 62nd street. The DON stated R1 had an initial temporal temperature of 93 degrees Fahrenheit (F) after he had come back into the facility. The DON stated R1 was a new admission and was on 1-hour checks for 2 days, as this was their protocol for new admissions. The DON stated staff did not initiate more frequent checks or increase his supervision prior to his elopement. They DON stated they had reviewed video footage and confirmed R1 used the elevator and left the facility through the front entrance. The Edina Police Department (EPD) Event Report on 1/5/21, indicated the call from the facility came into dispatch at 9:41 p.m. R1 was found by a Good Samaritan (GS) at 9:47 p.m. who phoned 911. The GS described to 911 R1 was in his pajamas and carrying his [CONDITION(S)] machine. The GS stayed with R1 at the corner of 62nd Street and [NAME] Ave until the EPD arrived. Paramedics were contacted due to concerns of frost bite to R1. The temperature in Edina, MN on 1/5/22, at 9:00 p.m. was 5 degrees Fahrenheit (F) with a wind chill of -14 degrees F. The facility Elopement Risk and Prevention Policy revised in June 2017, directed residents would be screened on admission and as needed for potential elopement risk. The policy lacked direction on what to do if there was an emergent elopement risk. The facility Missing Person Emergency Preparedness Policy revised June 2019, directed any staff member observing a patient attempting to leave the facility shall with proper conduct attempt to prevent such departure. The facility implemented corrective action to prevent recurrence by 1/7/22, when the facility implemented a systemic plan that included the following actions: On 1/6/22, through 1/7/22, the facility reeducated staff on their elopement risk, prevention, and missing person policies. A safety meeting was held on 1/6/22, to review the incident. R1's pre-admission screening was reviewed on 1/6/22. The facility layout was reviewed on 1/6/22. The facility reviewed all residents on their risk for elopement on 1/6/22. The facility contacted the contracted service for their stairwells and elevators to assess options for increased security measures available for stairs and elevators on 1/6/22. A missing resident drill was conducted on 1/7/22. This was verified through staff interviews on 1/11/22, from approximately 10:30 a.m. through 3:25 p.m. Policies and facility investigative files were reviewed on 1/11/22, at 12:57 p.m. which included emails with their elevator service company, EPD reports, assessments, DON staff interview notes, education provided to staff, education sign off sheets, elopement risk prevention policy, safety meetings notes, and elopement mock drills.

Based on interview and document review, the facility failed to ensure 3 of 3 residents (R165, R169, R49) received medications without significant medication errors related to improper transcription, failure to properly identify a resident prior to administration, and failure to implement appropriate procedures for discarding medications when a resident refused them. R169 sustained actual harm, a significant decline in condition, when his diuretic and potassium supplements were not administered per order. Findings include: R169's admission Minimum Data Set ((MDS) dated [DATE], indicated admission date of [DATE]. The MDS indicated R169 was cognitively intact and required assistance with all activities of daily living. R169's Admission Record indicated active [DIAGNOSES REDACTED]. Review of R169's Order Summery Report indicated the following orders: [MEDICATION NAME] (used to treat fluid retention caused by [MEDICAL CONDITION]) tablet, give 20 milligrams (mg) by mouth as needed for [MEDICAL CONDITION] based on R169's daily weight: 126 pounds do not take. ,[DATE] take 20 mg. ,[DATE] take 40 mg. ,[DATE] take 40 mg twice daily and call cardiologist. Document the number of tablets administered. Potassium Chloride extended released tablet, give 20 miliequivalents (mEq) by mouth as needed for [DIAGNOSES REDACTED], take ,[DATE] mEq (,[DATE]) tabs daily as needed. Give 40 mEq everytime 20 mg of [MEDICATION NAME] given. Give [AGE] mEq every time 40 mg of [MEDICATION NAME] is given (see [MEDICATION NAME] order). Document the number of tablets administered. R169's Weights and Vitals Summary indicated the following weights: [DATE], 126.8 Lbs. [DATE], 127.2 Lbs. [DATE], 128.4 Lbs. [DATE], 128.4 Lbs. [DATE], 130.2 Lbs. [DATE], 132.4 Lbs., 127.2 Lbs., 133 Lbs. Review of R169's Medication Administration Record [REDACTED]. Review of nurse practitioner (NP) Progress Notes dated [DATE], indicated R169 had been hospitalized for [REDACTED]. R169 underwent a paracentesis (removal of fluid) on [DATE], with one liter removed. During the NP visit at the facility on [DATE], the NP documented R169's weight was 127.2, lung sounds without crackles or wheezes, Plan was to continue with [MEDICATION NAME] and [MEDICATION NAME] based on daily weight. The note indicated the plan was discussed with nurse. NP reviewed labs from [DATE], with plan to continue with Potassium dose based on [MEDICATION NAME] dose. Review of NP Progress note from visit at facility dated [DATE], indicated lung sounds were clear, plan to continue [MEDICATION NAME] ,[DATE] mg daily based on daily weight and monitor volume status, heart rate, and blood pressure very closely. R169's TAR's dated ,[DATE] and ,[DATE], indicated following the NP visit, R169 received the scheduled [MEDICATION NAME] and correlating Potassium. Review of facility Progress Notes dated [DATE], indicated at 10:30 p.m. staff reported to nurse that R169's oxygen (O2) saturation level was 74%. Oxygen was administered and level increased to [AGE]%. Heart rate was 67, temperature 96.8 degrees Fahrenheit (F), blood pressure was ,[DATE], and respiratory rate was 26. At 11:55 p.m. Staff reported to nurse increased weakness while transferring. At 12:50 a.m. R169 stated I feel like I have to throw up. R169 was placed on side for comfort with emesis basin. 02 was 94% on 2L of oxygen, heart rate [AGE], and respiratory rate was 24. At 12:51 a.m. nurse charted they were informed of R169 gasping for air with wet gurgles and advised R169's nurse to call 911 immediately for transport. At 1:00 a.m. two nurses entered the room to find R169 unresponsive and cyanotic (blue or gray in color), with fixed pupils. R169's oxygen saturation level was 71%, blood pressure ,[DATE], respiratory rate 32 and gasping, and heart rate 67. 911 was called at 1:09 a.m. At 1:20 a.m. emergency medical verified R169 had no heart rhythm. During interview on [DATE], at 12:54 p.m. Registered Nurse (RN)-A confirmed R169's medications had not been administered as prescribed by the physician for 3 days. RN-A stated that since the incident with R169, the process for transcribing orders had been changed. During an interview on [DATE], at 1:16 p.m. NP- A stated she was able to recall R169 and stated the nurses had reported R169 looked bad the night he expired. NP-A stated staff had called the on-call, but this may not have been done early enough. NP-A verified staff should have given R169 [MEDICATION NAME] based on his weight. NP-A further stated the error had been found on the 30th after rounding with the physician. NP-A stated, R169 required 02 on the 27th when I saw him, the medication error could have contributed to his decline and death. During interview on [DATE], at 2:25 p.m. RN-A described the process for transcribing medications. RN-A stated when orders were faxed to the facility, the health unit coordinator (HUC) or a nurse would start entering them. When the resident arrived for admission, the final orders were compared to the ones already transcribed, and the orders were then checked again by a nurse. RN-A stated a third check was completed on the night shift by a nurse. RN-A stated this had been the facility's process for over a year. RN-A confirmed R169's medication error had been found by the NP and brought to the attention of nursing staff and the director of nursing (DON) during rounds. R165's admission MDS dated [DATE], indicated cognition was intact and indicated R165 required assistance with activities of daily living. R165's Admission Record indicated admission to the facility on [DATE], with active [DIAGNOSES REDACTED]. Review of a medication error report dated [DATE], identified R165 had been administered medications meant for the roommate. The medication error report indicated prevention of the error was to identify the resident by asking the resident their name before administration. As a result of the medication error, the physician requested R165 be evaluated in the emergency room . Review of an initial visit note dated [DATE], indicated R165 was admitted to the hospital on [DATE], and discharged back to the facility on [DATE], after observation overnight in the hospital. R165 remained stable and demonstrated no side effects after the medication error. Review of training titled Identification of patients with medication administration was completed on [DATE], and contained signatures of several staff who completed training. On [DATE], at 9:15 a.m. licensed practical nurse (LPN)-A confirmed training was completed and the medication rights were reviewed as well as how to identify the residents. Review of the facility's policy Administering Medications, indicated a check must be completed to ensure right resident, and this was to be completed by checking the resident's name band, asking a reliable resident for his/her first and last name, or referring to the photo attached to the electronic record. R49's admission MDS dated [DATE], indicated cognition intact and indicated R49 required extensive assistance with activities of daily living. During interview on [DATE], at 3:10 p.m. family member (FM) - B stated earlier that morning a nurse had brought R49 medication. FM-B asked the nurse to get some applesauce to assist with taking the medications. R49's medications were left with the family while the nurse left to get the applesauce. During the nurse's absence FM-B looked at the medications and counted six pills instead of the nine required. When the nurse returned to the room, FM-B informed the nurse that the medications in the cup were not for R49 and requested to see the nurse manager. Review of performance discussion summary dated [DATE], confirmed the wrong medications were brought in for R49. Nurse had medications in the medication cart from a resident who just refused her medication, instead of discarding those medications as the policy stated, the nurse mixed up the medication cups and brought the wrong medications to R49. Review of the facility's ,[DATE] policy, Medication Error Management, indicated that a no error was an event that had the capacity to cause an error and would be investigated to prevent further errors and resolve system issues.