Every finding on record at Avina of Fond du Lac

Based on observation, interview, and record review, the facility did not ensure food was served at a palatable and appetizing temperature for 3 of 9 sampled residents (R3, R4, and R5).R3, R4, and R5 indicated the facility's food was not palatable and was served at an unappetizing temperature. During the lunch meal on 7/6/26, a test tray contained items that were served below the appropriate temperatures.Findings include:The facility's Food Production and Food Safety 3-29 Food Temperatures policy indicates: The temperatures of all food items will be taken and properly recorded prior to service of each meal .1. All hot food items must be cooked to appropriate internal temperatures, and held and served at a temperature of at least 135 degrees Fahrenheit (F) .cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking .Hot food items may not fall below 135 degrees F after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F (for a minimum of 15 seconds) prior to serving .Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures (i.e., hot/cold carts, pellet systems, insulated plate bases, domes, etc.) .Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to unit storage areas to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods .On 7/6/26 at 9:10 AM, Surveyor interviewed R3 who stated the food is okay but would be more appetizing if it was served at a hot temperature. R3 stated they did not enjoy the food at times because it was served cold. R3 received a room tray for all meals. (R3's medical record contained a Quarterly Minimum Data Set (MDS) assessment, dated 5/6/26, that indicated R3 had moderately impaired cognition.)On 7/6/26 at 9:04 AM, Surveyor interviewed R4 who stated the food is served lukewarm and is unpalatable. R4 expressed dissatisfaction with the temperature and stated they do not want to eat lukewarm or cold food. R4 received a room tray for all meals. (R4's medical record contained a Quarterly MDS assessment, dated 4/24/26, that indicated R4 had intact cognition.) On 7/6/26 at 10:46 AM, Surveyor interviewed R5 who stated the food is served at an unappetizing temperature and is cold or warm at best. R5 stated they do not like the food which would taste better if it was served hot. (R5's medical record contained a Quarterly MDS assessment, dated 4/20/26, that indicated R5 had intact cognition.) During a continuous kitchen observation on 7/6/26 that started at 11:46 AM, Surveyor observed lunch service and noted second floor room trays left the kitchen on a cart at 12:18 PM. At 12:27 PM, Surveyor observed staff serve meal trays to residents on the second floor. The back door of the meal cart was left open during tray delivery. Halfway through tray delivery at 12:37 PM, Surveyor observed Dietary Manager (DM)-D obtain temperatures of food items on a test tray and noted the turkey burger was 110 degrees F and the French fries were 108 degrees F. DM-D left the thermometer in the items for more than 15 seconds. DM-D verified food was not being served at an appetizing or appropriate temperature, and indicated the process for serving room trays should be completed more efficiently. DM-D also stated having plate warmers would assist in serving food to residents at a palatable temperature.

Based on observation, interview, and record review, the facility did not ensure the accurate administration of medication for 1 of 5 residents (R1) in a total sample of 9 residents. R1 had an order for sliding scale insulin to be administered before meals. R1's insulin was not administered in accordance with the order. Findings include:The facility's Medication Administration policy, dated 1/1/25, indicates medications are administered .as ordered by the physician and in accordance with professional standards of practice .12. Compare medication source (bubble pack, vial, etc.) with Medication Administration Record (MAR) to verify name, medication name, form, dose, route, and time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician .23. Administer medication(s) according to the physician order. The facility's Liberalized Medication Pass Times Guideline, dated 3/8/26, indicates the facility will enhance patient-centered care and promote a home-like environment by liberalizing medication administration pass times .Time-critical scheduled medications will be exempt from the liberalized medication pass times and will be administered as designated by the physician (i.e., .insulin prior to meals).R1 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes with chronic kidney disease. A Quarterly Minimum Data Set (MDS) assessment, dated 5/15/26, stated R1's Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicating intact cognition. The assessment also indicated R1 received insulin. A care plan, dated 11/7/25, indicated R1 had type 2 diabetes with chronic kidney disease. The care plan contained interventions to give diabetes medication as ordered by the physician, and monitor and document for side effects and effectiveness. R1's medical record contained the following order:~ Insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 units/milliliter (ml). Inject per sliding scale before meals. Hold if blood sugar is less than 100 (dated 2/12/26) On 7/6/26, Surveyor observed the facility's posted mealtimes which indicated breakfast is served at 8:00 AM; lunch is served at 12:00 PM; and dinner is served at 5:00 PM. On 7/6/26 at 12:04 PM, Surveyor interviewed R1 who stated nurses do not consistently administer their insulin prior to meals. R1 stated they brought up the issue with staff, but nothing changed. R1 indicated they had not received insulin yet and it was time for lunch. Surveyor reviewed R1's MAR's for 5/1/26 through 7/5/26 and noted R1's sliding scale insulin was scheduled before meals at 7:30 AM, 11:30 AM, and 4:30 PM. Surveyor noted of the 198 administration opportunities, 65 (33%) were administered more than 15 minutes after the posted mealtime, 25 (13%) were administered more than an hour after the scheduled administration time, and 1 of 198 corresponding blood sugars was below 100. On 7/6/26 at 12:17 PM, Surveyor observed staff deliver R1's room tray. On 7/6/26 at 12:24 PM, Surveyor interviewed Medication Technician (MT)-C who stated they check R1's blood sugar before meals and administer insulin at mealtime. MT-C stated they had not yet administered R1's 11:30 AM insulin that should be administered prior to lunch. MT-C stated at times insulin is administered after R1 has started or finished eating. MT-C stated there is a one-hour window before and after the scheduled time to administer insulin. On 7/6/26 at 4:05 PM, Surveyor interviewed Director of Nursing (DON)-B who stated R1's sliding scale insulin should be administered before meals or as ordered by the physician. DON-B stated if R1's blood sugar is low, nurses may wait to administer insulin until after R1 has started eating to avoid hypoglycemia. DON-B stated the facility has liberalized parameters for medications ordered for morning, afternoon, or before bedtime. DON-B acknowledged R1's sliding scale insulin was not under those parameters and should be administered before meals.

Based on observation, interview, and record review, the facility did not ensure the provision of foot and nail care for 1 of 3 residents (R2) in a total sample of 9 residents.The facility did not provide toe nail care for R2 in accordance with their care plan or the facility's policy.Findings include:The facility's Nail Care policy, dated 5/2025, indicates: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .4. Routine nail care, to include trimming and filing, will be provided on a regular schedule .Nail care will be provided between scheduled occasions as the need arises .R2 was admitted to the facility on [DATE] and had diagnoses including acute respiratory failure with hypoxia and diabetes. A Minimum Data Set (MDS) assessment, dated 4/22/26, stated R2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. R2 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. A hospital wound consultation, dated 6/13/26, indicated R2 had elongated nails on all ten toes. R2's toe nails were cut without incident. The consultation indicated a concern for the development of pressure injuries to the first, second, and fourth left toes and the third right toe due to the toe nails curling into the skin. On 7/6/26, Surveyor reviewed R2's Treatment Assessment Record (TAR) for April, May, and June 2026. An order for daily diabetic foot checks (dated 4/15/25) was documented as completed on all days. R2's shower sheets indicated they often refused bathing. On 7/6/26 at 9:50 AM, Surveyor interviewed POAHC-H who indicated when R2 was sent to the hospital on 6/12/26, it was identified that toe nail care was not completed as expected. On 7/6/26 at 10:49 AM, Surveyor interviewed R2 who stated staff offered bathing once per week, however, R2 liked to be independent with bathing. R2 stated their toe nails were cut a few weeks ago at the hospital. On 7/6/26 at 3:08 PM, Surveyor interviewed Director of Nursing (DON)-B who acknowledged the toe nail concern from R2's 6/12/26 hospitalization. DON-B stated staff should complete skin assessments with weekly bathing and alert DON-B if there are any concerns. DON-B verified R2's TAR indicated daily diabetic foot checks were completed and confirmed the daily checks should have identified the need for toe nail care.

Based on observation and staff, resident, and family interview, the facility did not ensure a clean, comfortable, home-like environment for residents on the 100 wing. This practice had the potential to affect more than 4 of the 44 residents residing in the facility.A black and/or green, damp, and smudgeable substance was observed on walls and ceiling tiles on the 100 wing. In addition, a brown fuzzy growth was observed on a ceiling tile directly above the entrance to the common area/living room on the 100 wing. Findings include:The Centers for Disease Control and Prevention (CDC) website section titled Mold, dated 5/29/24, indicates: Stachybotrys chartarum is a greenish-black mold. It can grow on material with a high cellulose content, such as fiberboard, gypsum board, and paper. Growth occurs when there is moisture from water damage, water leaks, condensation, water infiltration, or flooding. Constant moisture is required for its growth .At present, no test exists that proves an association between Stachybotrys chartarum and particular health symptoms. Individuals with persistent symptoms should see their physician. However, if Stachybotrys chartarum or other molds are found in a building they should be removed .During an environmental tour of the facility on 4/22/26 beginning at 4:10 AM, Surveyor observed a ceiling tile outside the main dining area on the 100 wing. The tile contained two black fuzzy spots surrounded by a dark gray stain. Ceiling tiles behind the 100 wing nurses' station contained black fuzzy stains that spanned the corners of four tiles that connected in the middle and spread out into the tiles. Surveyor also noted a brown fuzzy stain covered the entire ceiling tile. A sprinkler head was mounted through the tile which was warped and did not correctly fit in the ceiling grid. On 4/22/26 at 6:52 AM, Surveyor interviewed Medication Techniction (MT)-D who stated there was mold in the nourishment room next to the nurses' station due to a leaking ice machine. MT-D was concerned about the mold because it spread over the walls of the room, to ceiling tiles above and behind the nurses' station, and to a bathroom behind the nurses' station. MT-D informed Director of Nursing (DON)-B and Maintenance Director (MD)-J about the concern and stated the mold was a concern since MT-D started at the facility approximately two years ago. MT-D stated the facility stopped using the ice maker because the ice appeared to have mold. MT-D again stated MT-D informed MD-J of the concerns surrounding all areas observed with mold. MT-D indicated there was no action was taken for a long time; however, the bathroom and nourishment rooms were being remodeled in the last week. MT-D informed Surveyor of an area behind the nurses' station that shared a wall with the nourishment room that contained the ice machine. MT-D indicated the area contained mold and was open where residents were.On 4/22/26 at 7:02 AM, Surveyor observed an area underneath the nurses' station that shared a wall with the nourishment room. Surveyor observed a black/green fuzzy stain approximately 6 inches long by 4 inches wide on the wall. The wall appeared bubbled. A baseboard that connected the wall and the nurses' station was falling off and exposed dry wall that contained black stains.On 4/22/26 at 8:07AM, Surveyor interviewed MD-J who verified the ice machine in the nourishment room leaked for a while before it was discovered. MD-J was not sure when the leak was discovered. MD-J stated the leak damaged walls in the nourishment room and spread to bathroom walls behind the nourishment room and nurse's station. MD-J stated approximately six months ago, a resident ran into the ice machine in the nourishment room with a motorized wheelchair. MD-J was not sure when the incident occurred. MD-J had not received concerns from staff or residents regarding the leaky ice machine or wall damage. MD-J and Surveyor then toured the areas Surveyor had previously observed. MD-J verified the ceiling tile outside the main dining area on the 100 wing contained two black fuzzy spots surrounded by a dark gray stain. MD-J stated it was a water stain from when a pipe burst in the ceiling approximately two years ago. MD-J stated MD-J did not pay attention to ceiling tiles and would replace the tile. MD-J and Surveyor also observed ceiling tiles behind the 100 wing nurses' station that contained multiple black fuzzy stains that spanned the corners of four tiles, connected in the middle, and spread out onto the tiles. MD-J stated the stain looked like dirt. MD-J and Surveyor observed an area underneath the nurses' station that shared a wall with the nourishment room. The area contained a black/green fuzzy stain that was approximately 6 inches long by 4 inches wide. The wall appeared bubbled. A baseboard that connected the wall and the nurses' station was falling off and exposed dry wall that contained black fuzzy stains. MD-J was not aware of the stain and stated the area appeared to be dried water. MD-J and Surveyor continued to the 100 wing common area/living room and stopped in front of the entrance to the room where MD-J and Surveyor noted the ceiling tile contained a sprinkler head, had a brown fuzzy stain that covered the entire tile, and was warped and did not fit the ceiling grid. MD-J stated the tile contained water damage from a leaky heating, ventilation, and air conditioning (HVAC) system on the roof. MD-J stated due to the amount of rain in the last week, leaks occurred and damaged the tile. MD-J had not contacted anyone for roof or HVAC repairs.On 4/22/26 at 8:24 AM, Surveyor interviewed R1 who stated the facility had mold on ceiling tiles and areas that were not observed, including bathrooms and walls. R1 felt the mold in common areas affected R1's asthma. R1 stated staff informed R1 there is mold in the facility which made R1 more concerned about things that are not seen. including leaky showers and pipes. (On 4/22/26, Surveyor reviewed R1's medical record. R1 had diagnoses including mild intermittent asthma, migraine with aura, and anxiety disorder. R1's Minimum Data Set (MDS) assessment, dated 2/20/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had intact cognition.)On 4/22/26 at 9:20 AM, Surveyor toured the facility with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who were not aware ceiling tiles contained black/green fuzzy stains, a leaky HVAC system damaged ceiling tiles, and a resident ran into the ice maker in the nourishment room which caused a leak. NHA-A and DON-B observed the ceiling tile above the 100 wing dining room area. NHA-A stated NHA-A could not tell if the stain was mold and indicated the pipe leaked a few years ago. NHA-A and DON-B observed the ceiling tile in the nurses' station and indicated the stain could be dirt. NHA-A and DON-B observed the wall and baseboard underneath the nurses' station and indicated they were not sure the area contained mold, however, it needed to be addressed. NHA-A and DON-B observed the ceiling tile above the entrance to the living room/common area and confirmed the tile was brown, damaged, and warped. NHA-A and DON-B stated they were not aware of the water damage or that there was a leak in the HVAC unit or any unit on the roof.

Based on staff and resident interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of drugs and biologicals for 1 resident (R) (R1) of 5 sampled residents.On 3/13/26, Licensed Practical Nurse (LPN)-I did not administer R1's dose of Estradiol as ordered.Findings include:The Facility's Medication Administration policy, revised January 2026, indicates: .1. Keep the medication cart clean, organized, and stocked with adequate supplies .23. Administer medication(s) according to physician order. 24. Correct any discrepancies and report to nurse manager.On 4/21/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including conversion disorder with motor symptom deficit, polycystic ovarian syndrome, asymptomatic premature menopause, and dysmenorrhea. R1's Minimum Data Set (MDS) assessment, dated 2/20/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had intact cognition.R1's medical record contained following order:~ Estradiol transdermal patch twice weekly 0.025 millgrams (mg)/24 hours (hr) Apply 1 patch transdermally once daily every Monday and Friday for hormones (dated 11/17/25)R1's Medication Administration Record (MAR) contained a 10 (MAR code 10 = Other/See progress note) for Estradiol administration on 3/13/26. (Of note: R1's progress notes did not contain a medication administration, omittance, or provider update for 3/13/26.)On 4/21/26 at 12:22 PM, Surveyor interviewed R1 who stated R1 did not receive an Estradiol patch a few weeks ago because staff could not find it. R1 stated R1 has pain when the patch is not on. On 4/22/26 at 12:54 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who stated LPN-I did not administer R1's Estradiol patch on 3/13/26 because LPN-I could not find the patch and there weren't any nursing staff around to ask. LPN-I verified LPN-I did not enter a progress note in R1's medical record that the medication was not administered and did not notify the provider. LPN-I stated staff administering medication are expected to call the pharmacy or ask another staff if a medication is missing from the medication cart. On 4/22/26 at 1:44 PM, Surveyor interviewed Director of Nursing (DON)-B who stated staff should find the medication or call the pharmacy if the medication is not in the facility. DON-B stated staff should enter a progress note in the resident's medical record if ordered medication is not given and should update the provider.

Based on observation, staff interview and record review, the facility did not ensure a care plan was updated in a timely manner for 1 resident (R) (R2) of 4 sampled residents.R2's care plan was not updated in a timely manner after a resident-to-resident altercation.Findings include:The facility's Care Plan Revisions Upon Status Change policy, dated 1/6/25, indicates: .The comprehensive care plan will be reviewed and revised as necessary when a resident experiences a status change. On 2/11/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, urinary tract infection, and altered mental status. R2's Minimum Data Set (MDS) assessment, dated 1/16/26, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R2 had severe cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC).On 1/20/26, R2 had a physical and verbal altercation with another resident. The facility submitted a facility-reported incident (FRI) to the State Agency and completed an investigation. R2 was placed on 15 minute checks for 72 hours and moved to a different unit.A progress note, dated 1/23/26 at 10:55 AM, indicated R2 was physically aggressive with staff and punched, grabbed, and twisted a staff's breast. R2 laughed and refused to let go.Surveyor noted multiple other progress notes that indicated R2 was physically aggressive toward staff.On 2/11/26 at 10:30 AM, Surveyor reviewed a care plan in R2's electronic medical record. The care plan did not indicate R2 had a history of physical and verbal aggression toward residents and staff or had grabbed staff inappropriately. A care plan, created on 1/20/26 (date of incident), indicated R2 was at risk for sleep pattern disturbance due to using sleep medication and was dependent on staff for meeting emotional, physicial, intellectual, physical, and social needs due to cognitive deficits. The care plan contained interventions for activity-related ideas. A care plan, initiated on 1/26/26, indicated R2 had adjustment issues to admission related to a new environment. The care plan indicated R2 was used to getting up and using the bathroom at home and was used to R2's own environment. The care plan contained interventions that were initiated on 1/26/26. Surveyor requested copies of R2's care plans.On 2/11/26 at 11:28 AM, Nursing Home Administrator (NHA)-A provided Surveyor with copies of R2's care plans. Surveyor reviewed the copies and noted the copies indicated the above care plans and all interventions were created on 1/20/26. Surveyor noted the care plan now indicated R2 was confused at times and had episodes of physical aggression toward residents and staff. Interventions included to redirect R2 when possible, offer 1:1 activities, and call R2's spouse to visit during episodes of high agitation. The interventions were not on the care plan that Surveyor reviewed at 10:30 AM; however, the copies indicated the interventions were added on 1/20/26. Surveyor re-checked the care plans in R2's electronic medical record and noted the history dates indicated the care plan was updated on 2/11/26 and the above interventions were created on 2/11/26. On 2/11/26 at 12:28 PM, Surveyor interviewed NHA-A who was not aware of the 1/23/26 progress note regarding R2 grabbing and twisting a staff's breast. NHA-A confirmed R2's care plan should be updated to include sexual inappropriateness toward staff. Surveyor pointed out the discrepancy between the care plan in R2's electronic medical record and care plan initiation and revision dates on the paper copies provided by NHA-A. Surveyor showed NHA-A the screen history that indicated R2's care plan was updated on 2/11/26 to indicate R2 had a history of physical aggression toward residents and staff and two interventions were added on 2/11/26. NHA-A stated NHA-A accessed R2's care plan but did not make any changes and was not sure why the paper copies showed creation dates of 1/20/26 but R2's electronic medical record indicated the initial care plan was created on 1/26/26 and was updated on 2/11/26 with additional interventions.

Based on observation, staff and resident interview, and record review, the facility did not ensure a clean, comfortable, or homelike environment for 1 resident (R) (R6) of 10 sampled residents. R6 reported to staff that the faucet in R6's bathroom did not work properly. The faucet was not repaired in a timely manner.Findings include:The facility's Reporting Maintenance Issues policy, revised 10/2025, indicates: All maintenance issues that may impact resident safety, clinical care, infection prevention, dignity, or facility operations must be reported immediately using the approved reporting process. Timely reporting is essential to minimize risk and ensure compliance with nursing home regulations and quality standards .7. Documentation: All maintenance issues must be documented, including: Date and time reported; Person reporting the issue; Description and location; Risk level and priority; Actions taken; and Completion date. Records must be retained in line with nursing home policy and regulatory requirements.On 1/5/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had a diagnosis of schizophrenia. R6's Minimum Data Set (MDS) assessment, dated 12/24/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 had intact cognition. On 1/5/26 at 12:15 PM, Surveyor interviewed R6 who indicated R6's bathroom faucet did not work well. R6 told multiple staff about the concern who said Maintenance Director (MD)-C would fix the faucet. R6 stated it had been a month or longer and the faucet was not fixed yet. Surveyor tested the faucet and observed a light trickle of water come out. On 1/5/26 at 12:50 PM, Surveyor interviewed MD-C who stated there were no work orders for R6's room. MD-C stated when items need attention, staff call, text, or tell MD-C in person. MD-C stated housekeepers sometimes fill out work orders. MD-C stated MD-C throws work orders away after they are addressed. MD-C was not aware that R6's faucet needed to be fixed. When Surveyor and MD-C went to R6's room, MD-C acknowledged the faucet did not work properly and began to repair it. On 1/5/26 at 1:30 PM, Surveyor interviewed Housekeeper (HK)-D who was aware R6's faucet did not work well. HK-D stated HK-D wrote down the concern and turned it in approximately a month and a half ago. HK-D worked part-time and thought MD-C fixed things timely. On 1/5/26 at 3:50 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated ways to tell MD-C about a repair included calling, texting, discussing in morning meeting, or filling out a work order. NHA-A verified R6's faucet should have been repaired timely.

Based on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of drugs and biologicals for 2 residents (R) (R1 and R7) of 8 sampled residents.On 9/11/25, Medication Technician (MT)-G administered another resident's medications to R1 and R7. Findings include:The facility's Medication Administration policy, revised 3/2025, indicates: .3. Identify resident by photo in the Medication Administration Record (MAR) .10. Ensure that the six rights of medication administration are followed: a. Right resident; b. Right drug; c. Right dosage; d. Right route; e. Right time; f. Right documentation .11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication, form, dose, route, and time.1. On 1/5/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of bladder, unspecified, infection and inflammatory reaction due to indwelling urethral catheter, and encounter for palliative care. R1's Minimum Data Set (MDS) assessment, dated 9/14/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1's cognition was severely impaired.On 1/5/26, Surveyor reviewed a Resident's Medication Occurrence, dated 9/11/25 and documented by Director of Nursing (DON)-B. The Medication Occurrence indicated R1 was administered another resident's medications on 9/11/25 and did not have a picture in the facility's medical record system. R1 was monitored. R1's vital signs were within normal limits. DON-B, the Nurse Practitioner (NP), Hospice, and R1's family were notified. R1's medical record did not contain a progress note regarding the medication error.R1's MAR indicated R1 was administered: allopurinol 100 milligrams (mg), amlodipine 2.5 mg, a multivitamin, cyanocobalamin 1000 micrograms (mcg), and isosorbide mononitrate extended release 30 mg on the 9/11/25 AM shift. On 1/5/26 at 2:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R1 was administered the following medications in error by MT-G on the morning of 9/11/25: furosemide 40 mg, potassium extended release 10 milliequivalents (mEq), donepezil 25 mg, metoprolol extended release 50 mg, sertraline 50 mg, memantine 5 mg, and ursodiol 300 mg.On 1/5/26, Surveyor reviewed a grievance filed by R1's daughter on 9/12/25 regarding notification of the medication error. 2. On 1/5/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including acute osteomyelitis of the left ankle and foot, aneurysm of the ascending aorta, cerebral infarction, and transient ischemic attack. R7's MDS assessment, dated 12/16/25, had a BIMS score 11 out of 15 which indicated R7's cognition was moderately impaired. On 1/5/26, Surveyor reviewed a Resident Medication Occurrence, dated 9/11/25 and written by DON-B. The Medication Occurrence indicated R7 was administered another resident's medication on 9/11/25 and did not have a picture in the facility's medical record system. R7 was monitored. R7's vital signs were within normal limits. DON-B, the NP, and R7's family were notified.R7's medical record did not contain a progress note regarding the medication error.On 1/5/26, Surveyor reviewed R7's MAR which indicated R7 was administered furosemide 40 mg, potassium extended release 10 mEq, donepezil 25 mg, metoprolol extended release 50 mg, sertraline 50 mg, memantine 5 mg, and ursodiol 300 mg on the 9/11/25 AM shift.On 1/5/26 at 2:15 PM, Surveyor interviewed NHA-A who confirmed R7 was administered the following medications in error by MT-G on 9/11/25: allopurinol 100 mg, amlodipine 2.5 mg, a multivitamin, cyanocobalamin 1000 mcg, and isosorbide mononitrate extended release 30 mg. On 1/5/26 at 1:28 PM, Surveyor left messages for DON-B and MT-G but did not receive return calls.On 1/5/26 at 3:30 PM, Surveyor interviewed NHA-A who indicated R1 was given R7's AM medication and R7 was given R1's AM medication on 9/11/25. NHA-A indicated MT-G reported the medication error to DON-B on 9/11/25 AM after the error occurred. NHA-A stated R1 was admitted on [DATE] and R7 was admitted on [DATE] and their pictures were not in the facility's medical record system. NHA-A also stated the name plaques outside R1 and R7's doors were incorrect. NHA-A indicated R1's family requested a different room when R1 was admitted and R1 was moved across the hall. Prior to R7's admission, NHA-A posted R7's name plaque outside the door but did not change the name plaque after R1 was moved into that room. NHA-A verified MT-G did not complete the 6 rights of medication prior to administering R1 and R7's medications. NHA-A stated MT-G was educated on the 6 rights of medication on 9/16/25 after a medication administration observation was completed. Medication administration observations were completed with 10 staff. NHA-A verified there was no education regarding the accuracy of residents' name plaques or the importance of entering residents' pictures in the medical record system upon admission.

Based on staff interview and record review, the facility did not ensure the right to make healthcare decisions was provided for 1 resident (R) (R1) of 1 sampled resident. R1's Power of Attorney for Healthcare (POAHC) was not activated; however, R1's medical record contained multiple documents signed by POAHC-F. The facility did not have documentation that R1 consented to POAHC-F signing documents on R1's behalf.Findings include:On 1/5/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including encounter for palliative care, severe protein calorie malnutrition, malignant neoplasm of bladder, and type 2 diabetes. R1's Minimum Data Set (MDS) assessment, dated 9/14/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severely impaired cognition. R1 passed away at the facility on 9/21/25. R1's medical record contained a Power of Attorney for Healthcare document that designated POAHC-F as R1's number 2 agent. R1 was not deemed incapacitated upon admission to the facility and was R1's own decision maker. The following documents were signed by POAHC-F: ~ An influenza vaccination consent on 9/8/25~ A COVID-19 vaccination declination on 9/8/25~ Do Not Resuscitate (DNR) paperwork on 9/8/25~ admission paperwork on 9/12/25On 1/5/26 at 11:57 AM, Surveyor interviewed Social Worker (SW)-E who confirmed R1 did not have an activated POAHC during R1's stay at the facility. SW-E stated there was mention of activating R1 prior to R1 passing away. SW-E stated R1 had a hard time signing documents so POAHC-F signed on R1's behalf. The facility did not have documentation that R1 was in agreement with POAHC-F signing documents on R1's behalf. On 1/5/26 at 2:05 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R1 did not have an activated POAHC while at the facility. NHA-A indicated POAHC-F signed a Hospice agreement for R1 and the facility was working on getting R1's POAHC activated when R1 passed away. NHA-A confirmed the facility did not have documentation that R1 was in agreement with POAHC-F signing documents on R1's behalf.

Based on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours per day 7 days per week. This practice had the potential to affect all 43 residents residing in the facility.The facility did not have an RN on duty 8 consecutive hours per day 7 days per week on 1/4/25, 1/5/25, and 2/16/25. From 7/15/25 through 7/17/25, Surveyor reviewed the nurse staffing schedules for sampled days based on the facility's Payroll Based Journal (PBJ). The facility triggered for low weekend staffing for Fiscal Year (FY) Quarter 2 (January 2025 through March 2025). The facility did not trigger for No RN Hours.The facility provided schedules for the following requested dates: 1/3/25, 1/4/25, 1/5/25, 1/6/25, 2/14/25, 2/15/25, 2/16/25, 2/17/25, 3/21/25, 3/22/25, 3/23/25, and 3/24/25.Surveyor cross-referenced the posted nurse staffing schedules with employee punches and noted there was not an RN scheduled on 3 (1/4/25, 1/5/25, and 2/16/25) of the 12 days reviewed.On 7/17/25 at 1:46 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed an RN did not work on 1/4/25, 1/5/25, and 2/16/25. DON-B acknowledged there are days when an RN is not on the schedule or in the building but indicated it is infrequent. DON-B was aware that an RN is required to work 8 consecutive hours per day 7 days per week and indicated the facility does not consistently have an RN on the schedule for weekends. DON-B could not confirm if the facility submitted a nursing waiver to the State Agency.On 7/17/25 at 3:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the facility does not always have an RN on the schedule. NHA-A verified the facility did not submit a waiver to the SA.

Based on observation, staff and resident interview, and record review, the facility did not ensure the safe and accurate administration of medication for 4 residents (R) (R3, R18, R28, and R7) of 23 sampled residents.Medication was observed on R3's overbed table. R3 did not have an assessment or a physician's order that indicated R3 could self-administer medication or store medication at the bedside.Medications were observed in a bin in R18's room and on R18's bedside table. R18 did not have an assessment or a physician's order that indicated R18 could self-administer medication or store medication at the bedside. In addition, R18 did not have an order for one of the medications.Medication was observed on R28's overbed table. R28 did not have an assessment or a physician's order that indicated R28 could self-administer medication or store medication at the bedside. In addition, R28 did not have an order for one of the medications.Medication was observed on R7's bedside table. Self-administration of medication assessments, dated 6/3/25 and 7/15/25, indicated R7 did not want to self-administer medication. Findings include: The facility's Self-Administration of Medication policy, dated 4/9/25, indicates: .1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility’s Interdisciplinary Team (IDT). 2. Resident’s preference will be documented on the appropriate form and placed in the medical record .4. The results of the IDT assessment are recorded on the Medication Self Administration Form which is placed in the resident’s medical record. 5. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the Medication Administration Record (MAR) .8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary .14. The care plan must reflect resident self-administration and storage arrangements for such medications . 1. On 7/15/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including macular degeneration, presbyopia, age related cataracts, and bipolar disorder. R3's Minimum Data Set (MDS) assessment, dated 5/11/25, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. R3’s care plan did not indicate R3 was able to self-administer medication or keep medication at the bedside and stated medications should be given as ordered. On 7/15/25 at 9:59 AM, Surveyor observed R3’s room and noted a container of miconazole nitrate 2% antifungal powder on R3’s overbed table. On 7/15/25 at 9:59 AM, Surveyor interviewed R3 who indicated staff leave the medication on R3’s overbed table. R3 indicated R3 does not self-administer the medication and stated staff apply it daily to R3's affected areas. On 7/16/25 at 10:18 AM, Surveyor noted the miconazole nitrate 2% antifungal powder medication was still on R3’s table. R3 indicated staff had applied the powder earlier that day and left it there. A self-administration of medication assessment, dated 5/5/25, indicated R3 was not able to self-administer medication. In addition, R3's medical record did not contain an order for miconazole nitrate 2% antifungal power to be left at the bedside. 2. On 7/15/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, and depression. R18's MDS assessment, dated 7/14/25, contained a BIMS score of 10 out of 15 which indicated R18 had moderately impaired cognition. R18’s care plan did not indicate R18 was able to self-administer medication or keep medication at the bedside and stated medications should be given as ordered. On 7/15/25 at 10:11 AM, Surveyor interviewed R18 and observed a bin of assorted self-care products and medications on R18's bedside table, including miconazole nitrate 2% antifungal powder and a pharmacy-labeled bag that contained diclofenac sodium 1% topical gel. R18 indicated staff assist R18 with the medications and leave them on the table. A self-administration of medication assessment, dated 2/12/25 and completed by Director of Nursing (DON)- B, indicated R18 was not able to self-administer medication. In addition, R18’s medical record did not contain an order for miconazole nitrate 2% antifungal powder. On 7/16/25 at 10:16 AM, Surveyor again observed miconazole nitrate 2% antifungal powder and diclofenac sodium 1% topical gel on R18’s bedside table. On 7/16/25, Surveyor observed a new self-administration of medication assessment (dated 7/16/25 and completed by DON-B) that indicated R18 could self-administer diclofenac sodium 1% topical gel. The assessment did not address miconazole nitrate 2% antifungal powder and Surveyor noted R18 still did not have an order for the medication. 3. On 7/15/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] and had diagnoses including liver cirrhosis, type 2 diabetes, muscle wasting, and atrophy. R28's MDS assessment, dated 6/25/25, contained a BIMS score of 15 out of 15 which indicated R28 had intact cognition. R28’s care plan did not indicate R28 was able to self-administer medication or keep medication at the bedside and stated medications should be given as ordered. On 7/15/25 at 9:43 AM, Surveyor interviewed R28 and observed [NAME] Pain Relief gel (Biofreeze), DermaSarra external analgesic cream, and Deep Sea Premium saline solution on R28’s overbed table. R28 indicated staff apply the analgesic and pain relief gel on R28's legs and feet for diabetic neuropathy and leave the medications on the table. R28 indicated R28 cannot apply the medications and cannot reach R28's toes. A self-administration of medication assessment, dated 6/18/25, indicated R28 was not able to self-administer medication. R28's medical record did not contain an order for [NAME] Pain Relief gel. On 7/16/25 at 10:20 AM, Surveyor again observed [NAME] Pain Relief gel (Biofreeze), DermaSarra external analgesic cream, and Deep Sea Premium saline solution on R28’s overbed table. On 7/16/25, Surveyor noted R28's medical record contained a new order for Biofreeze (dated 7/16/25) and a new self-administration of medication assessment (dated 7/16/25 and completed by DON-B) that indicated R28 could self-administer Biofreeze and keep the medication at the bedside. The assessment did not address DermaSarra external analgesic cream or Deep Sea Premium saline solution. Surveyor also noted R28’s plan of care had a new entry for Biofreeze to be applied to R28’s lower legs and kept at the bedside. R28's plan of care did not address DermaSarra external analgesic cream or Deep Sea Premium saline solution. On 7/16/25 at 2:16 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-J who indicated there were no residents on R3, R18, and R28's floor who were able to self-administer medication or keep medication at the bedside. On 7/16/25 at 2:18 PM, Surveyor interviewed LPN-K who joined Surveyor's interview with LPN-J. LPN-K confirmed no residents on R3, R18, and R28's floor could self-administer medication or keep medication at the bedside, including R3, R18, and R28. On 7/17/25 at 12:58 PM, Surveyor interviewed DON-B who indicated residents should not keep medication in their rooms unless they have a physician order for beside medication and a self-administration of medication assessment that indicates they can do so. DON-B indicated staff should let DON-B know if a resident wants to self-administer medication or store medication at the bedside. DON-B confirmed all medications should have a physician's order. DON-B indicated care plans should also indicate if residents are able to self-administer medication and store medication at the bedside. DON-B was unsure why R3 and R28 had medications in their rooms that were not prescribed. DON-B indicated DON-B started staff education the previous evening after Surveyor asked about bedside medications for R28 and indicated all staff will be educated on bedside medications, medication orders, and self-administration of medication. When Surveyor asked why R28 was assessed on 6/18/25 as not able to self-administer medication but was assessed as able to do so on 7/16/25, DON-B indicated DON-B spoke to R28 after Surveyor's interview on 7/15/25 and R28 indicated R28 wanted the medications in R28's room. DON-B was not aware R28 was unable to apply the medications independently. 4. From 7/15/25 to 7/17/25, Surveyor reviewed R7’s medical record. R7 was admitted to the facility on [DATE] and had diagnoses including seasonal allergic rhinitis, cirrhosis of liver, and anxiety. R7’s MDS assessment, dated 6/29/25, had a BIMS score of 15 out of 15 which indicated R7 had intact cognition. On 7/15/25 at 10:30 AM, Surveyor observed a bottle of Flonase nasal spray on R7's bedside table. R7 indicated R7 was supposed to self-administer the nasal spray and give it back to the nurse. R7 was not sure if a self-administration of medication assessment was completed or not. On 7/15/25 at 10:59 AM, Surveyor interviewed Med Tech (MT)-N who was not sure if R7 was able to self-administer Flonase. Surveyor also interviewed Assistant Director of Nursing (ADON)-P who indicated R7 was able to keep Flonase at the bedside per a self-administration of medication assessment on 6/2/25. R7’s medical record contained an order for Flonase allergy relief nasal suspension 50 micrograms/actuation, give 1 spray in both nostrils two times a day for allergies. Self-administration of medication assessments, dated 6/3/25 and 7/14/25, indicated R7 did not want to self-administer medication. R7's medical record did not contain an order for self-administration of Flonase. On 7/16/25 at 10:13 AM, Surveyor interviewed R7 who indicated R7 administered Flonase independently that morning while MT-N was not present and then gave the Flonase back to MT-N. On 7/16/25 at 11:13 AM, Surveyor interviewed MT-N, who confirmed MT-N allowed R7 to self-administer Flonase that morning without supervision and indicated R7 had a self-administration order for Flonase. When Surveyor asked to see the order, MT-N indicated MT-N would show Surveyor after MT-N administered medication to another resident. On 7/16/25 at 11:17 AM, Surveyor and MT-N reviewed R7’s medical record and which did not contain a self-administration order for Flonase. MT-N also confirmed R7’s self-administration of medication assessment indicated R7 did not want to self-administer medication. On 7/16/25 at 11:19 AM, Surveyor interviewed DON-B who indicated in order to self-administer medication, R7 should have a self-administration of medication assessment that indicates R7 wants to and is capable of self-administering medication.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R35) of 23 sampled residents received the necessary care and services to prevent or monitor weight loss.R35 had a significant weight loss. Appropriate follow-up was not completed, including timely notification of the physician, Registered Dietitian (RD), and R35's Power of Attorney for Healthcare (POAHC). Findings include: The facility's Weight Monitoring policy, revised 7/11/25, indicates: A comprehensive nutritional assessment will be completed upon admission to identify those at risk for unplanned weight loss, gain, or compromise nutritional status. Assessments should include the following information: .c. Weight (do not use the hospital weight) .3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following .: a. Identified causes of impaired nutritional status; b. Reflect the resident's personal goals and preferences; c. Identify resident specific interventions; d. And parameters for monitoring; e. Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective, or a new cause or nutrition-related problems are identified .6. Weight analysis: The resident's newly recorded weight should be compared to the previously recorded weight. A significant change in weight is defined as: a. A 5% change in weight in one month (30 days); b. A 7.5% change in weight in three months (90 days); c. A 10% change in weight in six months (180 days) .The physician should be informed of a significant change in weight and may order nutritional interventions .The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. F. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate .The facility's Notification of Changes policy, dated 1/20/25, indicates: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status .From 7/15/25 to 7/17/25, Surveyor reviewed R35's medical record. R35 was admitted to the facility on [DATE] and had diagnoses including dementia, congestive heart failure, chronic kidney disease, and mild intellectual disabilities. R35's Minimum Data Set (MDS) assessment, dated 6/25/25, did not contain a Brief Interview for Mental Status (BIMS) score. R35 had an activated Power of Attorney for Healthcare (POAHC).R35's plan of care included the following: Alteration in nutritional status (initiated 2/27/25); COVID-19 positive decreased intake with acute illness (3/2025); Significant weight loss (5/2025); Desired weight gain past month, intake within usual range (6/2025) .Resident will receive adequate nutrition and hydration as evidenced by no weight changes equal to or greater than 7.5% through next care plan review (initiated 2/27/25); Weigh resident per Medical Doctor (MD)/Registered Dietitian (RD) order. Document and notify MD/RD of any significant weight changes (initiated 2/27/25).R35 had a physician order, dated 3/1/25, for weekly weights x 4 weeks then monthly on the first of each month.R35's medical record indicated R35's weight was not obtained upon admission on [DATE] and the first facility documented weight was on 3/1/25. R35's medical record indicated R35 had a severe weight loss of 16.98% in approximately 4.5 months. On 3/1/25, R35 weighed 163.1 pounds. On 7/1/25, R35 weighed 135.4 pounds (which was a -16.98 % weight loss). R35's weight monitoring indicated the following: 3/1/25: 163.1 pounds; 3/10/25: 163.8 pounds; 3/31/25: 163.8 pounds; 4/10/25: 141.3 pounds (which was a 22.5 pound weight loss in 10 days); 4/17/25: 143.2 pounds; 5/1/25: 137.5 pounds; 5/5/25: 137.5 pounds; 5/5/25: 136.1 pounds; 5/19/25: 136.1 pounds; 6/4/25: 145.1 pounds; 7/1/25: 135.4 poundsA progress note, dated 4/21/25 and written by RD-L indicated R35 weighed 143.23 pounds (verified through re-weigh) which indicated R35 had a significant 12.5% weight loss over two weeks (On 3/31/25, R35 weighed 163.8 pounds). The note indicated will continue to monitor weight. On 4/21/25, RD-L requested 4 ounces of a house supplement three times daily for R35. The physician approved the request on 4/22/25. On 5/21/25, the physician ordered nutritional supplements twice daily.R35's medical record did not include any new weight orders related to R35's significant weight loss. Surveyor reviewed R35's Medication Administration Record (MAR) and Treatment Administration Record (TAR) and noted an order for monthly weights on the first of each month. In addition, R35's medical record did not indicate R35's POAHC, physician, or RD-L were notified of the significant weight loss on 4/10/25. The next progress note for R35's weight loss was 11 days later on 4/21/25 in which RD-L noted the weight loss and indicated RD-L would notify the physician. A progress note, dated 4/22/25, indicated the physician was notified of the weight loss and R35's family was updated.On 7/17/25 at 12:58 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R35's loss of 22.5 pounds in ten days should have been addressed right away. DON-B verified RD-L, the physician, and R35's POAHC should have been notified right away and an assessment should have been done with a re-weight. On 7/17/25 at 2:15 PM, Surveyor interviewed RD-L who worked once per week and reviewed residents' weights once weekly. RD-L indicated R35's 4/10/25 weight was obtained just after RD-L had worked and RD-L saw the weight the following week. RD-L asked for a re-weight and saw R35's 4/17/25 weight the next time RD-L worked at the facility. RD-L notified the physician on 4/21/25 of R35's weight loss from 4/10/25 and requested supplements for R35.On 7/17/25 at 3:35 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated RD-L is responsible for tracking weights and following-up as needed with the physician. DON-B indicated it can be problematic if RD-L only reviews weights once weekly. DON-B thought RD-L looked at weights more often and indicated weights should be reviewed more often to address issues more timely. DON-B indicated R35's weight loss should have been addressed sooner than 11 days. On 7/17/25 at 4:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R35's weight loss should have been addressed sooner than 11 days. NHA-A indicated a re-weight should have been done immediately and the physician and RD-L should have been notified right away.

Based on staff interview and record review, the facility did not ensure an evaluation of smoking risks was completed for 1 resident (R) (R29) of 2 sampled residents.A Comprehensive Smoking Evaluation, dated 10/21/24, indicated R29 required supervision while smoking. On 7/10/25, staff completed a Smoking Quarterly Review that indicated R29 did not require supervision while smoking. Staff did not complete a comprehensive evaluation that supported the change from supervised to unsupervised smoking. Findings include:The facility's Resident Smoking Policy, dated 3/2025, indicates it is the policy of the facility to provide a safe and healthy environment for residents, visitors, and non-smoking residents .6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all. A. Residents must be able to take themselves outside and back inside the facility. B. Residents must be able to smoke/vape independently and without supervision .13. Documentation to support decision making will be included in the medical record, including but not limited to: a. Resident's wishes, or those of the resident's representative, b. Assessment of relevant functional and cognitive factors affecting the ability to smoke safely, c. Response to smoking cessation interventions, d. Compliance with smoking policy.From 7/15/25 to 7/17/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including history of traumatic brain injury, alcohol abuse, nicotine dependence, and major depressive disorder. R29's Minimum Data Set (MDS) assessment, dated 4/26/25, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R29 had severe cognitive impairment. R29 had an activated Power of Attorney for Healthcare (POAHC).A Smoking Evaluation (Comprehensive), dated 10/21/24, indicated R29 was disoriented with unclear speech. The evaluation indicated R29 did not exhibit safe smoking awareness and did not have adequate fine motor skills to safely hold smoking materials or remove lit materials that fell on R29. In addition, the evaluation indicated R29 was unable to maintain an upright seated position, was unable to independently transport to the smoking location, and was unable to self-extinguish smoking materials or manage ashes. The evaluation indicated R29 required supervision while smoking.A Smoking Evaluation (Comprehensive), dated 11/13/24, maintained the prior evaluation responses and also indicated R29 required supervision while smoking.A health status progress note, dated 3/14/25 at 2:15 PM, indicated R29 was outside smoking and had brief seizure activity upon return to the unit.A nursing progress note, dated 4/16/25 at 5:45 PM, indicated R29 was outside smoking with R29's POAHC who indicated R29 had a seizure while outside.A Smoking Quarterly Review, dated 4/17/25, indicated there were no changes to R29's initial Smoking Evaluation and indicated R29 required supervision while smoking.A behavior progress note, dated 6/9/25, indicated R29 was outside asking other residents for cigarettes. R29 stated R29 borrowed some from another resident and was paying back what R29 owed. R29 was reminded of the smoking policy.A Smoking Quarterly Review, dated 7/10/25, indicated there were no changes to R29's initial Smoking Evaluation, however, the evaluation indicated R29 was changed from supervised to unsupervised smoking.On 7/17/25 at 10:43 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who was unsure if R29 required supervision while smoking and verified the facility had supervised smoking times. CNA-G stated R29's smoking materials should be kept at the nursing station. CNA-G stated R29's POAHC provides smoking materials to R29 who does not always give them to the nurses.On 7/17/25 at 1:40 PM, Surveyor interviewed Director of Nursing (DON)-B who stated R29 does not require supervision for smoking. DON-B stated DON-B changed R29's smoking status on 7/10/25 after DON-B completed R29's Smoking Quarterly Review which was based on DON-B's observations of R29. DON-B verified a Comprehensive assessment was not completed. DON-B stated R29 was unable to hold a lighter upon admission, however, that had changed. DON-B stated the facility changed the smoking policy on 4/9/25 and no longer allows supervised smoking unless a resident's family is willing to supervise them. DON-B stated an evaluation was done for R29 but confirmed supporting documentation was not completed.On 7/17/25 at 3:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed a new evaluation should have been documented prior to changing R29's smoking status to unsupervised.

Based on staff interview and record review, the facility did not ensure ongoing communication with a dialysis facility for 1 resident (R) (R2) of 1 resident who received dialysis services.R2 received dialysis three times per week. The facility did not ensure ongoing communication between the nursing facility and the dialysis facility prior to and following R2's dialysis appointments. In addition, R2's medical record did not specify which days of the week R2 went to dialysis.Findings include:The facility's Hemodialysis policy, revised 12/2/24, indicates: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis .The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring of complications before and after dialysis treatments .Ongoing assessment and oversight of the resident before, during, and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications.and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .3. The facility will coordinate and collaborate with the dialysis facility to assure that: a. The resident's needs related to dialysis treatments are met . c. Documentation requirements are met to assure the treatments are provided as ordered by the nephrologist, attending practitioner, and dialysis team, and d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home dialysis staff .5. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility, b. Physician/treatment orders, laboratory value, and vital signs, c.Any changes or need for further discussion with the resident/representative , and practitioners, d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions, or the provision of meals before, during, and/or after dialysis and monitoring intake and output measurements as ordered .8. The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications .13. The nurse will ensure the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill .From 7/15/25 to 7/17/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea, end stage renal failure with dialysis dependence, and chronic obstructive pulmonary disease (COPD). R2's Minimum Data Set (MDS) assessment, dated 6/20/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R2 had moderate cognitive impairment. R2 had an activated Power of Attorney (POA).Surveyor reviewed R2's dialysis center communication record forms and noted the following:~ A 6/14/25 form did not have the pre/post facility nurse section completed; A note from the dialysis center requested R2's med list and tuberculosis skin test results for 6/19/25. The 6/19/25 form did not have facility's pre/post note section completed; The dialysis center requested a med list be sent with R2 on 6/21/25; The facility's 6/21/25 form did not have the post dialysis facility nurse section completed. The dialysis center requested R2's med list again; The facility's 6/24/25 and 6/26/25 forms did not have the post dialysis facility nurse section completed; The facility's 6/28/25 and 7/1/25 forms did not have the post dialysis facility nurse section completed; The 7/3/25 form did not have the dialysis nurse section and post dialysis facility nurse sections completed; The facility's 7/5/25, 7/7/25, 7/9/25, 7/11/25, and 7/14/25 forms did not have post dialysis facility nurse sections completed. A hospital Discharge summary, dated [DATE], indicated R2's dialysis days were changed to Tuesday, Thursday, and Saturday to ensure transportation. R2's medical record did not contain an order or care plan that indicated which days R2 received dialysis. In addition, R2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not contain monitoring or documentation related to R2's dialysis access site.On 7/17/25 at 10:36 AM, Surveyor interviewed Med Tech (MT)-N who indicated R2's dialysis days were changed the week of 7/4/25 to Monday, Wednesday, and Friday. MT-N confirmed MT-N received the call from the dialysis center regarding the change and informed Assistant Director of Nursing (ADON)-P. The change was not documented in R2's medical record. When Surveyor asked if R2 had a care plan to ensure pre/post dialysis assessments were completed, ADON-P confirmed R2's medical record did not contain an area to document an assessment of the access site. ADON-P indicated there should be documentation to ensure the access site is assessed for bleeding.Surveyor also noted R2's medical record did not indicate R2's POA was notified of the R2's dialysis schedule change. Surveyor was unable to interview R2's POA during the investigation.On 7/17/25 at 11:55 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated nurses do not chart Permacath (a tunneled hemodialysis catheter used for long-term vascular access) assessments unless there are issues. DON-B indicated staff should assess for thrills/bruits as well as obtain vital signs and monitor for bleeding and infection, however, the assessments are not documented unless they are abnormal. DON-B confirmed R2's POA was not notified of the dialysis schedule change and indicated it was the dialysis center's responsibility to update R2's POA. DON-B indicated R2's dialysis treatment schedule was not documented in R2's medical record and confirmed there was no documentation of MT-N's communication of the schedule change.On 7/17/25 at 4:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, who indicated a resident's medical record should contain their dialysis schedule to ensure staff are aware of the schedule. NHA-A indicated when R2 goes to dialysis, the scheduler puts it in a transport binder at the nurses' station and it is relayed in shift report. NHA-A confirmed the schedule should be noted in R2's care plan and contained in an order. NHA-A also indicated staff should document any communications with the dialysis center and fill out dialysis communication forms with assessments and vital signs pre/post dialysis.

Based on observation, staff interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R16) of 23 sampled residents.During multiple observations, R16's call light was not within reach. In addition, R16's ability to use the call light was not assessed. Findings include: The facility's Call Light Policy, dated 10/2024, indicates: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. 4. Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.). 5. Staff will ensure the call light is within reach of resident and secured as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. From 7/15/25 to 7/17/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] following a stroke, did not have the ability to talk, and was bedridden. R16 had diagnoses including cerebral vascular accident (CVA) (otherwise known as stroke), hemiplegia, dysphasia, neuromuscular dysfunction of bladder, ulcerative colitis, and delirium. R16's Minimum Data Set (MDS) assessment, dated 7/9/25, indicated R16 was severely cognitively impaired and was dependent on staff for toileting, hygiene, transfers, eating, and mobility. R16's fall and bowel and bladder care plans, dated 7/3/25, contained interventions to keep R16's call light within reach. On 7/15/25 at 8:55 AM, Surveyor observed R16 who appeared disheveled. R16's hair was not combed and one boot was off. There were multiple items on R16's floor. A push button call light was clipped to the mattress behind R16 and above R16's head and was not within reach. On 7/15/25 at 11:42 AM, Surveyor noted R16's call light was hung on the wall behind R16 and not within reach. On 7/15/25 at 12:46 PM, Surveyor interviewed Family Member (FM)-M who expressed concerns regarding R16's ability to use the call light and stated staff do not check on R16 often enough. On 7/16/25 at 8:23 AM, Surveyor noted R16's call light was hung on the wall behind R16 and not within reach. On 7/16/25 at 1:17 PM, Surveyor attempted to interview R16, however, R16 was not able to respond or act on Surveyor's request to activate the call light. Surveyor noted the call light was under R16's bedsheet and not within reach. On 7/17/25 at 9:31 AM, Surveyor observed R16's call light under R16's arm pit and not within reach. On 7/17/25 at 11:54 AM, Surveyor interviewed Occupational Therapist (OT)-I who indicated it is nursing staffs' responsibility to determine if a resident has the ability to use a call light. OT-I indicated OT-I had seen R16 pick up the call light but not use the light to call for assistance. On 7/17/25 at 12:01 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who indicated R16 does not use the call light and has never had the ability to use the call light. On 7/17/25 at 1:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who indicated staff determine if a resident has the ability to use a call light and which type of call light to use upon admission. DON-B indicated R16 likely could not use a push button call light since R16 had a CVA. DON-B indicated the facility addresses a resident's inability to use a call light in the resident's care plan with more frequent checks or another type of call light. NHA-and DON-B verified R16's call light should have been within reach and R16's ability to use a push button call light should have been assessed.

Based on staff interview and record review, the facility did not implement policies and procedures to prevent abuse for 3 ((Certified Nursing Assistant)-C, CNA-D, and Laundry Aide (LA)-E) of 8 employees reviewed for caregiver background checks.The facility did not ensure Background Information Disclosure (BID) forms were signed and dated for CNA-C, CNA-D, and LA-E.Findings include:The facility's Abuse Prevention Program policy, dated 3/6/25, indicates the purpose of the policy is to assure the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. The policy indicates this will be done by .conducting pre-employment screening of employees.From 7/15/25 through 7/17/25, Surveyor reviewed caregiver background check information for 8 facility employees and noted the following:~ CNA-C was hired on 4/9/20. CNA-C's BID form was not signed or dated.~ CNA-D was hired on 5/30/25. CNA-D's BID form was not signed or dated.~ LA-E was hired on 6/30/18. LA-E's BID form was not signed or dated.On 7/16/25 at 12:39 PM, Surveyor interviewed Human Resources (HR)-F who was was employed by the facility for approximately 2 years. HR-F stated the missing date and signature on CNA-D's BID form was an oversight on HR-F's part. HR-F stated CNA-C and LA-E were hired prior to HR-F's employment and was unsure why CNA-C and LA-E's BID forms were not signed or dated.On 7/17/25 at 3:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed all employee BID forms should contain a signature and date.

Based on staff and resident interview and record review, the facility did not ensure range of motion (ROM) exercises were completed in accordance with a range of motion program for 1 resident (R) (R6) of 1 sampled resident.An occupational therapy (OT) discharge note indicated R6 was provided ROM exercises to decrease contractures and maintain ROM. R6's plan of care did not include the ROM exercises and staff did not provide ROM for R6. Findings include:From 7/15/25 to 7/17/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including cerebral vascular accident (CVA) (otherwise known as stroke) with aphasia, hemiplegia and hemiparesis affecting the right dominant side, and pressure ulcer of the sacral region. R6's Minimum Data Set (MDS) assessment, dated 4/21/24, had a Brief Interview for Mental Status (BIMS) assessment that was completed by staff due to R6's impaired cognition. R6 had a Guardian for decision making.A care plan, revised 7/15/24, indicated R6 had limited physical mobility related to a history of CVA with right-sided hemiplegia. (The care plan did not contain an intervention for ROM exercises as ordered by OT on 8/13/24.)An OT discharge note, dated 8/13/24, indicated caregiver training would be completed for upper extremity (UE) exercises to decrease contractures and maintain ROM and for R6 to participate in self-feeding tasks. The note also indicated a handout would be provided for ROM exercises.Surveyor reviewed R6's Medication Administration Record (MAR) and Treatment Administration Record (TAR) which did not indicate staff provided upper extremity (UE) ROM exercises for R6.On 7/16/25 at 11:48 AM, Surveyor interviewed R6 and noted R6 had rolled wash cloths in both hands due to contractures. R6 indicated staff give R6 rolled wash cloths to place in both hands at times but do not provide ROM exercises for R6's hands. R6 saw therapy a while ago and indicated it is difficult to eat and drink due to the contractures.On 7/16/25 at 12:13 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-J who verified R6's plan of care did not contain ROM exercises. LPN-J indicated staff try to put rolled wash cloths in R6's hands but R6 usually refuses. On 7/16/25 at 12:16 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-Q who indicated R6 may have had ROM exercises in the past but they did not work. CNA-Q verified R6's CNA Kardex (an abbreviated care plan used by nursing staff) did not contain ROM exercises and staff were not instructed to provide ROM exercises for R6.On 7/17/25 at 8:36 AM, Surveyor observed R6 in the dining room with rolled wash cloths in both [NAME] 7/17/25 at 9:12 AM, Surveyor interviewed Occupational Therapist (OT)-I who indicated staff received training on ROM exercises for R6 with a handout that illustrated the exercises. OT-I verified R6's plan of care did not contain ROM exercises and indicated ROM exercises should have been added. OT-I reviewed R6's OT note, dated 8/13/24, that indicated staff received training on ROM exercises including finger stretching and ROM for R6's UEs. OT-I indicated training is typically done with CNAs, however, staff did not sign that they received the training and OT-I was unsure when the training took place.On 7/17/25 at 9:46 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R6's plan of care did not contain ROM exercises as ordered by OT. DON-B indicated OT-I did not update nursing staff on the therapy recommendations or provide staff with a handout for ROM exercises.

Based on observation, staff interview, and record review, the facility did not ensure the necessary respiratory care and services were provided for 3 residents (R) (R2, R26, and R3) of 3 sampled residents.R2 used a nebulizer (a machine that transforms liquid medication into a fine mist that can be inhaled directly into the lungs) but did not have an order to clean the nebulizer after use. In addition, R2's care plan did not address how to clean or care for the nebulizer. R2 also used a continuous positive airway pressure (CPAP) machine but did not have orders for settings or maintenance of the machine.R26 used a nebulizer but did not have an order or care plan that addressed how to properly clean or care for the nebulizer after use.R3 had an order for as needed (PRN) oxygen that did not specify a flow rate. In addition, R3's plan of care did not indicate R3 used oxygen. Findings include: The facility's Noninvasive Ventilation policy, revised 12/3/24, indicates: It is the policy of this facility to provide noninvasive ventilation per physician’s orders and current standards of practice .2. The facility will obtain an order for the use of a CPAP .device from the practitioner .5. Replace equipment routinely in accordance with manufacturer's recommendations .a. Face mask and tubing - once every three months, b. Headgear, non-disposable filters, and humidifier chamber - once every six months, c. Disposable filters - twice monthly. The facility's Nebulizer Therapy policy, dated 1/20/25, indicates: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .13. When medication delivery is complete, turn the machine off. Treatment may be considered complete when the onset of nebulizer is sputtering. 14. Disassemble and rinse the nebulizer with water and allow to air dry. Care of the Equipment - 1. Clean after each use .3. Disassemble parts after every treatment, 4. Rinse the nebulizer cup and mouthpiece with water, 5. Shake off excess water, 6. Air dry on an absorbent towel .Record the administration in resident's medical record. The facility’s undated Oxygen Administration policy indicates: Oxygen will be safely administered per physician orders .D. Regulate the flow of oxygen according to the physician's order . 1.From 7/15/25 to 7/17/25, Surveyor reviewed R2’s medical record. R2 was admitted to the facility on [DATE] and had diagnoses including obstructive sleep apnea, end stage renal failure with dialysis dependence, and chronic obstructive pulmonary disease (COPD). R2’s Minimum Data Set (MDS) assessment, dated 6/20/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R2 had moderate cognitive impairment. R2 had an activated Power of Attorney (POA). On 7/15/25 at 10:40 AM, Surveyor noted R2’s nebulizer was hooked up to a medication cup and mouthpiece. Surveyor interviewed R2 who indicated R used the nebulizer that morning and it was not cleaned. R2 also indicated the nebulizer tubing had not been changed since admission. Surveyor also observed R2’s CPAP machine and noted the tubing did not contain a date. R2 indicated R2 did not have the correct mask for the CPAP machine since admission and staff were aware. Surveyor noted R2's medical record did not contain a physician’s order for CPAP use and did not contain CPAP or nebulizer cleaning schedules. R2’s Medication Administration Record (MAR) contained the following order: CPAP at (SPECIFY) centimeters (cm) with 6 liters (L) of supplemental oxygen at bedtime for obstructive sleep apnea. Cleanse mask before and after use. Remove in AM. May also apply if napping and remove per schedule (dated 6/14/25). (R2's medical record did not contain CPAP settings.) On 7/16/25 at 11:02 AM, Surveyor noted R2’s nebulizer medication cup, mouthpiece, and tubing were still attached to the compressor; however, the mouthpiece was hanging over the edge of the table and in contact with the floor. On 7/16/25 at 11:05 AM, Surveyor interviewed Med Tech (MT)-N who confirmed R2 received a nebulizer treatment that morning. MT-N indicated after a nebulizer treatment is completed, the mouthpiece is disassembled from the medication cup and rinsed and the pieces are then put back together since MT-N has to use them again. MT-N indicated MT-N did not rinse R2’s nebulizer equipment that morning. When Surveyor asked if the equipment should have been rinsed after use, MT-N indicated not right away because R2 receives two treatments daily and MT-N can rinse the pieces later. When Surveyor informed MT-N that R2’s medication cup and mouthpiece were on the floor, MT-N indicated R2 must have done that. When Surveyor asked how staff ensure the medication cup and mouthpiece are rinsed after each use, MT-N indicated there is no documentation to indicate the equipment was rinsed or cleaned and there is no place to document in the MAR or Treatment Administration Record (TAR). MT-N indicated MT-N did not know how often the tubing, medication cup, and mouthpiece should be changed and indicated it is the nurses' responsibility to change nebulizer tubing and equipment. On 7/16/25 at 11:38 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-O who confirmed R2 did not have orders or a care plan that addressed nebulizer care. On 7/17/2025 at 12:14 PM, Surveyor interviewed Director of Nursing (DON)-B and confirmed R2 did not have a CPAP care plan. 2. From 7/15/25 to 7/17/25, Surveyor reviewed R26’s medical record. R26 was admitted to the facility on [DATE] and had diagnoses including heart failure and COPD. R26’s MDS assessment, dated 4/26/25, had a BIMS score of 15 out of 15 which indicated R26 had intact cognition. R26’s medical record did not contain a care plan for nebulizer care. On 7/15/25 at 9:59 AM, Surveyor observed a nebulizer machine on R26's bedside table and noted the tubing, a mouthpiece, and medication cup were still still hooked to the compressor machine. The medication cup and mouthpiece did not appear to have been cleansed after use. Surveyor also noted two empty vials inside an empty compartment of the machine. R26 indicated the tubing had not been changed or cleaned and staff continued to use same tubing, medication cup, and mouthpiece and just added medicine to the cup. R26 indicated R26 did not see staff clean and dry the equipment after use. On 7/16/25 at 11:05 AM, Surveyor interviewed MT-N who confirmed R26 received a nebulizer treatment that morning. MT-N indicated after a nebulizer treatment is completed, the mouthpiece is disassembled from the medication cup and rinsed and the pieces are then put back together. When Surveyor informed MT-N that R26 indicated staff did not rinse the medication cup and mouthpiece, MT-N indicated R26 was not in the room when MT-N cleaned the equipment. When Surveyor asked how staff ensure the medication cup and mouthpiece are rinsed after each use, MT-N indicated there is no documentation to indicate the equipment was rinsed or cleaned and no place to document in the MAR or TAR. MT-N indicated MT-N did not know how often the tubing, medication cup, and mouthpiece should be changed and indicated it is the nurses' responsibility to change nebulizer tubing and equipment. On 7/16/25 at 11:38 AM, Surveyor interviewed LPN-O who confirmed R26 did not have orders or a care plan to address nebulizer care. On 7/16/25 at 11:46 AM, Surveyor interviewed DON-B who indicated nebulizer equipment and tubing should be changed every 5 days. DON-B also indicated the standard of practice is to rinse the medication cup and mouthpiece after each use. DON-B indicated nebulizer equipment should be rinsed and dried before attaching the mouthpiece and medication cup back together following each treatment. 3. On 7/15/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including macular degeneration, presbyopia, age related cataracts, and bipolar disorder. R3's MDS assessment, dated 5/11/25, contained a BIMS score of 15 out of 15 which indicated R3 had intact cognition. A care plan, initiated 9/5/24, indicated R3 had altered respiratory status and difficulty breathing related to shortness of breath and cough. The care plan contained interventions for staff to monitor R3 for air hunger and document signs of respiratory distress. The care plan did not refer to oxygen therapy. Surveyor also noted R3's Kardex (an abbreviated care plan used by nursing staff) did not include oxygen use or the need to monitor for signs and symptoms of respiratory distress. On 7/15/25 at 9:59 AM, Surveyor observed R3’s room and noted a portable oxygen container on the floor in the front corner of the room. On 7/15/25 at 9:59 AM, Surveyor interviewed R3 who indicated R3 did not use oxygen but would like to. R3 indicated Licensed Practical Nurse (LPN)-J twice told R3 that R3 did not need oxygen when R3 asked for it. R3 indicated R3 does not ask for oxygen anymore even though R3 would like to and feels R3 needs it at times. On 7/16/25 at 10:18 AM, Surveyor interviewed R3 who indicated R3 was not asked if R3 needed oxygen since Surveyor last spoke with R3. R3 indicated R3 did not need oxygen so far that day but would like to be able to use it if R3 wanted. On 7/16/25 at 2:16 PM, Surveyor interviewed LPN-J who indicated R3 had not used oxygen in approximately one year and had not had respiratory trouble lately. When asked if LPN-J had checked with R3 lately, LPN-J indicated R3 used oxygen more on the night shift. When asked if LPN-J ever denied R3 oxygen, LPN-J indicated R3 had never asked for oxygen on the AM shift. LPN-J indicated R3 could use oxygen on any shift if R3 asked for it. On 7/16/25 at 2:18 PM, Surveyor interviewed LPN-K who joined Surveyor's interview with LPN-J and indicated R3 had not used oxygen or an inhaler for a long time. LPN-K was not aware of staff denying oxygen to R3 and indicated R3 could use oxygen on any shift if R3 asked for it. On 7/17/25 at 12:58 PM, Surveyor interviewed DON-B who indicated R3 had PRN oxygen therapy. DON-B indicated a resident's care plan should contain the resident's needs so staff know how to care for the resident appropriately. DON-B confirmed a resident who uses oxygen should have a care plan for oxygen therapy including how many liters per minute are required per the physician's order. DON-B indicated a resident's Kardex should also indicate the resident's oxygen needs and an assessment should be completed with any changes. DON-B stated if a resident indicates they feel short of breath and/or need oxygen, staff should apply oxygen and follow the physician's order.

Based on observation, staff interview, and record review, the facility did not ensure dishes were washed and food was prepared in a safe and sanitary manner. This practice had the potential to affect all 46 residents residing in the facility. Staff did not appropriately test the sanitizing solution in the dishwashing sink. Cook (CK)-C did not wear gloves or wash hands appropriately when preparing pureed fish. Findings include: The facility's undated Cleaning Dishes-Manual Dishwashing policy, indicates: Dishes and cookware will be cleaned and sanitized after each meal .Check sanitation sink frequently using a test strip to assure the level of sanitizing solution is appropriate. Follow chemical manufacturer's guidelines to prepare sanitizing solution .Measure the appropriate amount of sanitizing chemical into the appropriate amount of water following the manufacturer's guidelines. Water should be 75 to 100 Fahrenheit (F). Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level . On 3/14/25, Surveyor reviewed the posted manufacturer's instructions for Hydrion QT-40 test strips to measure the concentration of sanitizer in the dishwashing solution. The instructions indicated the dishwashing solution should be between 65 and 75 degrees F when testing the sanitizer concentration. On 3/14/25 at 9:10 AM, Surveyor interviewed CK-C who indicated the hot water heater supplying the dishwasher broke in February of 2025. CK-C indicated staff had to hand wash dishes when the hot water heater was not functioning. Surveyor observed CK-C test the concentration of sanitizer in the three-compartment sink with a Hydrion QT-40 test strip. CK-C did not obtain the water temperature prior to testing the sanitizing solution. On 3/14/25 at 9:40 AM, Surveyor interviewed Maintenance Director (MD)-F who confirmed the hot water heater that supplied the dishwasher was broken from 12/29/24 to 1/2/25 and 1/19/25 to 2/18/25. On 3/14/25 at 10:40 AM, Surveyor interviewed Dietary Aide (DA)-D who indicated DA-D did not know how to test the concentration of the sanitizer in the three-compartment sink. DA-D indicated washing dishes was one of DA-D's job duties. On 3/14/25 at 11:05 AM, Surveyor interviewed DA-E who indicated DA-E did not know how to test the concentration of the sanitizer in the three-compartment sink. DA-E indicated washing dishes was one of DA-E's job duties. On 3/14/25 at 11:12 AM, Surveyor observed CK-C change the dishwashing water in the three-compartment sink. CK-C did not obtain the water temperature in the sink prior to testing the sanitizing solution. CK-C indicated CK-C does not test the dishwater temperature prior to testing the sanitizer concentration. On 3/14/25 at 11:25 AM, Surveyor observed CK-C prepare pureed fish. CK-C removed tinfoil from a pan of baked fish and touched the lid of a garbage bin when CK-C threw the tinfoil away. CK-C did not wash CK-C's hands before returning to prepare the pureed fish. CK-C removed several pieces of fish from the pan and put the fish in a bowl. CK-C then removed the fish from the bowl with bare hands and put the fish in a blender. Surveyor observed CK-C rinse dirty dishes and put the pureed fish in a holding container. CK-C then rinsed and washed dirty dishes. At 11:40 AM, CK-C removed tin foil from pans that contained lunch items. CK-C did not wash hands between washing dirty dishes and preparing lunch. On 3/14/25 at 2:15 PM, Surveyor interviewed Dietary Manager (DM)-G who indicated cooks are assigned to check the sanitizer concentration in the three-compartment sink. DM-G indicated cooks are supposed to temp the dishwater prior to testing the sanitizing solution. DM-G confirmed the dishwater should be between 65 and 75 degrees F when tested to obtain an accurate result.

Based on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R10 and R11) were allowed continued use of assistive devices to enhance their quality of life. When R10 and R11 were admitted to the facility, R10 and R11 were allowed to use an electric wheelchair/ motorized scooter inside the facility. R10 and R11 were no longer allowed to to use the devices inside the facility after the facility changed their policy. Findings include: The facility's Motorized Mobility Aids: Wheelchairs, Carts, and Scooters policy, dated 10/29/24, indicates: .Motorized mobility aids are permitted in any outside area of the facility unless they pose a direct threat to the safety of others .Motorized mobility aids are operated in such a manner that they do not impede or interfere with normal resident flow, including a roommate's ability to freely access the common area of the room. When common area activities are in progress and crowded, the facility may request that those using motorized devices enter or exit prior to or after other residents to encourage safe resident traffic flow . On 3/14/25 at 12:25 PM, Nursing Home Administrator (NHA-A) indicated the facility did not have any residents who used scooters or electric wheelchairs. NHA-A indicated the facility does not allow scooter or electric wheelchair use on inside the facility any longer. NHA-A did not recall the date the facility's policy changed and indicated it was a process to stop using scooters and electric wheelchairs. NHA-A indicated residents who had a medical need for a scooter or electric wheelchair had to discharge before the facility initiated no scooter/electric wheelchair use inside the facility. NHA-A indicated the last resident with a medical need for an electric wheelchair discharged on [DATE]. NHA-A indicated a Managed Care Organization (MCO) Ombudsman informed NHA-A that NHA-A had to decide all or nothing regarding scooter and electric wheelchair use for residents in the facility. NHA-A met with all residents who used scooters and electric wheelchairs in October and November of 2024 and notified them the facility's policy was changing and they would no longer allow scooter or electric wheelchair use in the facility. NHA-A indicated all [NAME] of Attorney for Healthcare (POAHC) and Guardians of residents who used scooters and electric wheelchairs were updated via phone. 1. On 3/14/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dementia, type 2 diabetes, bipolar disorder, anxiety disorder, post-traumatic stress disorder, venous insufficiency, difficulty in walking, and edema. R10's Minimum Data Set (MDS) assessment, dated 1/20/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R10 had intact cognition. R10 made R10's own medical decisions. On 3/14/25 at 2:11 PM, Surveyor interviewed R10 who indicated R10 was excited when the Veterans Administration (VA) brought R10's electric wheelchair to the facility. R10 used the electric wheelchair twice before R10 was told electric wheelchair were no longer allowed inside the facility. R10 was told the policy changed but did not receive a copy of the new policy. R10 indicated R10 felt a mixture of mild anger and depression about the policy change. R10 was upset about the change and contacted the Ombudsman but did not hear back. R10 indicated R10 was [AGE] years old and it wore on R10's hands to self propel a manual wheelchair. R10 indicated a Certified Nursing Assistant (CNA) used to bring R10 to the electric wheelchair. R10 transferred to the wheelchair, signed out, and wheeled out of the dining hall and out the exterior door if R10 was going to use the electric wheelchair. 2. On 3/14/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including polymyalgia rheumatica, lymphedema, asthma, chronic obstructive pulmonary disease, depression, anxiety, and delusional disorders. R11's MDS assessment, dated 1/29/25, had a BIMS score of 15 out of 15 which indicated R11's cognition was intact. R11 made R11's own medical decisions. On 3/14/25 at 2:24 PM, Surveyor interviewed R11 and observed a Styrofoam lunch tray in R11's room. R11 indicated R11 used a scooter in the facility and stated, They took it away. R11 stated R11 did not have any unsafe incidents in the facility when using the scooter. R11 indicated when R11 first arrived at the facility, a scooter was purchased to use inside and outside the building. R11 was devastated when informed R11 could no longer use the scooter in the facility. R11 indicated without the scooter, R11 could no longer go to the activity room independently and wash dishes. R11 indicated the bathroom sink in R11's room was too small to wash dishes. R11 stated R11 no longer went to activities because the CNAs were too busy to bring R11 to the activity room. If R11 felt unwell at an activity, R11 did not feel the CNAs could take R11 back to R11's room in a timely manner. R11 indicated R11 no longer ate meals in the dining room because R11 felt uncomfortable and could not self propel a manual wheelchair. On 3/14/25 at 2:47 PM, Surveyor interviewed NHA-A who indicated the facility's policy explicitly states residents may not use scooters or electric wheelchairs in the facility. NHA-A indicated each resident's situation is different depending on the resident's needs. NHA-A indicated some residents are able to transfer to an electric scooter or wheelchair and independently leave the facility. NHA-A indicated the reason for the policy change was the potential hazard to other residents.

Based on resident and staff interviews and record review, the facility did not ensure a safe discharge for 1 of 3 residents R1 (Resident) reviewed for discharge. Prior to admission R1 lived in a motorhome in a campground, which is not wheelchair or walker accessible and has a [NAME] bed. On 10/13/23, R1 was taken, by transport van, to his motorhome, with 2 staff accompanying. R1 was unable to navigate the three steps into the motorhome with staff assistance. R1 started to fall backwards, and staff assisted R1 into his wheelchair. Staff observations of the interior of R1's motorhome were it was uninhabitable, with multiple jugs of urine, no bathroom facilities, no running water, no food, and full of junk. Staff contacted NHA A (Nursing Home Administrator) to make her aware of their observations. NHA A informed staff to have the transport van take R1 to the emergency room at the local hospital and leave him as he was no longer a resident of the facility. R1 was taken to the hospital and left by the transport driver. The transport driver called the police and indicated to the hospital that he had been instructed to leave R1 there. The hospital had no reason to admit R1 so R1 was then taken to a hotel. The next day R1 was returned to his motorhome as he had nowhere else to go. R1 climbed into his motorhome and the [NAME] bed where he spent three days, without being able to leave the [NAME], urinating in jugs and defecating in his clothing and a plastic bag, until the Sheriff's Department was called and R1 was transported and admitted to a local hospital. The facility's failure to ensure a safe discharge created a finding of immediate jeopardy that began on 10/13/23. NHA A was notified of the immediate jeopardy on 10/19/23 at 4:45 PM. The facility removed the jeopardy on 10/19/23, however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Evidenced by: The facility's Discharge/Transfer of Resident policy, dated 5/3/22, includes, in part, the following: Purpose: To provide safe departure from the facility. To provide for continuity of care and treatment. Procedure: 1. Explain discharge procedure to resident and family. Provide additional health education or medication instruction information for resident or family as indicated in lay terms. 2. An attending physician order is required to discharge. Verbal or telephone orders are acceptable. 3. Inform all departments of anticipated and actual discharge. 4. Should the resident's family or resident desire to discharge without a physician's order, the resident or sponsor shall be required to sign a Discharge Against Medical Advice form. 5. Assist resident to dress and pack all personal belongings. Obtain items from storage. 6. Have resident or sponsor sign Personal Inventory of Effects Form if able. 7. Complete Transfer Form accurately and completely including vital signs. 8. Assist resident into wheelchair and escort to vehicle (if necessary) or assist attendants with transport onto stretcher. 9. Notify family and receiving facility when being transferred to another acute care facility. 10. Thoroughly assess resident prior to discharge/transfer. 11. Document discharge summary. Include notes on specific instructions given (medications, dressings, etc.) to resident an [sic] responsible parties in lay terminology. 12. Follow up with acute care receiving facility for admit diagnosis as applicable. R1's diagnoses include, in part, motorcycle accident, open fracture of shaft of left tibia, closed fracture of twelfth thoracic vertebra, closed fracture of transverse process of lumbar vertebra, spleen laceration, and pleural effusion. R1's Admission MDS (Minimum Data Set), dated 7/31/23, indicates that R1 understands and is understood and is cognitively intact. R1 has no behaviors. R1's Behavior Monitoring for the dates of 9/20/23 - 10/13/23 indicates No behaviors observed. R1's Discharge Planning Review, dated 8/1/23, includes, in part, the following: A. Anticipated Length of Stay 1. Anticipated LOS (Length of Stay): TBD (to be determined) 2. As stated by whom: Resident 3. Select one for resident's overall goal established during assessment process: Expects to be discharged to the community 4. What determination was made by the resident and the care planning team regarding discharge to the community: Determination not made B. Home Environment 1. Lives: Alone 3. List any concerns about returning home (i.e. finances, stairs, yard work, driving, etc.): Lives in mobile home, not wheelchair or walker accessible. Has [NAME] bed. 4. Does the resident have family or a support network to provide assistance post-discharge: No C. Treatment Care/Needs 2. Additional home care supports required: Possibly placement, in home care pending process D. Overall Summary of Potential For/Discharge [sic]: Resident lives in a remodeled mobile home that he primarily uses for storage and sleeping. He has a [NAME] bed. Ability to discharge home dependent on progress. R1's Care Plan Focus The resident has an ADL (Activities of Daily Living), self-care performance deficit r/t (related to) lumbar fracture, revision on 9/18/23. Interventions include, in part, Bathing/Showering: The resident is able to bath with 1 assist. Revision on: 7/27/23. Toilet use: The resident is independent with bump over transfer to/from wheelchair/toilet for toileting. Revision on: 9/8/23. Transfer: The resident is independent using a slide board to/from wheelchair/bed as necessary. Revision on: 9/8/23. R1's Care Plan Focus The resident would like to discharge home or community, revision on 8/2/23. Interventions include: Evaluate the resident's motivation and ability to safely return to the community. Date Initiated: 7/25/23. R1's Care Plan Focus The resident has limited physical mobility r/t lumbar fracture, revision on 7/27/23. Locomotion: The resident is able to: use a wheelchair for mobility at this time. Revision on 7/27/23. R1's Progress Note, written by NP H (Nurse Practitioner), dated 9/7/23, includes, in part, the following: Assessment/Plan: . Motorcycle accident - questioning if he is some type of residual memory concern. He repeats the same stories over and over again every time this provider is in the room. When you mention to him that you already heard the story, he states that you were mistaken. R1's Discharge Notice, dated 9/13/23, includes, in part, the following: This letter serves as a notice of discharge from (Facility Name). The reason for your being discharged is that: Your health and/or safety and/or the safety of others is endangered by your remaining at this facility. The anticipated date of your discharge is 10/13/23. The location to which you'll be discharging to is home. You have a right to relocation assistance and to be prepared for and oriented to being discharged . A separate notice will be provided inviting you to a discharge planning conference. R1's Physical Therapy Discharge Summary, dated 10/13/23, includes, in part, the following: Short Term Goals: #1. Once standing, the patient will improve ability to safely ambulate at least 10 feet in a room, corridor, or similar space with adequate cardiopulmonary function using two-wheeled walker with independence. Discharge 10/12/23: Partial/moderate assistance. Goal: #2. Patient will improve ability to safely go up and down a curb and/or one step with partial/moderate assistance, using handrails and AD (assistive device) in the presence of high sensory demand situation and with ability to right self to achieve/maintain balance. Discharge 10/12/23: Partial/moderate assistance. Goal: #6. Patient will safely ambulate 15 feet using two-wheeled walker on inclines and on declines with supervision or touching assistance with implementation of compensatory strategies in order to facilitate increased participation in functional activity and to increase independence within household environment. Discharge 10/12/23: 5 feet, partial/moderate assistance. Status/Prior Living/Discharge: Prior Living Environment = Patient resided in private residence. Prior Living Description: Pt (patient) lives in mobile home with 3 - 4 STE (stairs to enter), limited room in mobile home for AD (assistive device) if needed. Standard toilet with grab bar, utilizes shower stall where mobile home is parked. Independent with all transfers, mobility, ADLs, and IADLs. Discharge Location: Patient discharged to home w/ (with) support/(A) (assist) from others. Assistance/Support to be Provided = AM assistance/caregiver available, PM assistance caregiver available. Functional Skills Assessment: Ambulation: Walk 10 feet = Partial/moderate assistance. Walk 50 feet with Two Turns = Partial/moderate assistance. Walk 150 feet = Substantial/maximal assistance. Stairs/Curbs: 1 step (curb) = Partial/moderate assistance. W/C Mobility: Resident uses a wheelchair and/or scooter? = Yes. Other: Picking up an object = Not attempted due to medical conditions or safety concerns. Discharge Recommendations and Status: Discharge Recommendations: Patient would benefit from BLE (bilateral lower extremity) HEP (home exercise program), wheelchair for mobility, and continue home health to further progress in skilled therapy. Prognosis to Maintain CLOF (current level of function) = Other Prognosis: Factors Impacting Prognosis = Cognitive status, Risk for change in medical condition. D/C Destination: Home. D/C Reason: Other. R1's Progress Notes include, in part, the following: 9/13/23, 16:13 (4:13 PM), Type: Health Status Note: Resident was provided discharge notice. Resident was explained that he has the right to appeal and the process. Social Worker present. Care Conference pertaining to discharge planning scheduled for 9/20. MD (Medical Doctor) updated. 9/20/23, 11:06 (AM), Type: Care Conference Summary. Social Service Review (Mood/Affect/Behavior/Cognition/Communication/D/C (discharge) Plans, Concerns & Goals: Reviewed discharge plan in depth. Resident was given a 30-day discharge notice 9/13/23, due to being a threat and endangerment to others. Resident indicated that he would not talk about his living arrangements when asked. Previously indicated he would return to his mobile home and that it is an option for discharge. Resident agreeable to discharge to mobile home, discussed need for ramp d/t (due to) 2 stairs to enter home. Resident also needs a two-wheeled walker and possibly a shower chair. Discussed that medications will be sent to pharmacy of choice. Resident stated he is unsure which pharmacy he will use. Writer will follow up with him prior to discharge to coordinate. Educated resident PT (Physical Therapy) and OT (Occupational Therapy) will likely be ordered as recommended by facility therapy team to continue therapies at home. Notified resident air mattress will be provided by facility d/t resident having a lofted bed. Discussed a referral to Family Care/options counseling. Resident prefers not to communicate referral process with facility staff at this time. Resident open to meeting with ADRC (Aging and Disability Resource Center). Writer will complete a referral. Therapy/Restorative Review (ADLs-Improve/Decline, Continence Programs/Participation, Goals): Resident is walking 50 - 100 feet twice with two-wheeled walker with CGA (Caregiver Assist). Therapy is planning to work with him in his room to evaluate his mobility in the room with the two-wheeled walker as well as transfers from bed to standing. He is independent at wheelchair level with mobility, dressing, donning and doffing his brace and personal hygiene. OT planning to discharge next week. 9/28/23, 16:01 (4:01 PM), Type: Social Service Note: Discussed with resident setting up another care conference to discuss discharge planning. Resident told writer that he's not planning anything. Writer notified resident care conference is already scheduled for 10/2 at 1:30 PM, unless he would like to change it. Resident did not respond. Writer offered resident written reminder of care conference. Resident told writer to hang it on the door. Writer hung care conference reminder on resident's door, with conference information facing the door for resident's privacy. When writer passed by resident's room approximately 15 minutes later, the care conference reminder was flipped to have the conference information facing out towards the hallway. 10/2/23, 14:00 (2:00 PM), Type: Social Services Note: Resident had care conference at 1330 (1:30 PM). At that time writer observed resident exit the building and sitting outside. Writer approached resident and reminded him of care conference in the conference room. Resident did not respond, writer stated she will wait for him in conference room. After 15 minutes (NHA A) approached resident outside, asking the resident to come in for care conference. Resident did not respond. Writer, (NHA A) and (DON B (Director of Nursing) approached resident outside. Brought him to picnic table area. Writer and (NHA A) asked resident about where he plans to discharge to. Resident refused to reply. (NHA A) asked about stairs into his home, he declined to reply. Stated he will not be doing any talking. Writer asked if any other DME (Durable Medical Equipment) is needed. Resident did not reply. (NHA A) informed resident that he will be discharged on ,d+[DATE] with transportation arranged. Medications will be sent to (Pharmacy) in (City Name). Writer will coordinate getting resident a two-wheeled walker for discharge as well. An air mattress will be ordered via Amazon and will be given to resident prior to discharge. Administrator is also looking into purchasing portable steps for him. Resident was asked if he had any questions, to which he did not reply. Writer reminded him if he had any questions he can let writer know, and writer plans to follow up with him later this week. Offered to bring resident into building, resident declined. Staff checked on resident a short bit later, and he agreed to be wheeled in. 10/4/23, 14:06 (2:06 PM), Type: Health Status Note: Resident refused to answer questions in regard to installing a ramp at resident home prior to discharge. APS (Adult Protective Services) contacted in regard to resident discharging on 10/13. Resident continues to be offered services and given resources in the community prior to discharge. 10/6/23, 14:24 (2:24 PM), Type: Health Services Note: (MS E (Maintenance Staff) and (HR F (Human Resources) asked resident in regard to installing a ramp at his home. Resident refused to answer. (MS E) asked for dimensions and permissions to install a ramp, resident refused to answer. Resident stated, I'm not talking about this. (MS E) stated that the facility will pay and install the ramp but needs to know an answer today. Resident continued to refuse to answer. 10/12/23, 11:10 (AM), Type: Health Status Note: SS (Social Services) went into resident's room to speak to him about discharge. Medication list sent to (Pharmacy) in (Town Name). SS inquired about discharge address and lot number so that medications could be mailed. Resident stated, That's non [sic] of your business. Medications will remain at (Pharmacy) for pick up due to resident's refusal to be mailed. 10/13/23, 09:45 (AM), Type: Health Status Note: reviewed dc (discharge) and medications/times with resident, resident aware scripts ready at (Pharmacy) in (Town Name) will send resident home with remaining medications from facility. Resident aware has f/u (follow up) appointment with MD 10/25 and needs to arrange for transportation to appointment. DC folder given to resident. Resident agreed to have staff follow transport van to follow home. 10/13/24, 14:24 (2:24 PM), Type: Orders-Administration Note: Resident discharged . R1's Discharge Summary Information, dated 10/11/23, includes, in part, the following: A. Discharge Information 1. Type of Discharge: Planned 2. Planned discharge date : 10/13/23 3. Mode of Transport: Other Describe Other: Wheelchair taxi 4. Accompanied by: Self 5. Reason for Discharge: Issued a 30-day discharge notice due to safety concerns. C. Physical Assessment on Discharge and Instructions Physical & Mental Functional Status (including ADLs and Ambulation): 1. Independent with cares/dressing. Independent at wheelchair level. Able to safely use wheelchair for mobility, can also walk with a two-wheeled walker. Mental, Psychosocial and Behavior Status: 4. Resident is cognitively intact, has some mental health dx (diagnosis). Resident has multiple behaviors at the facility, including recording staff with his cell phone and being verbally abusive towards staff. Social Service Discharge Summary: 3. Resident admitted post hospitalization for a fractured lumbar following a MVA (motor vehicle accident). Resident worked with PT and OT and is now independent at wheelchair level. Resident has been uncooperative with discharge planning after being issued a 30-day notice of discharge. Per IDT's (Interdisciplinary Team's) best knowledge, DME needed for his home has been ordered for his discharge. He will be transported back to his home via (Transport Company). Medications sent to (Pharmacy); PT/OT orders sent to (Home Health Agency). Timeline provided to Surveyor by NHA A includes, in part, the following: 10/11 - Writer went in with ADON (Assistant Director of Nursing) as witness to deliver a recap of resident's discharge. Resident was on the phone with (FM I (Family Member). (FM I) asked to be filled in on what is happening in regard to resident's discharge. Resident gave permission for writer to speak with (FM I). (FM I) asked if she could call (NHA A's) direct line and continue the conversation. Resident gave permission to (NHA A). (NHA A) later spoke with (FM I) and informed her of resident's discharge, ultimate reason for the discharge, and resources that were offered to (R1). (FM I) expressed that (R1) stated he was not able to return back to the address on file due to not having heat and running water. (NHA A) stated that she has called the owner of the lot that (R1) resides at previously but, would call him again to get clarification. (FM I) stated that there was no need to as she is going to figure it out from here on since the facility has done what they could for him. (FM I) asked if resident could transfer to another facility in the area. (NHA A) stated that it would be unrealistic to get him transferred to another facility by Friday and expressed concerns with a facility accepting him due to behaviors. (FM I) acknowledged that the facility has offered him numerous resources and apologized on behalf of resident's behavior. (FM I) agreed to meet (R1) at his trailer at 1:30 PM on 10/13. 10/12 - (RFOD J (Regional Field Operations Director) called (NHA A) to further discuss resident's discharge. (RFOD J) expressed that more information was provided to her in regard to concern with resident not having electric or heat at his camper/trailer. (FM I) did express concern with this, however, told writer not to worry about it as she heard it from (R1) and was not sure if it was true. After speaking with (RFOD J), writer decided to contact (CO K (Campground Owner) again. Writer inquired about heat and water at the long-term rental lots and (CO K) stated that a female actually called him today inquiring the same information for (R1's) lot. (NHA A) expressed she could not confirm that she was calling for (R1). (CO K) expressed that (R1) has lived at the campground for a few years and went through a few [NAME]. (CO K) stated that (R1) is able to return back to the campground and that the campground does have electric and heat. Water is shut off before winter, but (R1) usually has jugs of water within his trailer/camper. Knowing this information, the facility will send (R1) with gallons of water. (NHA A) also informed (RFOD J) that facility is offering to send staff with to (R1's) residence to ensure his safety. Law enforcement will also be contacted to escort resident out of the facility due to threatening to cause a disturbance. 10/13 - Law enforcement at facility to assist with escorting resident from the facility. Residents were removed from the hallway to avoid a disturbance. (R1) continued to record staff and law enforcement. Medications and appointments went over with (DON B). Facility offered assistance in having staff tag along with back to his trailer. (R1) in agreement however denied having (DON B) go with and instead requested a different staff member. Facility sent (HUC G (Health Unit Coordinator) and (MS E (Maintenance Staff) with. (Transport Company) transported resident and stopped at (Pharmacy) for prescriptions prior to going to his residence. Resident was sent with an air mattress due to having a lofted bed, facility wheelchair, facility walker, and facility reacher. When facility staff and (R1) made it to his residence staff reported that (R1) was able to get up on the first step of the trailer but, stated he was going to fall on the second. Both staff stated it appeared (R1) could get up the steps but, by the way he was acting and what he was stating it appeared he wanted to fall. Staff assisted (R1) back into his wheelchair and then into the cab while they went into the trailer/camper. (HUC G) and (MS E) expressed that (R1's) residence was filled with junk and there was an estimated 20 plus gallons of urine that was scattered throughout the trailer. Both staff attempted to empty and clean out what they could but ultimately there was too much stuff for them to continue. (R1) was offered to go to the ER (emergency room ) not for not being able to make it into the trailer/camper but, because the trailer was too cluttered and dirty for them to leave him there. Information that (R1) did not disclose to the facility. In collecting (MS E's) statement, (MS E) stated that he could have build [sic] a ramp into the trailer/camper however that was not the issue. The issue was the condition of the home. (R1) was taken to (Hospital Name) by (Transport Company). Social Worker at the hospital called the facilities [sic] Admissions Coordinator for an update on R1. Admissions Coordinator gave SS (Social Services) at the hospital an update on (R1's) living situation and his behaviors. At the hospital, (R1) reported to the SS that he fell at his trailer and was unsure why (Facility Name) discharged him when he was not able to ambulate. SS made aware that resident did not fall. (R1) then informed the ER (emergency room ) doctor that he was walking around (City Name) when he fell and was lowered to the ground. ER Doctor refused to increase resident's oxycodone like asked and proceeded to discharge (R1) back to his trailer in (city name) due to no medical reason for resident to remain at the hospital. On 10/19/23 at 9:00 AM, Surveyor spoke with R12. Surveyor asked R12 if she remembered R1. R12 stated R1 would often visit her and that she never heard R1 yell at anyone. R12 also stated that nursing staff would be reporting R1 all the time for things he did not do. Surveyor asked R12 if she was ever afraid of R1. R12 stated, No, I was never afraid of him. On 10/19/23 at 1:00 PM, Surveyor interviewed R13. Surveyor asked R13 if she remembered R1. R13 stated yes, he would come in and visit me and he talked to me about his accident. R1 was very pleasant, he knew I couldn't do anything for myself and would offer to get me things if staff were busy. Surveyor asked R13 if she was afraid of R1. R13 stated he was never mean to me. I was never afraid of him, he was always very nice to me. On 10/19/23 at 1:10 PM, Surveyor interviewed R15. Surveyor asked R15 if she remembered R1. R15 stated yes, R1 would sit outside and talk with R15 all the time. Surveyor asked if R15 was afraid of R1. R15 stated she felt safe around R1, R1 would stick up for other residents, but would complain about staff. On 10/19/23 at 1:15 PM, Surveyor interviewed R14. Surveyor asked R14 if she remembered R1. R14 stated yes, I remember him. Surveyor asked R14 if she was ever afraid of R1? R14 stated, oh, he yelled a couple of times but that is nothing new around here, people are always yelling but I was never afraid of him. On 10/19/23 at 10:00 AM, Surveyor interviewed PTA D (Physical Therapy Assistant). Surveyor asked about R1's therapy, including abilities. PTA D stated, when R1 started therapy, he was seen by me and OT (Occupational Therapy). R1 was a sit to stand and parallel bars. At time of discharge R1 transferred with a bump transfer and slide board with one assist. Surveyor asked PTA D if R1 had completed therapy goals and therapy at time of discharge. PTA D stated, in my opinion R1 was not ready for discharge from therapy. Surveyor asked PTA D if R1 ever refused therapy. PTA D stated, R1 refused therapy one time after he received his involuntary discharge and another time before that when I was late. R1 was usually good with me. I never had any issues with him. Surveyor asked PTA D if she ever witnessed R1 become aggressive with residents. PTA D stated, R1 never complained about other residents but would about staff. Surveyor asked PTA D if R1 ever recorded her or if PTA D ever witnessed R1 record any residents. PTA D stated, he had a brace or phone in his lap a lot of the time and he would record me at times. I never asked him to stop. I believed at the time he was doing it so he could remember the exercises. Surveyor asked PTA D if she ever noted any cognitive issues with R1. PTA D stated, I believe he had some. R1 would forget I worked with him. It took a long time for R1 to remember me and R1 would often repeat himself. Surveyor asked PTA D if R1 would be able to climb a ladder into his [NAME] bed. PTA D stated, No. Surveyor asked PTA D if R1 would be able to get up off a mattress if it was placed on the floor. PTA D stated, No. Surveyor asked PTA D if anyone from the facility had ever discussed with her R1's abilities prior to discharge. PTA D stated, at the time of R1's discharge, No. No one came and talked with me about him though I was his main PTA. On 10/16/23 at 9:10 AM, Surveyor interviewed R1 via telephone. Surveyor asked R1 about his stay at the facility. R1 stated he started to have a difficult time with staff after asking for an advocate number for the State Agency. R1 stated staff would not answer his call light timely, staff would turn off R1's call light and leave without assisting R1, staff would not assist R1 with his cares when he requested, R1 did not regularly receive showers, and staff would not empty his urinal. Surveyor asked R1 about his discharge. R1 stated he was given a 30-day Involuntary Discharge and told he had to leave. Surveyor asked R1 about his living situation. R1 stated he lived in a smaller motorhome, there was no running water, no bathroom, nowhere to sit, and had a lofted bed about 4 feet off the ground. R1 stated he would have to climb up into the [NAME], which he did not think he could do at this time. R1 stated he used most of the camper for storage. R1 states he was too embarrassed to tell anyone at the facility the state of his camper, but everyone, including NHA A, knew he lived in a camper. Surveyor asked R1 about his day of discharge. HUC G and MS E were to follow R1 to his camper. R1 stated he was taken, via van transport, to the pharmacy to get his medications and then to the campground where his camper is parked. R1 stated he got up the first step, but when attempting to step up on the second step started to fall backwards, staff assisted R1 back into his wheelchair. R1 stated he did not have the strength to get up the steps. R1 stated he was wet and cold, R1 only had a t-shirt and shorts on. R1 was returned to the transport van while staff went into R1's camper. R1 heard HUC G tell MS E that the camper was not fit to live in. R1 stated MS E locked the camper door and informed R1 they were returning to the city they came from. R1 thought he was returning to the facility. R1, TD L (Transport Driver), HUC G and MS E all stopped at a gas station. TD L got out of the transport van and spoke with staff. TD L got back into the van and drove towards the city they came from. R1 informed TD L that he was in the wrong lane to return to the facility. TD L stated to R1 that he was taking R1 to the hospital emergency room . TD L left R1 inside the emergency room entrance, spoke with emergency room staff and left. R1 was given a blanket by emergency room staff due to being cold and wet. R1 was assessed by a physician and told he had to leave due to no medical need to be admitted to the hospital. R1 was informed by hospital security he had to leave the hospital no later than 7:30 PM. R1 called the facility, asking if he could return. Facility staff told R1 he could not return as he was discharged , and they would no longer take R1's calls. R1 called FM I for assistance. FM I paid for a cab to take R1 to a hotel, which FM I paid for, for the night. 10/14/23, FM I paid for a cab to return R1 to his camper, as R1 stated he had nowhere else to go. R1 was dropped off at his camper with his wheelchair, walker, and belongings and left outside by the cab. R1 crawled up the outside steps backwards, into the camper. R1 had a blanket and pillow and laid on the floor of the camper after closing the camper door. R1 stated he could hardly move. R1 used a water jug to urinate in and a plastic bag to have a bowel movement in. R1 had no way to clean himself up and was unable to get onto the makeshift toilet. R1 stated he got onto the lofted bed, this took R1 many hours, leaving R1 in a great deal of pain. R1 stated he called FM I to let her know he got to the camper, and he had no food and no way to get food. FM I had a pizza delivered to R1 at FM I's expense. R1 stated he was unable to care for himself while he was in the camper. R1 stated he did not leave the lofted bed the entire time he was in the camper and soiled himself due to not being able to get to any bathroom facilities. On 10/12/23 at 4:52 PM, Surveyor interviewed CO K (Campground Owner). Surveyor asked CO K if R1 had a camper at the campground. CO K stated yes, R1 has lived at the campground for the past few years. Surveyor asked CO K if R1 had water in his camper. CO K stated the water at the campground would be turned off on 10/15/23 until the spring of 2024. R1 would have to bring water in if he wanted water in his camper. Surveyor asked CO K if R1's camper had a bathroom. CO K stated R1's camper did not have a bathroom. Surveyor asked CO K if R1's camper had heat. CO K stated he did not know if R1's camper had heat. CO K stated he had seen R1 at the beginning of October 2023. CO K stated he did not believe R1 could get into the camper using a walker. CO K stated he did not believe that it would be safe for R1 to live in the camper at this time as he would not be able to care for himself and was not sure R1 would be able to do everything needed to safely live in the camper in the winter in his current state of health. On 10/16/23 at 10:27 AM, Surveyor interviewed FM I via telephone. Surveyor asked FM I if she was aware of R1's discharge. FM I stated she was made aware of R1's discharge by R1. FM I stated she had spoken with NHA A a few days before R1's discharge and voiced her concerns to NHA A about R1 not being safe to live in his camper independently at this time due to his current condition. FM I stated she asked NHA A if R1 could be referred to another facility. NH A told FM I that R1's choices for discharge were his camper or a homeless shelter. Surveyor asked FM I if she offered to take care of or assist R1 after he was discharged . FM I stated she did not tell NHA A she could take care of or assist R1 after he was discharged . FM I stated she has her own family to care for. On 10/1 [TRUNCATED]