Every finding on record at Avina on Division

Based on interview and record review, the facility did not monitor for adverse reactions to a high-risk medication for 1 resident (R) (R33) of 3 sampled residents. R33 was prescribed Novolog and Lantus insulin. The facility did not monitor R33 for adverse reactions to the medications. In addition, R33 did not have hypoglycemia management orders.Findings include:The facilitiy's Accucheck/Blood Glucose Monitoring policy, revised 2/7/26, indicates: It is the policy of this facility to perform accuchecks as ordered by the resident's physician and to report alert levels to the attending physician as warranted. Standard parameters are as follows: Blood glucose level of <60 or >400 unless otherwise specified by the physician .3. During episodes of increased/decreased blood glucose levels, nursing staff will use standard nursing practices in conjunction with the Hypoglycemic Protocol to assure the health and welfare of the resident (i.e., providing juice, administering insulin per physician order/sliding scale, holding insulin, calling 911, etc.).The facility's Hypoglycemic Protocol indicates: Residents with hypoglycemia (<60 milligrams/deciliter (mg/dL) or less than the physician-ordered parameter): a) Give the resident an oral form of rapidly absorbed glucose .b) Recheck blood glucose in 15 minutes; c) If blood sugar is <60 mg/dL, repeat oral glucose and recheck blood glucose in 15 minutes; d) If no improvement, notify physician or Nuse Practitioner (NP) for further orders; e) If resident becomes unresponsive or is failing, call 911 (in accordance with the resident's advance directives) and if blood sugar remains <60 mg/dL give intramuscular (IM) glucagon . From 8/3/26 through 8/5/26, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R33's medical record contained orders for Novolog (insulin) 4 units before meals, additional doses of Novolog per sliding scale, and Lantus (insulin) 24 units at bedtime. The orders indicated to update the physician of blood glucose levels greater than 400 mg/dL. On 8/4/26 at 12:45 PM, Surveyor interviewed Medication Technician (MT)-C about the process for management of hyper- and hypoglycemia. MT-C stated they update the nurse if a resident has a high or low blood sugar level. MT-C did not indicate how low of a blood sugar level required notification but stated they would probably update the nurse if R33's blood glucose level was 80 mg/dL because it was usually over 100 mg/dL. Surveyor reviewed R33's orders with MT-C who verified the orders did not contain a low blood glucose parameter or indicate how to manage hypoglycemia. On 8/4/26 at 12:54 PM and 8/5/26 at 10:25 AM, Surveyor reviewed R33's current orders with Director of Nursing (DON)-B who verified the orders did not contain a low blood sugar parameter or indicate how to manage hypoglycemia. DON-B confirmed blood glucose parameters and hypoglycemic management should be in place for R33.

Based on interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R12) of 1 sampled resident.R12 received supplemental oxygen. R12 did not have a care plan for oxygen use. In addition, staff did not document that R12 received oxygen.Findings include:The facility's Oxygen Administration policy indicates: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care planand the resident's goals and preferences .1. Oxygen is administered under the orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 2. Personnel authorized to initiate oxygen therapy include physicians, Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and respiratory therapists. 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: .b. When to administer, such as continuous or intermittent and/or when to discontinue .equipment setting for the prescribed flow rates .monitoring of oxygen saturation levels .Between 8/3/26 and 8/5/26, Surveyor reviewed R12's medical record. R12 was admitted to facility on 1/15/19 and had a diagnosis of chronic respiratory failure.R12's medical record contained an order, dated 8/21/23, for oxygen as needed (PRN) 1-2 liters per minute (LPM) via nasal canula to keep oxygen saturation level > 90%. On 8/3/26 at 9:27 AM, Surveyor interviewed R12 who stated they used oxygen every night and sometimes during the day if short of breath. R12 stated they put on and took off the oxygen themself. R12 stated staff did not assist them with oxygen but occasionally checked their oxygen saturation level.R12's medical record did not contain an oxygen care plan, indicate they received oxygen nightly, or contain documentation that their oxygen saturation level was checked by staff prior to the administration of oxygen. On 8/4/26 at 3:13 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who was a full-time PM shift nurse. LPN-E verified R12 used oxygen independently at night when they felt short of breath. LPN-E verified they only check R12's oxygen saturation level once weekly with vital signs. On 8/5/26 at 9:14 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R12 should have a care plan for oxygen use and nursing staff should document that oxygen is administered.

Based on interview and record review, the facility did not ensure 1 resident (R) (R7) of 1 sampled resident received assessments or treatments as ordered by a physician. R7 had an order for a follow-up appointment with podiatry following a fall that resulted in broken toes. After the appointment was cancelled by the provider, the facility did not ensure the appointment was rescheduled or that R7 received a follow-up assessment and treatment. Findings include:The facility's Consulting Physician/Practitioner Orders policy, dated 8/2025, indicates: The attending physician shall authenticate orders for the care and treatment of assigned residents .1. Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician .The facility's Fall Policy, dated 1/2/26, indicates: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .Interventions will be monitored for effectiveness and reviewed/revised following a fall event, quarterly, annually, and with a significant change or as needed.On 8/3/26, Surveyor reviewed R7's medical record. R7 had diagnoses including fracture of unspecified metatarsal bones, right foot, subsequent encounter for fracture with routine healing, and abnormalities of gait and mobility. A Quarterly Minimum Data Set (MDS) assessment, dated 7/21/26, stated R7 had a Brief Interview for Mental Status (BIMS) score of 14 out 15, indicating intact cognition.R7's medical record indicated they fell on 1/3/26, 1/5/26, 1/13/26, 1/16/26, and 2/13/26. R7 was transferred to the emergency room (ER) on 1/13/26 due to severe pain and a hematoma on the back of the head following an unwitnessed fall. An ER Discharge summary, dated [DATE], indicated R7 fractured the 2nd through 5th metatarsals (toes) on the right foot. R7 was prescribed an ace wrap and a walker boot. The boot was to be in place when R7 was up. The summary indicated R7 was to be non-weight bearing on the right foot and should follow-up with podiatry.An Interdisciplinary Team (IDT) progress note dated late entry 1/13/26 indicated R7 was at risk for falls due to multiple diagnoses, including morbid obesity, type 2 diabetes, pulmonary hypertension, abnormalities of gait and mobility, osteoarthritis, and glaucoma. An immediate intervention was to send R7 to the ER for evaluation and treatment. A podiatry referral related to broken metatarsals was recommended in the ER.R7's care plan was updated on 1/13/26 with an intervention to send R7 to the ER for evaluation and treatment post-fall with a referral to podiatry.On 8/3/26 at 9:30 AM, Surveyor observed R7 in bed asleep. The bed was in the lowest position and a wheelchair was at the side of the bed. R7 was sleeping sideways in bed with their lower extremities hanging off of the bed.On 8/4/26 at 10:41 AM, Surveyor interviewed R7 who did not recall falling or having broken toes. R7 stated they had not seen a podiatrist aside from the facility's podiatrist that provided toenail care. On 8/4/26 at 1:42 PM, Surveyor interviewed Director of Nursing (DON)-B who stated they would check R7's medical record for podiatry appointment information and follow-up care. On 8/4/26 at 2:54 PM, Nursing Home Administrator (NHA)-A gave Surveyor a progress note written by the Social Services Department and dated 1/14/26 that indicated R7 would be seen by the podiatrist on 2/12/26 at 1:30 PM. NHA-A provided podiatry visit notes that indicated R7's appointment on 2/12/26 was canceled. NHA-A stated a request was sent to (the facility's provider) for R7 to be seen due to the canceled appointment. NHA-A provided a podiatry request form, dated 2/11/26 and signed by the facility's Nurse Practitioner (NP), that requested R7 be seen for thick toe nails. NHA-A provided a podiatry visit note from the facility's provider, dated 4/14/26, that indicated R7 was treated for thick toe nails. (Surveyor noted the request sent to the facility's provider on 2/11/26 occurred before R7's 2/12/26 follow-up podiatry appointment was canceled.) On 8/4/26 at 3:25 PM, Surveyor interviewed NHA-A who stated they spoke to the podiatry clinic who indicated R7's appointment was canceled because the provider was not available. NHA-A stated they would look into the cancelation to determine who at the facility was informed of the cancelation. On 8/5/26 at 1:30 PM, Surveyor interviewed NHA-A who stated the provider informed R7 that the appointment would be canceled. NHA-A was unsure who was informed within the facility and who canceled transportation for R7. NHA-A verified the facility set up the appointment and transportation for R7 and stated there appeared to be a miscommunication about the cancelation and the appointment needing to be re-scheduled.

Based on observation, interview, and record review, the facility did not ensure food preferences were honored for 1 resident (R) (R17) of 8 sampled residents.R17 had a 25.12% weight loss since April of 2026. R17's meal ticket listed a food preference of double portions. R17 was not served double portions.Findings include: The facility's Therapeutic Diet Orders policy, dated 9/2025, indicates: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the Interdisciplinary Team (IDT) to support the resident's treatment/plan of care, in accordance with their goals and preferences . On 8/3/26, Surveyor reviewed R17's medical record. R17 had diagnoses including adult failure to thrive and absence of teeth without dentures. A Comprehensive Minimum Data Set (MDS) assessment, dated 7/22/26, indicated R17 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. A care plan indicated R17 had a nutritional problem, was edentulous (without natural teeth), and tolerated a general diet with soft or pureed foods per their preference. The care plan contained interventions (dated 3/10/23) to provide/serve diet as ordered and Registered Dietician to evaluate and make diet change recommendations as needed. R17's medical record indicated they weighed 125 pounds (lbs) on 4/29/26. R17's most recent weight was documented as 93.6 lbs on 7/14/26 which indicated they had a 25.12% weight loss. On 8/3/26 at 9:33 AM and 12:23 PM, Surveyor interviewed R17 who stated they like some of the food served by the facility, specifically vegetables, cold cereal, eggs, and certain meats. R17 stated they lost a lot of weight and do not receive the foods they order, including vegetables and double portions. R17 stated the food they received for lunch was shameful and they wrote a concern on the back of the meal ticket to be sent to dietary staff or administration. R17 stated they circled the top of the meal ticket that indicated Double Portions and wrote on the back of the ticket their request for vegetables and that they did not receive double portions. Surveyor observed R17's lunch tray which contained a bowl of Jell-O with fruit dessert and a bowl of tater tots. R17 confirmed they did not receive any other food. On 8/4/26 at 8:18 AM, Surveyor interviewed R17 after their breakfast tray was served. R17 stated they did not receive what they ordered. Surveyor noted R17's meal ticket stated Double Portions, however, they received 2 ounces of eggs and a bowl of cold cereal. On 8/5/26 at 10:50 AM, Surveyor interviewed Dietary Manager (DM)-D who stated they were new to the facility and did not know R17. DM-D asked the Cooks and Dietary Aids if R17 received double portions that morning. DM-D was not aware that R17 was not receiving food as ordered and had just received Jell-O and tater tots for lunch. DM-D stated vegetables should be added if R17 enjoys them and indicated a better plan should be made to provide more nutrition per residents' requests and dietary orders.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all of the 31 residents residing in the facility.The facility's Water Management Plan (WMP) did not include water management team members who were knowledgeable about the facility's high-risk plumbing fixtures, identify all locations where Legionella could grow and spread, or identify where control measures should be applied based on where Legionella could grow and spread. Findings include: The facility's Water Management Program (WMP) policy, dated 12/10/25, indicates: It is the policy of this facility to establish a water management plan for reducing the risk of legionellosis (illnesses caused by Legionella bacteria such as Legionnaires' disease) and other opportunistic pathogens in the facility's water systems .1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing. a. The water management team has access to water treatment professionals, environmental health specialists, and state/local health officials. 2. The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder .5. Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens as needed. 6. The water management team shall regularly verify the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program activity for which they are responsible .11. In the event of an update to the water management program, the water management team shall: a. Update the water system schematic/description, associated control points, control limits, and any pre-determined corrective actions. b. Train those responsible for implementing and monitoring the updated program. 12. Documentation of all the activities related to the water management program shall be maintained with the water management program binder .On 4/29/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE]. R7's Minimum Data Set (MDS) assessment, dated 3/17/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 had intact cognition.On 4/29/26 at approximately 9:45 AM, Surveyor interviewed R7 who stated the shower in R7's room did not work and had not been used. R7 showered in the shower room down the hall. Surveyor observed the shower which was a walk-in shower with a plastic surround. There was a box of personal belongings in the shower that belonged to R7. The shower floor contained what appeared to be thick soap scum. There was no evidence of moisture or water use in the shower. On 4/29/26 at 9:57 AM, Surveyor and Nursing Home Administrator (NHA)-A observed R7's bathroom and shower. NHA-A stated the shower was one of two showers in the facility that were in resident rooms. NHA-A stated neither shower had been used since NHA-A started approximately five years ago. On 4/29/26 at 10:25 AM, Surveyor interviewed Maintenance Director (MD)-C. Surveyor and MD-C toured the facility and identified the two showers (the unused shower in R7's room and an unused shower shared between R4 and R9's room). MD-C verified the showers had not been used since MD-C started approximately two years ago. Surveyor and MD-C observed capped water fixtures in R5 and R9's rooms on the rehab hallway. MD-C stated MD-C had not flushed any of the hand-held showers that had faucets and had not flushed any of the dead ends (capped hand-held shower fixtures) in the rehab hallway bathrooms. MD-C stated the rehab wing was an addition to the original building and the unused fixtures were not identified in the facility's WMP. MD-C stated the fixtures were stand-up shower fixtures that were not used. MD-C stated some rooms have capped faucet fixtures on the wall but are not used. MD-C stated the metal capped pieces on the walls above the stand-up shower fixtures are breather valves. The rooms contain a sink and a toilet. MD-C stated the activity sink is probably used, however, MD-C does not see staff use the sink so MD-C flushes it weekly. MD-C stated another room contains a bathtub which MD-C flushes weekly. MD-C stated MD-C does not flush the other unused fixtures. MD-C verified MD-C is the only one who flushes unused fixtures. (Of note: The facility did not have documentation to verify MD-C flushes the activity sink and the bathtub.)On 4/30/26 at 1:43 PM, Surveyor interviewed NHA-A who acknowledged the facility's WMP does not include identification and control measures for high-risk areas such as the unused showers or the capped and unused plumbing fixtures. Surveyor requested and NHA-A provided the facility's Water System Infection Control Risk Assessment Tool. After review of a Risk Assessment, dated June 2025, Surveyor verified the facility identified water system components including six shower heads and hoses. Two showers were observed during the facility tour. No further documentation was provided to verify the unused fixtures were maintained according to the facility's WMP policy.

Based on observation, staff interview, and record review, the facility did not ensure parenteral medications were administered in accordance with a physician order for 1 resident (R) (R2) of 1 sampled resident.Licensed Practical Nurse (LPN)-D administered two intravenous (IV) normal saline (NS) flushes through a midline catheter for R2 who did not have an order for the flushes. In addition, R2's midline catheter was not accurately measured by Director of Nursing (DON)-B or reflected in R2's medical record.Findings include:The facility's PICC/Midline/CVAD Dressing Change policy, revised 1/2026, indicates: .To inspect the catheter and hub .use sterile measuring tape to measure external catheter length of the catheter from hub to skin entry to ensure it has not migrated.The facility's Medication Orders policy, dated 1/5/26, indicates: .Medications should be administered only upon the signed order of a person lawfully authorized to prescribe.From 4/29/26 to 4/30/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including urinary tract infection (UTI) and extended-spectrum beta-lactamase (ESBL) producing bacteria infection. R2's Minimum Data Set (MDS) assessment, submitted 2/13/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2's cognition was intact.R2 returned to the facility from the hospital on 4/21/26 with an IV catheter.R2's care plan, dated 4/22/26, indicated R2 was on antibiotic therapy (IV Ertapenem) related to a UTI. The care plan did not contain an intervention to monitor the IV site.On 4/29/26 at 9:25 AM, Surveyor observed R2's IV catheter dressing which was initialed and dated 4/24/26. Surveyor interviewed R2 who indicated the IV catheter was placed during a recent hospitalization.R2's Treatment Administration Record (TAR) indicated to change R2's peripherally-inserted central catheter (PICC) dressing every 7 days and as needed (PRN) to include all caps and connectors every evening shift every Wednesday (start date: 4/29/26). (The treatment was initialed as completed by DON-B on 4/29/26.) On 4/29/26 at 9:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who stated LPN-D had already administered R2's antibiotic through R2's PICC line. LPN-D indicated LPN-D would monitor the PICC line for swelling at the insertion site and look at the catheter to identify if it had moved out of place. LPN-D stated LPN-D could also ask a Registered Nurse (RN). LPN-D stated the facility previously didn't always have RN coverage but had it now and an RN was usually in the facility during IV therapy. LPN-D stated LPN-D was trained and could do PICC line dressing changes.On 4/29/26 at 4:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated LPNs who took the All Stat Portable IV course could do PICC line infusions, dressing changes, and monitoring.On 4/30/26 at 9:00 AM, Surveyor observed LPN-D enter R2's room with Ertapenem 1 gram (an antibiotic) in a single-use disposable ball pump that used natural pressure from an internal balloon to deliver the medication over time without the use of an electronic pump or gravity. LPN-D rubbed alcohol on the catheter hub and connected a syringe that contained 10 milliliters (ml) of NS to the hub. LPN-D unclamped the catheter and pushed NS into the catheter. LPN-D disconnected the syringe from the catheter hub and connected the end of the primed antibiotic tubing to the hub. LPN-D unclamped the IV tubing and opened a blue cap on top of the ball pump. LPN-D set the ball pump on the bed next to R2 who was sitting in a wheelchair. LPN-D removed personal protective equipment (PPE), completed hand hygiene, and left R2's room. (Of note: R2's medical record did not contain an order to flush the catheter with NS.)On 4/30/26 at 9:05 AM, Surveyor observed LPN-D document administration of the antibiotic. When Surveyor asked where LPN-D documented the NS flush, LPN-D stated LPN-D could not find an order for the flush in R2's medical record. LPN-D stated it was normal to flush an IV line with NS before and after an infusion.On 4/30/26 at 9:42 AM, Surveyor observed LPN-D enter R2's room, clamp R2's IV tubing, and swab the catheter hub with alcohol. LPN-D connected a syringe with 10 ml of NS to the hub and pushed NS into the catheter. LPN-D clamped the catheter, disconnected the syringe, removed PPE, and exited the room.On 4/30/26 at 10:24 AM, Surveyor interviewed DON-B who stated DON-B completed R2's PICC line catheter change on 4/29/26. DON-B indicated staff documented monitoring for signs and symptoms of infection of a PICC line in a resident's progress notes. Surveyor verified progress notes indicated R2's PICC line did not show any signs or symptoms of infection or leaking. DON-B stated DON-B measured R2's PICC line external catheter on 4/29/26 but did not have a place to document the length. DON-B stated DON-B would provide Surveyor with the measurement and paperwork from placement of the PICC line that indicated the external catheter length after catheter placement. DON-B verified with Surveyor that R2 did not have an order for a NS flush and verified there should be physician order for flushes before and after an IV infusion.On 4/30/26 at 12:00 PM, DON-B informed Surveyor the measurement for R2's PICC line external catheter was 10 centimeters (cm) without the hub and 14 cm with the hub. DON-B provided documentation from the placement of the IV catheter and exited the room.On 4/30/26 at approximately 12:20 PM, Surveyor reviewed the placement documentation which indicated the external catheter length was 0 cm. The placement document indicated R2 had a single lumen power midline for continuation of IV antibiotics.On 4/30/26 at 12:26 PM, Surveyor interviewed Registered Nurse (RN)-E who worked at the infusion clinic written on the bottom of the placement documentation provided by DON-B. RN-E stated R2 had a midline catheter, not a PICC line catheter, and a midline catheter external length should be 0 cm. RN-E stated if any external length was present, the midline catheter was likely migrating out. RN-E indicated the total length of the catheter was 18 cm and a stat lock should hold the catheter in place. RN-E indicated if the midline catheter was migrating out, hash marks that indicated 1 cm would be visible on the catheter. RN-E stated the facility needed a physician order for flushes every 24 hours and before and after an infusion. RN-E indicated flushing assisted with preventing clogging of the site.On 4/30/26 at 12:39 PM, Surveyor observed R2's midline catheter and noted a stat lock against R2's skin holding the catheter in place underneath a transparent dressing. The catheter line contained the words midline catheter. Surveyor observed a 2x2 gauze over the insertion site with a transparent dressing that covered the stat lock and gauze. Surveyor did not observe hash marks, leaking fluid, redness, or swelling underneath the transparent dressing.On 4/30/26 at 2:06 PM, Surveyor informed DON-B that R2 had a midline catheter which would not have any external catheter to measure as indicated on the placement document DON-B provided earlier. DON-B then stated there was 0 cm of external catheter visible and DON-B did not see any hash marks during R2's dressing change on 4/29/26.

Based on observation and staff and resident interview, the facility did not ensure a sanitary, comfortable, and home-like environment for 6 residents (R) (R7, R8, R4, R9, R6, and R5) of 6 sampled residents. R7's shared bathroom contained a walk-in shower that contained a tan/gray/green chalky substance and a cardboard box of personal belongings that were scattered on the shower floor. An unmarked plastic cup of green, cylindrical pellets was set on an area that surrounded the top of the shower. R7's room also contained brown discoloration in the corner of the ceiling and a deteriorating area that contained water damaged plaster and trim that measured approximately 5 inches by 5 inches behind the door in the interior corner of the room.R8's room contained brown discoloration in the corner of the ceiling. R4 and R9's shared bathroom contained a walk-in shower. The shower floor contained a rust-colored substance and stains. The shower contained a cardboard box of personal belongings with items scattered on the shower floor. R6's private bathroom contained bulging drywall and deterioration on the wall below where the toilet was attached. R5's bathroom contained a hole approximately 1 foot wide by 1 foot tall with exposed brick and wall material below where the toilet was attached. Findings include: On 4/29/26 at 9:57 AM, Surveyor and Nursing Home Administrator (NHA)-A observed R7's room, including the shower which contained a tan/gray/green chalky substance that went up the walls of the shower and a box of R7's personal belongings which were scattered on the shower floor. Surveyor and NHA-A also observed a discolored ceiling in the corner of the room and an area of disintegrating trim and wall on the lower corner behind the door. NHA-A stated there was a previous issue with the roof and the roof was recently replaced. NHA-A stated there were no concerns with the room and NHA-A had not noticed the areas. NHA-A stated the shower had not been used for at least five years. Surveyor and NHA-A also observed an unmarked four to eight ounce plastic cup of green cylindrical pellets on top of the shower. NHA-A stated the cup contained an odor absorbing product called Dumpster Breath. NHA-A took the cup out of the room per R7's request. R7 shared a bathroom with another room which was vacant. On 4/29/26 at 10:28 AM, Surveyor and Maintenance Director (MD)-C observed R7's room and bathroom. MD-C verified the corner of the ceiling was discolored and stated plaster work was done on the lower half of the wall due to water damage from the old roof. MD-C stated the discoloration was cosmetic. MD-C was waiting for warmer weather and rain before completing repairs to ensure the roof did not have any more leaks. MD-C observed the lower corner behind the door where the drywall and baseboard were in disrepair. MD-C verified a ceiling tile in the hall outside the room had water damage and would be fixed when no further leaks were identified in the roof. Surveyor and MD-C viewed the adjoining wall of R7's room (in R8's room) which had similar discoloration in the corner of the ceiling and in the hallway where a ceiling tile was sagging from water damage.Surveyor and MD-C also observed R4 and R9's shared bathroom which contained a walk-in shower. The shower floor contained a rust-colored substance, stains, and a cardboard box of personal belongings with items scattered on the shower floor.On 4/29/26 at 12:54 PM, Surveyor interviewed R6 who had a private bathroom that contained a hole in the wall below where the toilet was attached to the wall. The wall was in disrepair and falling apart. Surveyor then observed R5's room. R5 stated there was a hole in the wall below the toilet in the bathroom. R5's family member reported the hole to staff but it had not been fixed.On 4/29/26 at 1:30 PM, Surveyor, NHA-A, and Director of Nursing (DON)-B observed the damage below the toilets in R6 and R5's rooms. NHA-A and DON-B verified the damage to R6 and R5's walls and were not previously aware of the damage. While NHA-A, DON-B, and Surveyor were in R5's room, R5 indicated R5 was upset and stated R5's family member informed staff about the hole and wanted the hole fixed.On 4/29/26 at 2:35 PM, Surveyor and MD-C observed R6 and R5's rooms. MD-C acknowledged the damage in R6's room and indicated the outside layer of plaster may have been wet at one point and needed to be repaired. MD-C stated the way the toilet was mounted to the wall may have something to do with the damage. R6 was in the room and stated R6 felt safe using the toilet. MD-C also acknowledged the damage in R5's room as a hole in the wall below the toilet. MD-C was not aware either of the bathrooms had damage and stated it was possible a plumber had to get in the wall and did not notify MD-C when the repair was done.

Based on observation, staff interview, and record review, the facility did not provde the appropriate care and treatment to promote healing of a pressure injury for 1 resident (R) (R3) of 1 sampled resident.R3 had a stage 4 pressure injury on right lateral lumbar region. During wound care, Licensed Practical Nurse (LPN)-D used soiled scissors to cut silver alginate that was applied to R3's pressure injury. In addition, LPN-D opened a 4x4 gauze package, removed the gauze, and sprayed it with wound cleanser. LPN-D placed the wet gauze on the outside of the gauze package that had touched soiled surfaces.Findings include:The facility's Pressure Injury Prevention and Management policy, revised 6/17/25, indicates: .Provide treatment and services to heal the pressure ulcer/injury, prevent infection .evidence-based treatments in accordance with current standards of practice will be provided for all residents.From 4/29/26 to 4/30/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had a diagnosis of pressure-induced deep tissue damage of unspecified site. R3's Minimum Data Set (MDS) assessment, dated 1/28/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3's cognition was intact.R3's medical record contained the following physician's order for a treatment to R3's right lateral lumbar region distal area:~ Cleanse with wound cleanser or normal saline (NS), apply skin prep to the peri-wound followed by silver alginate to the wound base. Cover with abdominal (ABD) pad dressing and secure with Hypafix tape. Change daily and as needed (PRN) (start date: 2/6/26).On 4/29/26 at 10:05 AM, Surveyor observed LPN-D set scissors, a 4x4 gauze package, and an ABD package on a personal protective equipment (PPE) cart outside R3's room. LPN-D donned a gown, completed hand hygiene, and donned gloves. LPN-D picked up the scissors, gauze, and ABD dressing and entered R3's room. LPN-D set the supplies on R3's uncleansed bedside table. LPN-D picked up the scissors, retrieved silver alginate from a drawer, cut the silver alginate, and placed it back in the package. LPN-D put the scissors and silver alginate on the same bedside table. LPN-D removed gauze from the package, put wound cleanser on the the gauze, and set the wet gauze on top of the package which had touched the PPE cart and bedside table. LPN-D removed R3's soiled dressing, cleansed the wound, and applied skin prep to the peri-wound. LPN-D removed gloves, cleansed hands, and donned new gloves. LPN-D placed the silver alginate on the wound bed, put an ABD dressing over the wound, and used Hypafix tape to secure the dressing. LPN-D assisted R3 onto R3's back, removed gloves, and placed the remainder of the silver alginate in its original package and back in the drawer. LPN-D then exited the room. LPN-D removed LPN-D's gown outside the room then put the gown in the garbage in R3's room. Surveyor interviewed LPN-D who indicated LPN-D acknowledged the concern with contamination from transferring wound supplies from the PPE cart to the bedside table which were then in contact with R3's wound bed.On 4/29/26 at 10:15 AM, Surveyor interviewed Director of Nursing (DON)-B who verified LPN-D should not have put the scissors on the PPE cart and uncleansed bedside table and used the scissors to cut silver alginate that was directly applied to R3's wound bed. DON-B confirmed putting wet gauze used during wound care on the outside of a package that was in contact with the PPE cart and uncleansed bedside table could contaminate the wound.

Based on interview, record review, and facility policy review, the facility failed to employ a Registered Nurse (RN) ensuring the minimum requirement of having an RN providing services at least eight consecutive hours a day, seven days a week and failed to employ an RN who was designated to serve as the Director of Nursing (DON) on a full-time basis. These failures caused the facility's nursing staff department to have no oversight of Licensed Practical Nurses (LPNs) and non-licensed personnel (Certified Medication Aide/Medication Technician [CMA/MTs]) who administered medications which placed all residents at risk of not being able to attain or maintain their highest practical physical, mental, and psychosocial well-being. This had the potential to affect 34 of 34 residents who resided at the facility. The facility failed to have adequate nursing oversight of licensed nurses who administered medications and cared for residents with high acuity needs, including Peripherally Inserted Central Catheters (PICC lines,) dialysis shunts, and stage III or higher pressure injuries. Additionally, during the time the facility employed a fulltime DON/RN and during the time the facility did not employ a fulltime DON/RN, LPNs were administering intravenous (IV) medications and completing nursing assessments which were outside of their scope of practice and CMA/MTs were injecting insulin medications, completing residents' pain assessments, and administering PRN (as needed) pain medications which was outside of their scope of practice. The facility's failure to employ a Registered Nurse to provide services and nursing oversight created a finding of immediate jeopardy that began on 03/14/26. Surveyor notified the Regional Director of Operations (RDO) and the [NAME] President of Clinical Operations (VPCO) of the immediate jeopardy on 03/27/26 at 10:45 AM. The immediate jeopardy was removed on 03/28/26, however, the deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility continues to implement its action plan. Findings include:Review of the Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ) Staffing Data Report, dated for the first quarter of 2026 (10/01/25-12/31/25), revealed a one star staffing rating and no RN hours were triggered (four or more days within the quarter with no RN hours.)Review of the Daily Staffing schedules, dated 03/22/26 through 03/27/26, revealed there was not an RN scheduled to work on any of the dates. This indicated there was no RN assigned to supervise the nursing staff and the overall care of the residents.Review of the facility's policy titled, Nursing Services and Sufficient Staff, dated 01/05/26, revealed, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment.Policy Explanation and Compliance Guidelines: .8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. 9. The Director of Nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. 10. The facility must designate a registered nurse (RN) to serve as the DON on a full-time basis. Additionally, the facility may permit the DON to serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.1. LPNs completing admission Assessmentsa. Review of Resident (R) 5's admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses to include diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare.Review of R5's 72 HR [hour] Admission/re-admission Charting, progress note, dated 03/24/26, revealed documented evidence the assessment was completed by LPN2. b. Review of R9's admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) and traumatic ischemia of muscle.Review of R9's NRSG [Nursing]: admission Data Collection Progress Notes, dated 03/17/26 and located in the resident's EMR under the Progress Notes tab, revealed documented evidence the assessment was completed by LPN1.Review of R9's NRSG: admission Data Collection and Baseline Care Plan Tool-V 11, dated 03/17/26 and located in the resident's EMR under the Forms tab, revealed documented evidence the assessment was completed and signed by LPN1.Review of R9's Late Entry Health Status Note, created on 03/24/26 (seven days post admission), with an effective date of 03/17/26, and located in the resident's EMR under the Progress Notes tab, revealed the note was completed by the facility's Sister Facility DON (SFDON).c. Review of R8's admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses to include chronic congestive heart failure.Review of R8's NRSG: admission Data Collection Progress Notes, dated 03/17/26, revealed the note was completed by LPN4.Review of R8's NRSG: admission Data Collection and Baseline Care Plan Tool-V 11, dated 03/17/26 and located in the resident's EMR under the Forms tab, revealed the document was completed and signed by LPN4.d. Review of R6's admission Record, located in the resident's EMR under the Profile Tab, revealed the resident was admitted to the facility on [DATE] with diagnoses to include sepsis, diabetes type 2, congestive heart failure, and end stage renal disease (ESRD.)Review of R6's NRSG: admission Data Collection Progress Notes, dated 03/24/26 and located in the resident's EMR under the Progress Notes tab, revealed the note was completed by LPN4.Review of R6's Nurses Note, dated 03/24/26 and located in the resident's EMR under the Progress Notes tab, revealed the note was completed by LPN1 and included details of the resident's admission to the facility. 2. LPNs Administering IV Medications with no RN oversighta. Review of R5's Order Listing Report, located in the resident's EMR under the Reports tab, revealed an order dated 03/24/26 of Ertapenem (a broad-spectrum carbapenem antibiotic used to treat severe or moderate bacterial infections) Sodium Injection Solution Reconstituted.use 1 gram intravenously at bedtime for abscess.Review of R5's Medication Administration Record (MAR,) dated March 2026 and located in the resident's EMR under the Orders tab, revealed the resident was administered the IV antibiotic medication on 03/25/26 by LPN1 (out of the LPN's scope), 03/26/26 by the Assistant Director of Nursing (LPN,) and on 03/27/26 by the ADON. 3. CMA/MTs Assessing Pain, Administering PRN Pain Medications, and Administering Insulina. Review of R2's admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes type 2, stage II pressure ulcer of right heel, stage II pressure ulcer of left heel, chronic pulmonary embolism, and osteomyelitis of vertebra.Review of R2's Order Listing Report, located in the resident's EMR under the Reports tab, revealed an ordered dated 03/13/26 of oxycodone (narcotic pain medication) 5 mg [milligram] oral tablet, give 2 tablet [sic] by mouth every 4 hours as needed for pain.Review of R2's Pain Level Summary, located in the resident's EMR under the WTS [weights]/Vitals tab, revealed CMA/MT1 completed six pain assessments on R2 from 03/14/26 through 03/27/26 with no RN employed to provide direct supervision of the CMA/MT.Review of R2's MAR, dated March 2026, located in the resident's EMR under the Orders tab, revealed CMA/MT1 administered six doses of PRN pain medication to R2 between 03/14/26 and 03/27/26 with no RN employed by the facility to provide direct supervision of the CMA/MT.Review of R2's Order Listing Report, located in the resident's EMR under the Reports tab, revealed an order dated 03/13/26 of Insulin Lispro Injection Solution 100 unit/ML [milliliter] .Inject 4 unit [sic] subcutaneously with meals related to Type 2 Diabetes Mellitus. The ordered was discontinued on 03/19/26.Review of R2's Order Listing Report, located in the resident's EMR under the Reports tab, revealed an ordered dated 03/19/26 of Insulin Lispro Injection Solution 100 unit/ML.Inject as per sliding scale.Review of R2's MAR, dated March 2026 and located in the resident's EMR under the Orders tab, revealed CMA1 administered six doses of insulin to R2 without the facility having a RN employed to provide direct supervision of CMA/MT1.During an interview on 03/25/26 at 8:45 PM, the Administrator stated the facility did not currently have a DON. The Administrator stated the DON resigned and her last day working was 03/13/26.During an interview on 03/26/26 at 4:20 PM, the ADON stated that since the resignation of the Former DON (FDON) on 03/13/26, there had not been an RN employed by the facility. This indicated there had not been a RN who worked in the facility eight consecutive hours a day, seven days a week. The ADON also stated when the facility did employ a DON, most weekends did not have an RN who worked in the facility. When asked who completed the initial admission assessments for newly admitted residents and/or readmitted residents, the ADON stated LPNs completed the nursing assessments when residents were admitted to the facility. When asked what the nurses were supposed to do if a resident had a change in condition, the ADON stated the LPNs were to notify the Nurse Practitioner (NP,) the Physician, or the FDON when she was employed by the facility. When asked if LPNs were within their scope of practice to administer IV medications through PICC lines, the ADON stated all but two LPNs for the facility were certified or trained to administer IV mediations. The ADON identified LPN1 and LPN2 as not having the required certification/additional training to administer IV medications. During an interview on 03/26/26 at 7:02 PM, when asked who had been responsible for supervising the nursing staff since the FDON's resignation, the Regional Director of Operations (RDO) stated two DONs from their sister facilities had been helping out. When asked if she could provide any documented evidence of either DON being in the facility and for how long each time they were in the facility, the RDO stated she could not. When asked who had been responsible for the clinical care and well-being of the residents, the RDO again stated she had two DONs from sister facilities helping out and both were just a phone call away and one DON was just a short distance away from the facility. During an interview on 03/28/26 at 4:39 PM, the Medical Director stated it was her understanding the facility was having other RNs/DONs from other facilities covering the RN position. The Medical Director stated it was her expectation the corporate leadership would have ensured there was RN coverage until the facility could hire a DON/RN. The Medical Director stated it was important the facility would have RN coverage as RNs complete resident nursing assessments, IVs, and supervise staff to ensure they are staying within their scope of practice. During an interview on 03/28/26 at 7:16 PM, when asked if the facility met the minimum regulatory requirement of having an RN who worked eight consecutive hours a day, seven days a week during her tenure, the FDON stated she was at the facility Monday through Friday and rarely called in. The FDON stated if the facility was short nurses on the weekends, she would have to come in and work as a floor nurse. When asked what duties and tasks she delegated to the LPNs, the FDON stated if she had observed an LPN apply a wound vac and felt they were competent, she would allow the LPNs to independently apply them. The FDON stated there was not any type of documentation or formal training, just demonstration by her and return demonstration by the LPNs. When asked about LPNs administering medications through PICC lines, the FDON stated most of the LPNs employed by the facility had received extra training through a third party contracted by the facility, however, she would still demonstrate and require a return demonstration prior to the LPNs being able to independently administer IV medications. When asked if LPN1 and LPN2 had received additional training/certification to be able to administer medications intravenously, the FDON stated she thought they were certified and she had observed both LPNs administer IV medications and had no concerns. When asked what tasks were delegated to the CMAs, the FDON stated there were only three or four employed by the facility, however, CMA1 was the only one who was utilized regularly for medication administration. Continued interview revealed that the CMAs had completed the required course to become CMAs and she was their preceptor. When asked if CMA1 had completed any type of additional education or courses for insulin administration, the FDON stated not that she was aware of. The FDON stated she had completed competencies on CMA1. When asked if the CMA should have completed some type of additional training or education on insulin administration since it was the route of injection, the FDON stated she went with the principle that it had always been done just by return demonstration competency at the facility. When asked about CMA1 administering PRN pain medications, the FDON stated CMAs were only allowed to give PRN pain medication after a nurse had completed an evaluation for pain. The FDON also stated all LPNs had been educated that nurses had to complete the pain assessments on residents. When asked who should be completing admission assessments on newly or readmitted residents, the FDON stated that LPNs complete a lot of them because 99% of admissions are on the evening shift. The FDON stated she would always review admission assessments completed by LPNs her next scheduled day of work. The facility's failure to employ a Registered Nurse ensuring the minimum requirement of having an RN providing services at least eight consecutive hours a day, seven days a week, the the failure to employ an RN who was designated to serve as the Director of Nursing on a full-time basis created a likelihood for serious harm, thus leading to a finding of immediate jeopardy beginning on 03/14/26. The facility removed the immediate jeopardy on 03/28/26, however, the deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility continues to implement the following action plan: Employ a full-time interim DONProvide staff education on notification of changes in conditionAssessments of nurses' IV competencyEmployment of an agency RN to ensure RN coverage on Saturdays and SundaysReassess all residents with IVs, pressure injuries, new admissions since 03/14/26Reassess all residents with a documented change in condition since 03/14/26

Based on interview and record review, the facility failed to conduct an assessment for a patient-reported change in condition for one of five residents (Resident (R) 2) reviewed for change in condition. On 02/17/26, R2 complained to Licensed Practical Nurse (LPN) 1 that she might need to go to the hospital. LPN1 did not immediately assess the resident to determine if R2 had an emergent need after R2 reported respiratory symptoms. This resulted in R2's Family Member (F1) calling 911. R2 was transferred to the hospital and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli (PE) without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection.Findings Include:According to BOARD OF NURSING N 6.03 Chapter N 6 STANDARDS OF PRACTICE FOR REGISTERED NURSES AND LICENSED PRACTICAL NURSES> N 6.04 Standards of practice for licensed practical nurses. (1) PERFORMANCE OF ACTS IN BASIC PATIENT SITUATIONS. In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care delegated acts which the L.P.N. is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. N 6.03 Standards of practice for registered nurses. (1) GENERAL NURSING PROCEDURES. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation.Review of R2's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including osteomyelitis of the vertebra, lumbar region; chronic obstructive pulmonary disease (COPD); panlobular emphysema; and chronic myeloid leukemia, not having achieved remission.Review of R2's Care Plan, dated 12/14/25 and located under the Care Plan tab in the EMR, revealed a focus of, The resident and resident's spouse display socially inappropriate and maladaptive behavior related to making inappropriate phone calls to the emergency medical system (EMS 911) when an actual emergent/crisis situation does not exist. The goals included, The resident will communicate needs to staff and follow his/her recommended treatment plan without abusing the EMS by the next review. Interventions included, Educate the resident about the role and purpose of the EMS, specifically for its use for persons with serious injuries and life or death situations. Explain the consequences of diverting fire, police and paramedic resources away from an emergency. This behavior may place an innocent citizen in serious jeopardy.Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/26 and located in the EMR under the MDS tab, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded R2 had functional limitations in range of motion to her lower extremities on both sides and was mobile by wheelchair.Review of R2's Progress Note, dated 02/17/26 at 8:09 AM and located under the Progress Notes tab of the EMR, revealed R2 received a nebulizer treatment of Ipratropium-Albuterol Inhalation Solution, 0.5-2.5 (3) mg (milligrams)/3ml [milliliter] 1 [one] application inhale orally every 6 [six] hours as needed for SOB [shortness of breath]/whezzing [sic] . At 8:59 AM, it was documented that the nebulizer treatment was effective.Of note, the LPN did not collect data or alert a Registered Nurse of R2's report of feeling SOB with wheezing. The facility did not complete a comprehensive respiratory assessment or vital signs despite R2's complaint of SOB. Review of a Progress Note, dated 02/17/26 at 1:52 PM, located in the resident's EMR under the Progress Notes tab, and signed by Licensed Practical Nurse (LPN) 1, revealed, .Resident transferred out to hospital after husband called ambulance for them to come get her for resident stating she was having increasing shortness of breath . Review of R2's hospital Discharge summary, dated [DATE] and provided by the facility, revealed, .came to the ER [Emergency Room] with dyspnoea [sic] [shortness of breath] and wheezing. She denied any chest pain or leg swelling. No nausea or vomiting .She came to the ER where CTA [Computerized Tomography Angiography, a type of medical test to help diagnose and evaluate blood vessel disease or related conditions, such as aneurysms or blockages] showed no acute PE [pulmonary emboli] but possibility of chronic PE and lung nodule. [Physician name withheld, pulmonologist] was contacted and recommended starting the patient on heparin drip. Whilst in the ER she was hypoxic with SAO2 [oxygen saturation of arterial blood] in the low 80's .Patient was then transition [sic] to Eliquis prior to discharge. Patient has been off oxygen through the night and maintain saturations at 98% on room air .Of note, R2 was found to have hypoxia, low oxygen saturation, and a pulmonary embolism upon admission to the emergency room. According to https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/symptoms-causes/syc-20354647, A pulmonary embolism is a blood clot that blocks and stops blood flow to an artery in the lung. Because one or more clots block blood flow to the lungs, pulmonary embolism can be life-threatening. However, prompt treatment greatly reduces the risk of death. Review of a facility grievance file, dated 02/17/26, with a report date of 02/20/26 and provided by the facility, revealed, Grievance Details .Resident [R2] stated that when she was sent to the hospital, on 2/17/26, her requests to be sent out to the hospital were 'Ignored' .Summary of Investigation .Resident stated to a staff member that she was trying to be sent out to the hospital on 2/17/[26], but 'nobody listened to her.' .Summary of Findings .the nurse on duty and CNA [Certified Nursing Assistant] was in and out of her room providing cares. There was at no time she was noticed to be in distress. She never let the nurse know either way, and the next thing the facility knew was that the husband had called EMS [Emergency Medical Services]. Before the nurse could even get in to assess the resident, the EMTs [Emergency Medical Technicians] were here and taking [R2] to the hospital .Summary of Actions Taken .Staff interviews conducted. [R2] did not mention to any staff members that she wanted to go out . This grievance had a resolved date of 02/20/26 by the Administrator. The Resolved Note recorded, [R2]'s husband came in on the 20th. Was happy with the resolution to concern and has no other concerns at this time. [R2] expresses no concerns.Contained within the grievance file were statements dated 02/19/26 from the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Medication Technician (MT) 2. Each statement recorded that R2 did not tell any of them she wanted to go to the hospital. A statement from MT1 was also contained within the file. The statement recorded R2 told MT1 that she needed a nebulizer treatment. It was recorded that MT1 told R2 that the nurse would provide the nebulizer treatment. MT1 recorded that R2 received her nebulizer treatment as ordered. MT1 stated R2 did not tell her that she needed to go to the hospital. A statement from LPN1 was also contained in the file. LPN1's statement recorded, [R2] stated she 'may need to go to the hospital' I told her to let me know if she does. Next thing I knew, EMS had been called by her husband. She never told me that she wanted to officially go to the hospital.Review of a Progress Note, dated 02/19/26 at 1:11 PM and located in the Progress Notes tab of the EMR, revealed, .Writer did not have time to assess resident as EMT's had already arrived . During an interview on 03/26/26 at 8:30 AM, R2 was asked to tell Surveyor what happened in February when she wanted to go to the hospital. R2 stated she asked LPN1 to come to her room and told her what was going on. R2 was asked what she specifically told LPN1 about how she was feeling. R2 stated she told LPN1 she needed to go to the hospital. R2 stated she was wheezing a lot but not gasping for air. She stated she tried to take deep breaths and stay calm. When asked if LPN1 did any type of assessment, like listening to her lungs, R2 stated LPN1 did not do anything. R2 stated LPN1 said she would have to wait to hear from the doctor to get permission to send her over (to the hospital.) R2 asked how long she waited. R2 stated she waited for about an hour but then called her husband, told him what was going on, and he called 911. R2 was asked what they found at the hospital. She stated the hospital found a blood clot in her lung.During an interview with FM1 on 03/26/26 at 9:00 AM, FM1 was asked about calling 911 for R2 in mid-February. FM1 stated that R2 called him, was crying, and she was calling out to anyone in the hallway. FM1 stated he called 911 for R2 because she was saying she needed to go to the hospital and staff was not doing anything.During an interview on 3/26/26 at 11:55 AM, LPN1 stated R2 was pretty independent. LPN1 stated that if staff were not responsive, R2 would call on the facility's phone. LPN1 was asked if she was working on the day R2 stated she was not feeling well and was short of breath. LPN1 stated she was completing the medication pass when R2 told her she may need to go to the hospital. LPN1 stated that R2 told her she was feeling short of breath. LPN1 stated she could see R2 was not in dire need and by the time she went down to the resident's room, which was in maybe five minutes, the resident's husband had already called 911. LPN1 stated R2 had just came back in from smoking and stated her chest had been feeling funny lately. LPN1 stated R2 will say things like that a lot and nothing seemed different. When asked what the resident specifically said to her, the LPN stated that all the resident said was, I may need to go out. LPN1 stated that because R2 complained about different things and ailments and was talking fine and was not short of breath, she figured she had a few minutes to get down there (to the resident's room.) LPN1 was asked if she would have responded differently if this had been any other resident. LPN1 stated she would have assessed them. LPN1 was asked if anything had happened as a result of this incident. She stated that the Administrator and DON talked to her about it. LPN1 stated she had been instructed that an assessment should have been completed.During an interview on 03/28/26 at 4:39 PM, the Medical Director stated it was her expectation that when a resident stated they wanted to go to the hospital, staff would conduct an assessment, obtain vital signs, and report to her or the Nurse Practitioner. The Medical Director stated this was the first time she had heard about the incident with R2 but that the Nurse Practitioner might be aware.

Based on interviews and record review, the facility failed to have an effective system in place to ensure residents were free from significant medication errors for 1 of 5 sampled residents (R2). R2's infectious disease doctor ordered two oral antibiotics on 01/15/26 upon completion of an intravenous (IV) antibiotic for discitis osteomyelitis (a serious spinal infection affecting vertebrae and intervertebral discs, characterized by severe, persistent back pain). The facility did not transcribe the order or administer the antibiotics until after R2 was sent to the emergency room (ER) with redevelopment of previously cleared osteomyelitis. Additionally, R2 was intravenously administered another resident's antibiotic on 01/13/26.Review of the facility's policy titled, Medication Errors, dated 2025, revealed, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors .Definitions: .'Significant medication error' means one which causes the resident discomfort or jeopardizes his/her health and safety .Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders . Review of the facility's policy titled, Physician Orders-Entering and Processing, revised 01/31/18, revealed, Purpose: To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders. (a prescriber is noted as physician, nurse practitioner, and a physician's assistant.) Guidelines: .5. Following a physician visit, a licensed nurse will check for any orders that require confirmation under Clinical>orders>pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed . 1. R2 was originally admitted to the facility after a hospital stay on 10/22/25 with diagnoses which included osteomyelitis of vertebra, lumbar region, and chronic myeloid leukemia, not having achieved remission. R2's hospital Discharge summary, dated [DATE], stated, R2 .was admitted for management of lumbar discitis/osteomyelitis at L2-L3 (lumbar discs) .Infectious Disease (ID) recommended continuation of IV vancomycin (an antibiotic medication) .with plans to transition to IV daptomycin (an antibiotic medication) via PICC (peripherally inserted central catheter) line for a minimum of six weeks . A repeat MRI (magnetic resonance imaging) and ID follow-up are planned prior to completion of the antibiotic course . R2 had a follow up MRI on 1/12/26. MRI results, dated 01/14/26, indicated, .IMRESSION: 1. Evolving L2-L3 discitis/osteomyelitis .compared to prior [MRI] there is only trace residual fluid signal in the disc space. The findings are indicative of improvement. Progress notes from R2's ID visit stated, .Progress Notes documented this encounter .1/12/26 MRI lumbar spine .Evolving changes of discitis/OM [osteomyelitis] as expected with only trace residual fluid in disc space. Suspect area of enhancement and myositis (chronic muscle inflammation causing muscle weakness, fatigue, and pain) are likely from residual inflammatory changes rather than persistent infection as she has completed over 3 months of antibiotics and endorsed improved back pain .I contacted Neurosurgery who noted improvement compared to MRI 10/01/25. Neurosurgery agreed that ongoing changes are likely inflammatory rather than infectious .Will discontinue daptomycin and monitor off antibiotics. Will arrange follow up visit in 4-6 weeks to reassess her symptoms off antibiotics. On 1/14/26, R2's ID Physician faxed orders to the facility that were located in R2's EMR. The orders stated, .DC (discontinue) daptomycin, remove PICC. Please follow up in 4-weeks. DC weekly labs. R2's ID notes dated 01/15/26 indicated, .I reviewed MRI with radiology on call who stated that overall MRI is significantly improved compared to study from October (2025) .Daptomycin was discontinued and PICC was removed. Given inability to completely rule out persistent infection based on MRI findings and elevated, although somewhat improved, inflammatory markers would recommend transition to oral antibiotics for another 4-6 weeks for ongoing treatment .will transition to PO (oral) levofloxacin (an antibiotic medication) 750 mg (milligrams) daily.Will also add daily PO vancomycin 125 mg for C diff prophylaxis given history of C diff colonization. Review of R2's faxed order from the ID Physician, dated 01/15/26 and provided by the facility (after requested from the facility's fax company), revealed, .start PO levofloxacin 750 mg daily for at least 4 weeks .add PO vancomycin 125 mg daily for c. diff prophylaxis. R2's Medication Administration Record (MAR) for January 2026 found no evidence that levofloxacin and vancomycin were administered to R2 as ordered by the physician. R2's ID progress notes, dated 02/03/26 stated, .This is a telemedicine encounter.(R2) states she is doing well. Denies back pain. Reports ongoing pain in her legs and weakness in her legs which is unchanged .(R2) states she is currently tolerating levofloxacin well without any side effects. Will continue PO levofloxacin 750 mg daily to complete at least 6 weeks tentative EOT (end of treatment) 2/27/26. Continued PO vancomycin 125 mg daily for C diff prophylaxis while on levofloxacin . R2's MAR for February 2026 found no evidence that levofloxacin and vancomycin were administered to R2 as ordered by the physician. Based on R2's ID progress notes, R2 was not aware that levofloxacin and vancomycin were not being administered. Review of R2's physician Order Listing Report, from 01/01/26 through 03/31/26, indicated orders for PO levofloxacin and PO vancomycin were not included until 03/13/26. On 3/13/26, R2 was sent to the ER related to fever and left knee pain. The hospital discharge summary stated, .Patient is chronically on Levaquin, PO vancomycin for discitis .follows with infectious disease .CT (computed tomography) L-spine (lumbar spine) reconstruction: Showed extensive osseous erosion at the L1-2 highly concerning for discitis/osteomyelitis .ER physician discussed the case with on-call orthopedic surgery and neurosurgeon .Broad-spectrum antibiotics started .Continued vancomycin, cefepime (antibiotic used to treat severe bacterial infection) started in the ER .Recommended discharge back on levofloxacin 750 mg daily and follow-up with infectious disease .Also resumed po vancomycin 125 mg daily prophylaxis. Previous imaging in January found R2 had inflammation but did not have an infection. Imaging on 3/13/26 found R2 again developed osteomyelitis. Evidence in the MAR found R2 had not received levofloxacin or vancomycin for 2 months. R2's MAR for March 2026 indicated levofloxacin and vancomycin were first administered to R2 on 03/14/26. During an interview on 03/25/26 at 9:00 PM, R2 stated while she was hospitalized for knee pain, she learned she had not been receiving the two oral antibiotics ordered by her ID Physician once hospital staff asked why she was not taking them. On 03/27/26 at 2:10 PM, Surveyor spoke with R2 who stated she had a telehealth appointment with her ID Physician in January 2026. R2 stated the Social Services Director (SSD) was present during her telehealth appointments as they were completed using the SSD's computer. R2 indicated during the January 2026 appointment, the ID Physician told her he was going to have her PICC line removed because the MRI showed the spinal infection was gone, and he was going to order two oral antibiotics to make sure the infection did not return. R2 stated she did not know she had not received them as she would just take the medication the facility gave to her. When asked if she had follow-up appointments between January 2026 and March 2026 and if the oral antibiotics were discussed, R2 stated she did have follow-up appointments; however, when the doctor asked how she was doing with the antibiotics, she told him she was doing good because she thought she was taking them. (Of note, R2's Minimum Data Set (MDS) assessment, dated 01/28/26, has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates R2 is cognitively intact.) On 03/27/26 at 10:04 AM, Surveyor spoke with the Assistant Director of Nursing (ADON) who verified R2 had not received oral antibiotics of levofloxacin and vancomycin in January 2026 and February 2026. The ADON verified the first time they were administered was on 03/13/26 when R2 was readmitted to the facility from the hospital. The ADON stated the orders for the two oral antibiotics came with R2 from the hospital. The ADON also stated the facility never received any orders from the ID Physician on 01/15/26 for R2 to start oral antibiotics. During an interview on 03/27/26 at 1:45 PM, Consultant Pharmacist (CP) 1 verified there were no orders in January 2026 received by the pharmacy from the facility for levofloxacin or vancomycin. When asked why oral antibiotics would be ordered by the Infectious Disease doctor if the osteomyelitis was resolved, CP1 stated if the infection was clear, oral antibiotics may have been ordered prophylactically, or if R2 had continuous infections and was on IV antibiotics for a long time, it would be prudent to start oral antibiotics to prevent reccurrence of the infection. During an interview on 03/28/26 at 4:39 PM, the Medical Director stated she was not aware R2 was supposed to have started two oral antibiotics on 01/15/26 that were ordered by the Infectious Disease doctor. The Medical Director stated it was her expectation that if the facility received a faxed order for R2 to start oral antibiotics, the orders would have been processed and administered to R2 as ordered. When asked why it would be important for the oral antibiotics to be administered to R2 as ordered in January 2026, the Medical Director stated because there could still have been infection in the spine. On 03/27/26 at 2:26 PM, Surveyor interviewed the Business Office Manager (BOM) who indicated she was responsible for scanning residents' medical records into their EMR. The BOM stated when a resident had a telehealth appointment, nursing staff would receive the visit notes and any orders via fax. The BOM stated nursing staff would place the received records in a bin at the nurses' station and she would retrieve the records throughout the day and scan them into the resident's medical record under the miscellaneous tab. The BOM was asked if there was a way to retrieve faxes that were received at the facility. The BOM with the assistance of the fax machine company retrieved faxes that were sent to the facility on [DATE]. It was confirmed that a fax from R2's ID physician was received by the facility on 01/15/26 and stated, .start PO levofloxacin 750 mg daily for at least 4 weeks .add PO vancomycin 125 mg daily for c. diff prophylaxis. 2. R2's MAR for the month of January 2026 included an order for Daptomycin (antibiotic) Intravenous Solution Reconstituted (Daptomycin) Use 540 mg intravenously one time a day for cholecystitis related to osteomyelitis of vertebra, lumbar region, psoas muscle abscess. The medication was ordered to be given from 12/18/25 to 01/14/26. A Medication Occurrence, dated 01/13/26 at 8:30 AM, revealed Licensed Practical Nurse (LPN) 1 prepared the report and identified R2 as the resident. The Incident Description section noted, Nurse gave IV from another resident to resident. Resident was to get daptomycin and got ertapenum (antibiotic). The Medication Occurrence indicated the Nurse Practitioner (NP) and resident were notified of the error. The document also noted there were no injuries observed at the time of the incident. A 01/14/26 Risk Management review included, IDT (Interdisciplinary Team) met and discussed the circumstances related to medication occurrence noted 1/13/26 at 0830 (8:30 AM). Resident received another resident's IV medication. Resident was to receive Daptomycin 540 mg IV and was administered Ertapenem 1gm (gram) instead. No adverse reactions noted from receiving IV Ertapenem.APNP (Advanced Practice Nurse Prescriber) called regarding medication occurrence. Continue to monitor resident. No further orders received. All nurse education provided regarding the 6 rights of medication administration. Resident updated and declined family to be updated. CM (Case Manager) updated. Resident monitored (for) 72 hours for any changes. No changes noted. During an interview with LPN1 on 03/27/26 at 3:14 PM, LPN1 was asked about the wrong antibiotic being given to R2. LPN1 stated it was an honest mistake and the facility previously only had one resident with an IV. LPN1 stated on that day, she didn't check thoroughly enough and grabbed the wrong one out of the refrigerator. When LPN1 was asked what happened after she realized the wrong antibiotic was given to R2, she said the DON had her notify the on-call physician to see if there would be an issue. LPN1 stated she was educated on the five patient rights. When asked if others were trained, she stated it was just her, adding that it was a stupid mistake and should not have happened.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure expired food was discarded and the kitchen was maintained in a clean and sanitary manner. These failures placed 34 of 34 residents who resided at the facility at risk of foodborne illnesses.Findings include:Review of the facility's undated policy titled, Food Safety and Sanitation, revealed .All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department .4. Food Storage .Food is protected from contamination .Perishable foods with expiration dates are used prior to the use by date on the package .Review of the facility's undated policy titled, Labeling and Dating, revealed, .2. All foods will be monitored for expiration date, use-by-date. Foods that are out of date will be discarded .Observation on 03/26/26 at 3:19 PM of the kitchen's walk-in cooler revealed the following items that were either labeled by the facility to be past the use-by date or expired per the manufacturer's expiration date:A one-gallon clear juice pitcher with a red lid labeled, Cranberry Juice date: 03/22 [26] .use by date of 03/24 [26].A one-gallon clear juice pitcher with a red lid labeled, OJ [orange juice]: date:03/20 [26] .use by 03/22 [26].A one-gallon clear juice pitcher with a red lid labeled, Apple Juice: date 03/23 [26] .use by 03/25 [26].A one-gallon clear plastic container labeled, Concentrated Lemon Juice, with a manufacturer's expiration date of 03/07/26. Continued observation revealed the container had a facility label of use by: 04/27/26.Observation on 03/26/26 at 3:23 PM of the kitchen's walk-in freezer revealed the following:A package of hot dog buns, torn open from the middle of the package, exposing several buns to air.An opened box of fish with a manufacturer's expiration date of 03/05/26. Observation on 03/26/26 at 3:33 PM of the kitchen revealed multiple cobwebs and dead insects on the wall behind the portable shelving where clean dishes were stored, extending from the window to the edge of the window seal, directly behind the shelving. Continued observation revealed a build up of black and gray dust and debris. To the left of the shelving were two window unit air conditioners which had the potential to blow debris and pests onto clean dishes if the air conditioners were turned on.During observations and an interview on 03/26/26 at 3:38 PM, Dietary Aide (DA) 1 observed the concerns listed above in the walk-in cooler and walk-in freezer. DA1 stated all dietary staff should be checking use-by and expiration dates and removed the items from the cooler and freezer.During an observation and interview on 03/26/26 at 3:45 PM, DA1 observed the wall behind the shelving with clean dishes. DA1 stated with the air conditioners so close to the shelving, the air conditioners could possibly blow debris and bugs onto clean dishes. The facility's Dietary Manager resigned on 03/23/26; therefore, there was no interview with the Dietary Manager. During an interview on 03/28/26 at 8:52 PM, the Regional Director of Operations (RDO) stated it was her expectation that the kitchen would not have items beyond the use-by and expiration dates and would not have dust and dead bugs.

Based on observation, interview, and record review of the facility's Administrator's Job Description, the Administrator failed to administer the facility in a manner that ensured a Director of Nursing (DON) and/or a Registered Nurse (RN) was employed to provide oversight of nursing staff that enabled the facility to attain and maintain the highest practicable care and well-being of each resident. The lack of nursing oversight due to the Administrator's decisions caused or is likely to cause serious injury, harm, impairment, or death to residents. Administration was aware the facility did not have a qualified Director Nursing overseeing resident care since 3/13/26.Administration was aware there was not an RN in the building for a minimum of 8 hours a day, 7 days a week. On 03/27/26, the facility was notified that an Immediate Jeopardy was identified in the area of S483.35 Nursing Services and was related to Administration of the facility. Findings include:Review of an undated job description titled, Job Description-Administrator, provided by the facility, revealed, Purpose of your job description. The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Delegation of Authority: As Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Job Functions: .Assist in the recruitment and selection of competent department directors, supervisors, facility non-licensed staff, consultants, etc .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .The following failures were identified:1. The facility failed to ensure a Director of Nursing (DON) was employed to supervise the facility's nursing staff. During an interview on 03/25/26 at 8:45 PM, the Administrator confirmed the facility did not currently have a DON. The Administrator confirmed the last day the facility had a DON was 03/13/26.During an interview on 03/26/26 at 7:02 PM, the Regional Director of Operations (RDO) confirmed the facility did not have a DON. The RDO stated two DONs from sister facilities were helping out but confirmed there was no documented evidence of the two DONs presence in the facility. (Refer to F727)2. The facility failed to ensure a Registered Nurse (RN) was employed to meet the minimum requirements of having an RN on duty eight consecutive hours each day, seven days a week. During an interview on 03/26/26 at 4:20 PM, the Assistant Director of Nursing (ADON) confirmed the facility had not had an RN on staff since the Former DON (FDON) left on 03/13/26. The ADON confirmed that while the FDON was in her position, the facility did not have an RN for most weekends. (Refer to F727)3. The facility failed to ensure Licensed Nurses and Certified Medication Aides/Medication Technicians (CMAs/MTs) provided care and services only in their respective scope of practice. Review of clinical records for Resident (R) 2 revealed documented evidence CMA/MT1 assessed R2's pain levels, administered as needed narcotic pain medications, and reassessed pain levels following the administration of as needed narcotic pain medications.During an interview on 03/27/26 at 11:56 AM, CMA/MT1 confirmed she had been assessing pain levels and administering as needed narcotic pain medications throughout her employment. During an interview on 03/28/26 at 11:34 AM, the [NAME] President of Clinical Operations (VPCO) stated it was not in the scope of practice for a CMA/MT to assess pain or administer as needed pain medications. (Refer to F658)4. The facility failed to ensure the facility had sufficient staffing. Review of the local police department's narrative, dated 11/28/25 at 1:24 PM and transcribed from body-worn camera (BWC) footage, revealed a police officer responded to a call at the facility for a complaint about lack of care. The narrative recorded, .I [police officer] then spoke to a nurse administrator for the Manor (former facility name). Her name was (Administrator's first name) and she told me that (R2) needs constant care for her condition and that it is very difficult to get her that amount of care due to the lack of staffing .An interview on 03/26/26 at 8:30 AM with R2 revealed it took between one-half hour to 45 minutes for call lights to be answered.An interview on 03/26/26 at 3:50 PM with R18 revealed during mealtimes, all staff go to the dining room leaving no staff on the halls to assist residents if they need help.During an interview on 03/26/26 at 11:55 AM, Licensed Practical Nurse (LPN) 1 was asked if there were enough staff to meet residents' needs. LPN1 stated she felt like the residents needed more attention than the staff could provide. (Refer to F725)During an interview on 03/28/26 at 8:52 PM, the RDO stated it was her expectation the facility would have been in compliance with the regulatory requirements.

Based on interview and record review including review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) report, review of the documented narrative from the local police department's body-worn camera, review of job descriptions, review of facility policies and procedures, and facility document review, the facility failed to ensure sufficient nurse staffing was available to meet the immediate care needs of the residents, failed to ensure staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, and failed to ensure Licensed Practical Nurses (LPNs) and Certified Medication Aides/Medication Technicians (CMAs/MTs) provided services that met professional standards of practice. These deficient practices had the potential to affect all 34 residents currently residing in the facility. Findings include:The facility's undated job description titled, Certified Medication Aide included: .Purpose of Your Job Position .The primary purpose of your job position is to assist in the administering of medications to residents as ordered by the attending physician, under the direction of the attending physician, the nurse supervisor or charge nurse, and the Director of Nursing Services. The administration of medications shall be in accordance with established nursing standards, the policies, procedures, and practices of this facility, and the requirements of this state . The facility's policy titled, Delegation of IV Therapy to Licensed Practical Nurses in Wisconsin, reviewed on June 2024 included: Purpose: To ensure a consistent and compliant delegation process of specific IV related nursing tasks from the Registered Nurse to the Licensed Practical Nurse .1. Delegation: is the act of allowing the Licensed Practical Nurse to perform a skill or task that would be outside their traditional role or not be part of their normal routine. 2. Delegated Responsibility: a nursing activity, skill or procedure that is transferred from a licensed nurse to delegatee. 3. Delegatee: the Licensed Practical Nurse that accepts the delegated task. 4. Delegator: the Registered Nurse delegating the nursing task. 5. Basic Patient Situation: As determined by an RN, physician .means the following three conditions prevail at the same time in a given situation: a. The patient's clinical condition is predictable; b. Medical or nursing orders are not changing frequently and do not contain complex modifications; AND c. The patient's clinical condition requires only basic nursing care .8. General Supervision: Regularly coordinates, directs, and inspects the practice of another .2. Nursing tasks related to IV therapy may be delegated to the LPN by the RN under general supervision if it is determined that the task is within the criteria of a Basic Patient Situation. This is determined by assuring the following: a. The IV skill/task has been performed prior without resident complication. b. Medication infusion is not a first dose and the resident has demonstrated tolerance of the first dose. c. The resident is medically stable as it relates to the IV task being delegated. d. The task does not require IV push medication administration .5. The LPN accepting delegation of IV tasks must be properly trained. This training will include but not be limited to: a. Didactic knowledge of principles and complications of peripherally inserted IV lines. b. Able to identify resident data that signals fluid overload or intolerance of IV administered medications c. Knowledge of complications and data that would suggest compromised or infected IV line. d. Must be able to demonstrate skill in administering IV flushes, administration of IV antibiotics, discontinuation of peripheral IV line, and operation of infusion pump. e. Knowledge of when to update RN about issues related to IV tasks. f. Knowledge of overall emergency procedures related to resident change in condition. The facility's policy titled, Medication Tech Policy for WI (Wisconsin), dated 01/05/25, included: Policy: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely and ensuring medication technicians assist in providing medications to the residents within their scope of practice .Allowed (under RN Delegation and Competency) Administer routine oral medications they've been trained for per Wisconsin training curricula. Perform tasks that the RN has delegated after confirming competency. Additional Training Needed .PRN medication decisions (medication aides are not trained in PRN judgment.) RNs may decide to delegate tasks not included in base training only after documented training and competency validation, and only with appropriate supervision. This is a decision that warrants additional scrutiny .Ensure competency documentation is available for all medication aides, including agency or floating aides .Be sure licensed nurses understand the restrictions medication aides have so that they do not ask them to practice outside of their scope .Also included in the above Med Tech policy under Additional Training Needed is: Injections .RNs may decide to delegate tasks not included in base training only after documented training and competency validation, and only with appropriate supervision. This is a decision that warrants additional scrutiny .Ensure competency documentation is available for all medication aides, including agency or floating aides .Be sure licensed nurses understand the restrictions medication aides have so that they do not ask them to practice outside of their scope .Review of the State of Wisconsin Department of Health Services, Medication Administration by Unlicensed Assistive Personnel (UAP), dated 05/2023, revealed .All nursing homes providing administration of a medication by an UAP (Medication Aide/Nurse Aide) must meet the following conditions: 1. The nursing home has written policies and procedures designed to provide safe and accurate administration of medication. Personnel assigned to administer medications shall follow these policies .2. There is a written delegation of this nursing act (medication administration) by the registered nurse. ((DHS 132.62(2)(a)3) 3. There is documentation to support the educational preparation of the caregiver that administers medications. (DHS 132.60(5)(d)1) 4. There is immediate and accessible supervisory support available to the caregiver administering medications. (42 CFR 483.45) .A state-approved nursing home medication administration course covers medication administration technique including: oral, sublingual, topical, rectal suppositories, eye drops, eye ointments, ear drops, vaginal suppositories, multi dose oral inhalers, and nasal inhalers. All unlicensed personnel who administer medications in a nursing home must take this State of Wisconsin approved course or meet the course requirements. If these individuals will administer other types of medications (e.g., nebulizers, intravenous injections, oxygen, medication via a tube, insulin), they must receive additional training, and that training must be documented .The facility's Facility Assessment, last updated on 02/18/25, included: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies with a Staffing Plan which indicated a ratio of one CNA for ten to sixteen residents on the evening shift.The census on Surveyor entry on 03/25/26 at 8:25 PM was 34 residents. The posted staffing for 03/25/26 on the evening shift listed three Certified Nursing Assistants (CNAs) with one of the three working 4:30 PM to 10:00 PM, or a partial shift. The surveyors validated the staff working on that shift was as posted.Wis. Stat. ch. N6 Standards of Practice for Registered Nurses and Licensed Practical Nurses provides guidance as to which nursing tasks can be performed by a licensed practical nurse (LPN) and also defines what measures must be taken in order for certain nursing tasks to be delegated to LPNs. According to Wis. Stat. ch. N6, LPNs are able to perform acts of basic patient care, under the general supervision of a Regsitered Nurse (RN) which is defined in N6 as, care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.Example 1:Resident (R) 2 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of the vertebra lumbar region, chronic obstructive pulmonary disease (COPD,) pan lobular emphysema, and chronic myeloid leukemia, not having achieved remission. R2's admission Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (intact cognition,) functional limitations in range of motion to her lower extremities on both sides, was mobile by wheelchair, and was frequently incontinent of bowel. R2 was dependent for chair/bed-to-chair transfers.On 11/28/25, the local police department responded to a call at the facility from R2. According to the report, R2 reported that she had been waiting for assistance after a bowel movement for over 3 hours. Transcription from the officers' body worn camera shows the officer spoke with NHA-A. NHA-A told the officer R2 needed constant care for her condition and that it was difficult to get her that amount of care due to lack of staffing. The report also included a conversation with LPN1 (Licensed Practical Nurse,) .Upon arriving, I spoke with one of the nurses, who later identified as LPN1. LPN1 told me that they have been following up as best they can, but that there could have been miscommunication with the prior shift that resulted in her (R2) not getting the care she needed. On 03/26/26 at 8:30 AM, Surveyor spoke with R2. R2 said it usually took a long time, about a half hour to 45 minutes before call lights were answered. R2 indicated she would not even be dressed right now, but because the state is here, it's different today. On 03/26/26, Surveyor spoke with Family Member (F) 1. F1 stated it takes staff forever to get down here (R2's room.) FM1 said he can't go and drag somebody down here to help R2, so he tries to be as patient as possible. F1 stated he complained to the Assistant Director of Nursing (ADON) about the length of time it takes for staff to assist R2. F1 stated when he notified the staff, R2 was provided care. On 03/26/26 at 11:55 AM, Surveyor interviewed LPN1 (Licensed Practical Nurse) and LPN1 was asked about R2 and the type of care she needed. LPN1 stated R2 was pretty independent but needs assistance when she is in bed. LPN1 stated R2 will call the facility from her cell phone if staff are not responsive. LPN1 stated she was working the day the police officers came into the building and acknowledged she made the statement referenced in the police narrative. LPN1 told Surveyor she felt like the residents needed more attention than the staff can provide. Example 2: R2's physician's orders include an order dated 03/13/26 for oxycodone (a narcotic pain medication) 5 mg (milligram) oral tablet, give 2 tablet [sic] by mouth every 4 hours as needed for pain.As part of as needed pain medication administration, nursing staff must assess the resident's pain prior to administration and after administration. This is an important assessment to ensure a resident's pain management regime is effective for the resident. R2's MAR (Medication Administration Record) found that CMA/MT1 administered as needed pain medication to R2 on the following dates with documented pain level assessment:~03/17/26 at 10:57 AM and 12:11 PM~03/18/26 at 11:52 AM (no follow up documented)~03/19/26 at 11:32 AM and 12:57 PM~03/24/26 at 11:18 AM and 1:42 PM~03/25/26 at 11:14 AM (no follow up documented)~03/27/26 at 11:22 AM and 12:56 PMWis. Stat. ch. N6 Standards of Practice for Registered Nurses and Licensed Practical Nurses indicates that LPNs may collect data regarding a resident's condition and only RNs (Registered Nurses) may complete an assessment of a resident's condition. Assessments cannot be delegated to unlicensed assistive personnel such as Certified Medical Assistants or Medication Technicians.On 03/27/26 at 11:56 AM, CMA/MT1 told Surveyor she had been employed at the facility since 2015 and had been assessing residents' pain and administering pain medications since her employment began. CMA/MT1 also stated that when she assessed residents' pain, she asked the resident what their pain level was, where the pain was, and reported this to the nurse. Then she administered the PRN pain medication to the resident and documented both the pain level and the administration of the PRN pain medication on the resident's MAR. Surveyor asked about residents who are nonverbal or who may be able to report the location or quality of their pain. CMA/MT1 stated she went by a nonverbal pain scale that went from smiley faces to frowning with tears. CMA/MT1 also stated it was within her scope of practice as a CMA to assess for pain and then to administer PRN pain medication. During an interview on 03/28/26 at 11:34 AM, the [NAME] President of Clinical Operations (VPCO) stated it was not in a CMA/MT's scope of practice to assess residents' pain or to administer PRN pain medications. During an interview on 03/28/26 at 7:16 PM, FDON was asked what tasks were delegated to CMA/MT1. FDON stated CMA/MT1 had completed the required course to become a CMA/MT, and FDON was her preceptor. When asked about CMA/MT1 assessing residents' pain and administering PRN pain medications, FDON stated a CMA/MT was only allowed to give PRN pain medication after a nurse had completed an evaluation for pain. FDON also stated all LPNs were educated that nurses had to complete the pain assessments on residents. When asked if a CMA/MT assessed a resident's pain and documented they assessed the pain, would that be out of the CMA/MT's scope of practice, the FDON stated yes it would be. Example 3:R5 admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses to include diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare. R5's 72 HR (hour) Admission/re-admission Charting, progress note dated 03/24/26 was completed by LPN2. There was no evidence that the assessment had been completed by an RN.Example 4: R5 had a physician's order dated 03/24/26 of Ertapenem (a broad-spectrum carbapenem antibiotic used to treat severe or moderate bacterial infections) Sodium Injection Solution Reconstituted .use 1 gram intravenously at bedtime for abscess.R5's MAR dated March 2026 indicated R5 was administered the intravenous (IV) antibiotic medication by an LPN on 03/25/26 (LPN1,) 03/26/26 (ADON, who is an LPN,) and 03/27/26 (LPN.) Review of LPN1's employee file revealed no documented evidence that LPN1 received any additional training related to administering IV medications. During an interview on 03/26/26 at 4:20 PM, the ADON stated LPN1 was not certified to be able to administer medications via IV/peripherally inserted central catheter (PICC) lines.During an interview on 03/27/26 at 3:14 PM, LPN1 stated she had been hanging IV medications to be administered via PICC lines since she was employed at the facility. LPN1 stated she had not received any type of formal training from the facility on administering IV medications, however, this was something she had learned while in school to become an LPN. Continued interview revealed at times she was the only nurse in the facility to be able to administer medications to residents with PICC lines; the other staff person was a CMA/MT.During an interview on 03/28/26 at 7:16 PM, the FDON stated during her employment at the facility she was responsible for the oversight and supervision of licensed nursing staff. When asked if LPN1 and LPN2 had received additional training/certification to be able to administer medications intravenously, the FDON stated she had observed both LPNs administer IV medications and had no concerns. Example 5:R6 admitted to the facility on [DATE] with diagnoses to include sepsis, diabetes type 2, congestive heart failure, and end stage renal disease (ESRD).R6's NRSG (nursing): admission Data Collection Progress Notes, dated 03/24/26 was completed by LPN4.R6's Nurses Note, dated 03/24/26 was completed by LPN1 and included details of R6's admission to the facility.There was no evidence that an RN completed R6's assessment.Example 6:R8 admitted to the facility on [DATE] with diagnoses to include chronic congestive heart failure.R8's NRSG: admission Data Collection Progress Notes, dated 03/17/26 was completed by LPN4.R8's NRSG: admission Data Collection and Baseline Care Plan Tool-V 11, dated 03/17/26 was completed and signed by LPN4.There was no evidence that an RN completed R8's assessment.Example 7: R9 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD) and traumatic ischemia of muscle.R9's NRSG (Nursing): admission Data Collection Progress Notes, dated 03/17/26 was completed by LPN1.R9's NRSG: admission Data Collection and Baseline Care Plan Tool-V 11, dated 03/17/26 was completed and signed by LPN1.There was no evidence that an RN completed R9's assessment. During an interview on 03/28/26 at 7:16 PM, the FDON stated during her employment at the facility she was responsible for the oversight and supervision of licensed nursing staff. When asked who should be completing admission assessments on newly or readmitted residents, the FDON stated LPNs complete a lot of them because 99% of admissions are on the evening shift. FDON stated she would always review admission assessments completed by LPNs on her next scheduled day of work. When asked per an LPN's scope of practice, were LPNs permitted to complete residents' admission assessments, the FDON stated probably not, but she was the only RN employed by the facility. During an interview on 03/26/26 at 4:20 PM, ADON stated since the facility has been without a DON who was the facility's only employed Registered Nurse (RN,) LPNs have been completing all initial nursing assessments for newly admitted residents. During an interview on 03/27/26 at 3:14 PM, LPN1 stated she completes residents' admission assessments when they are admitted to the facility. During an interview on 03/28/26 at 8:12 PM, LPN6 stated they (LPNs) started doing all of residents' admission assessments approximately seven or eight years ago.During an interview on 03/28/26 at 8:20 PM, LPN5 stated prior to her being educated this date, LPNs could complete residents' admission assessments.

Based on interview, record review, review of the local police department's body worn camera (BWC) report, and policy review, the facility failed to ensure one of five sampled residents (Resident (R) 2) was treated with dignity related to toileting needs. R2 was care planned to use the toilet; however, staff used a bedpan and/or incontinence pad. This caused R2 to feel discomfort and embarrassment. Findings include:Review of the facility's policy titled Dignity, revised 01/2025, revealed, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth.Review of R2's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), osteomyelitis of the vertebra, lumbar region, pan lobular emphysema, and chronic myeloid Leukemia, not having achieved remission.Review of the local police department's narrative, dated 11/28/25 at 1:27 PM and transcribed from body worn camera (BWC) footage, revealed police officers responded to a call at the facility for a complaint about lack of care. The report recorded that upon arriving at the facility, the officer spoke to one of the nurses and was told they (the facility) were following up as best they could, but that there could have been miscommunication with the prior shift that resulted in R2 not getting the care that she needed. It was recorded the police officer spoke with the facility's Administrator who stated R2 needed constant care for her condition and that it was difficult to get her that amount of care due to lack of staffing. The report recorded that R2 told the police officer that the facility put down the chucks (an absorbent incontinence pad) instead of a bedpan and that she had been sitting in her bowel movement for quite some time. The report recorded that R2 told the officer that the last time that she had her chucks changed was around 11:30 AM or 12:00 PM, and it had been over three hours since she had been cared for. The report recorded the officer spoke with nursing staff and told them they should try and follow up with R2 as soon as possible to make sure she is taken care of.Review of R2's Care Plan dated 01/22/26 and located in the EMR under the Care Plan tab, revealed a focus of, The resident has constipation r/t (related to) opioid use. The goal was, The resident will have a normal bowel movement at least every 3-4 days through the review date. Interventions included, Encourage resident to sit on the toilet to evacuate bowels if possible.Review of R2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/26 and located in the EMR under the MDS tab, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R2 was cognitively intact. It was recorded R2 had functional limitations in range of motion to her lower extremities on both sides, was mobile by wheelchair, and was frequently incontinent of bowel. The assessment revealed R2 was dependent on staff for chair/bed-to-chair transfers and toilet transfer was not attempted due to medical condition or safety concerns.Review of R2's undated Kardex (an abbreviated care plan used by nursing staff) located in the EMR under the Care Plan tab, revealed, TOILET USE: The resident requires assistance by 2 staff using a bed pan for toileting. The information recorded on the Kardex was inconsistent with the interventions listed on R2's Care Plan. During an interview on 03/25/26 at 9:00 PM, R2 stated she was aware of when she needed to have a bowel movement. R2 stated that sometimes staff would give her the bedpan to use, but other times, staff would place an incontinence pad underneath her. R2 was asked how using the bedpan or incontinence pad made her feel. R2 stated that it was uncomfortable and embarrassing. She stated she would prefer to be gotten out of bed with the lift and use the toilet. R2 stated that recently someone transferred her using the sit-to-stand lift and that it worked well. R2 stated if staff would use the sit-to-stand lift to get her up, then maybe she could use the toilet.During an interview on 03/26/26 at 11:55 AM, Licensed Practical Nurse (LPN) 1 confirmed she was working on 11/28/25 when the police responded to a call from R2. LPN1 confirmed she told the police there had been a miscommunication and R2 did not get the care she needed. LPN1 stated she felt like the residents needed more attention than staff could provide.

Based on observation, staff interview, and record review, the facility did not ensure kitchen equipment and dishware used to serve residents were free from residue accumulation. This practice had the potential to affect all of the 33 residents residing in the facility. Kitchen equipment and dishware used to serve residents contained visible white residue that made it difficult to tell if the equipment and dishware were clean. Findings include: During an initial kitchen tour on 5/19/25 at 10:55 AM, Surveyor interviewed Dietary Manager (DM)-F who stated the facility follows the Federal Food Code. The 2022 FDA Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. The 2022 FDA Food Code documents at 4-602.13 Nonfood-Contact Surfaces: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. The 2022 FDA Food Code documents at 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (a) Except as specified in (d) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) in a clean, dry location; (2) where they are not exposed to splash, dust, or other contamination; and (3) at least 15 centimeters (cm) (6 inches) above the floor. (b) Clean equipment and utensils shall be stored as specified under (a) of this section and shall be stored: (1) in a self-draining position that allows air drying; and (2) covered or inverted. The facility's undated The Dining Experience: Staff Responsibilities policy indicates: The dining experience will enhance each individual's quality of life through person-centered dining providing nourishing, palatable, and attractive meals .2b. Providing an attractive, safe, functional, sanitary, home-like or restaurant-like dining environment (depending on the facility) that is roomy, comfortable with nice decor, contrasting colors, and appropriate furniture for patients/residents, staff and the public . During an initial kitchen tour that began on 5/19/25 at 10:55 AM, Surveyor observed an accumulation of white/gray residue on food prep equipment, including a food processor and pots and pans. The food processor contained so much white residue that the clear canister could not be seen through. Surveyor noted pots, pans, and shelves also contained white residue. DM-F indicated the food processor was clean, but confirmed the residue was hard to see through. DM-F indicated the residue was a hard water issue that the facility had been dealing with for at least two months. DM-F indicated DM-F heard the facility had not gotten salt for the water softener. DM-F indicated kitchen staff soaked the silverware in vinegar so it did not look dirty but they were unable to clean residents' plates, cups, bowls, pots, pans, and equipment. On 5/20/25 at 9:17 AM, Surveyor interviewed Dietary Aide (DA)-G who was washing dishes. DA-G indicated the residue on the cups, bowls, plates, pots, pans, and equipment made it hard to tell if the items were clean or dirty. DA-G indicated DA-G just rewashed two plates that contained so much residue that DA-G couldn't tell if the plates were clean. DA-G picked up a coffee pot and stated, Look at this coffee pot. It's disgusting. I wouldn't drink out of that. Surveyor noted the silver and black coffee pot was covered in white residue on the inside and outside. DA-G showed Surveyor a plate out of the dishwasher that was supposed to be clean but was covered in white residue. DA-G indicated it was embarrassing that residents ate on dishware that looked like that. DA-G indicated the residue had been there for a while and had occurred in the past. DA-G indicated DA-G heard the facility was out of water softener pellets and stated someone should get salt pellets if that was the issue. On 5/20/25 at 9:23 AM, Surveyor and DA-G took photos of a coffee pot, a plate, a rack of plastic cups used by residents at breakfast, a bowl, and insulated plate covers all of which were covered in white hard water residue and were supposed to be clean. On 5/20/25 at 9:29 AM, Surveyor interviewed DA-H who indicated the white residue on the dishware, cups, and equipment was gross. DA-H stated DA-H would not use the facility's dishware and brought dishware from home. DA-H indicated the issue had been ongoing for a few months. DA-H indicated DA-H was told the facility did not have water softener pellets. On 5/20/25 at 10:17 AM, Surveyor interviewed Maintenance Director (MD)-I who confirmed there was a billing issue with the provider who delivered salt for the water softener which contributed to the hard water residue and build-up on the dishware and equipment. MD-I indicated MD-I spoke with the provider yesterday and worked out the billing issue which will put the facility back on a salt delivery schedule soon. MD-I indicated the issue had been occurring for one and a half to two months. When asked why the facility did not buy salt themselves or find another provider, MD-I indicated it was too much salt to purchase on their own and they were trying to work it out with the provider. MD-I indicated MD-I understood the dishware and equipment looked bad but stated they were clean from a sanitization standpoint. MD-I indicated that was the worst the residue had ever been. On 5/20/25 at 12:43 PM, Surveyor interviewed R10 who stated R10 did not know if the cups R10 drank out of were clean or not. On 5/21/25 at 12:03 PM, Surveyor interviewed R6 who indicated R6 did not like residue on R6's cups and dishware and stated R6 had dirty drinking glasses. R6 indicated R6 asked staff about the residue and was told it was the dishwasher and the cups were clean. R6 indicated R6 was skeptical and hoped the cups were clean. R6 felt the glasses were dirty and wanted dishes and cups that appeared clean. On 5/21/25 at 12:19 PM, Surveyor interviewed R3 who indicated R3 could not see but did not want to drink out of dirty cups. R3 hoped the facility provided clean cups. On 5/22/25 at 2:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated residents should have visibly clean dishes to eat and drink from and clean equipment to prepare food.

Based on observation, staff interview, and record review, the facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. This practice had the potential to affect all of the 33 residents residing in the facility. The garbage containers outside the facility were not covered and contained loose/unbagged garbage. Findings include: The facility's Disposal of Garbage and Refuse policy, revised 12/2/24, indicates: .1. Garbage shall be disposed of in refuse containers with plastic liners and lids. 2. Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks and covered when not in use .7. Refuse containers and dumpsters outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded . During an initial kitchen tour on 5/19/25 at 10:55 AM, Surveyor and Dietary Manager (DM)-F observed two approximately 8 feet long by 3 feet wide rolling containers positioned against the building outside the right side of the door. One container was full of bags of garbage and the second container was half full of bags of garbage. The second container also contained unbagged garbage and debris including food wrappers, food particles, unidentified matter, and paper coffee cups. Both of the rolling containers were not covered and Surveyor did not observe any lids with which the containers could be covered. DM-F thought either housekeeping or maintenance staff brought the garbage from the rolling containers to the dumpsters across the parking lot. When asked how often the rolling containers were emptied, DM-F thought they were emptied when they were full. DM-F indicated the garbage in the rolling containers was left uncovered. On 5/20/25 at 10:14 AM, Surveyor and Dietary Aide (DA)-H observed the two rolling containers outside the door. The container nearest the door was two-thirds full of bagged garbage. The second container had approximately 4 inches of loose garbage and debris on the bottom. DA-H indicated the rolling dumpsters are emptied daily by housekeeping staff. DA-H indicated the second container should not contain loose garbage and debris and should have bagged garbage only.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 33 residents residing in the facility. R17 was on contact precautions. On 5/19/25, Licensed Practical Nurse (LPN)-K twice entered R17's room and administered medication without wearing the appropriate personal protective equipment (PPE). On 5/19/25, Laundry Aide (LA)-C transported uncovered clean clothes in hallways and delivered them to residents' rooms. On 5/20/25, LA-C wheeled a cart of clean linens from the clean side of the laundry room through the dirty side and into the housekeeping closet. In addition, a soiled linen hamper was observed in the clean area of the laundry room. Findings include: The facility's Personal Protective Equipment (PPE) policy, revised 11/2024, indicates: PPE refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. It includes gloves, gowns, face protection, and respiratory protection .1. All staff who have contact with residents and/or their environments must wear PPE as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious material is likely. 2. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. The facility's Laundry policy, revised 1/21/25, indicates: The facility launders linens and clothing in accordance with current Centers for Disease Control and Prevention (CDC) guidelines to prevent transmission of pathogens .3. Soiled laundry shall be kept separate from clean laundry at all times . Per the CDC, the best practices for management of clean linen .Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items. Clean Linen Storage- Designated areas: .Use separate rooms or designated areas for storing clean linens. Secure Storage: Store clean linen in closed carts or containers to prevent contamination. Separate Soiled and Clean Linen: Keep soiled linen separate from clean linen to prevent cross contamination. 1. On 5/19/25 at 3:52 PM, Surveyor observed LPN-K prepare medication for R17 who had a contact precautions sign on R17's door. LPN-K entered R17's room without donning PPE. When Surveyor asked if LPN-K should be wearing PPE, LPN-K indicated yes, exited R17's room, and donned gloves. LPN-K then re-entered R17's room and administered R17's medication. Surveyor observed LPN-K lean against R17's bed rail when LPN-K administered the medication. At 4:06 PM, Surveyor observed LPN-K enter R17's room with gloved hands to administer a second medication. LPN-K again leaned against the bed rail while administering the medication. LPN-K did not wear a gown during the observation. On 5/20/25 at 12:45 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should follow posted signs and should wear a gown and gloves when entering the room of a resident on contact precautions. 2. On 5/19/25 at 12:38 PM, Surveyor observed Laundry Aide (LA)-C carry laundry on hangers down a hallway in LA-C's hands. Surveyor interviewed LA-C who indicated the clothes in LA-C's hands were clean. When Surveyor asked if that was how LA-C usually transports clean clothing, LA-C indicated yes and confirmed LA-C walks laundry to residents' rooms. LA-C stated the facility has a cart, but it is too full and not many residents have laundry done at the facility. LA-C also indicated the cart does not fit through the door and the facility does not have a cover for it. LA-C indicated staff have never covered clothing or been told to cover clothing when transporting it from the laundry room to residents' rooms. On 5/20/25 at 12:45 PM, Surveyor interviewed DON-B who indicated clean clothing that is being transported from the laundry room should be covered when in the hallway. 3. On 5/20/25 at 9:50 AM, Surveyor toured the laundry room and observed LA-C wheel a clean basket of towels through the dirty side past the washing machines and into the housekeeping/dirty clothes storage area. Surveyor interviewed LA-C who indicated dirty and clean clothes should be kept separate at all times. LA-C indicated there is no other way to get clean towels back to the housekeeping storage area except to go by the washing machines. LA-C indicated the cart was left in the housekeeping/dirty linen area for housekeeping staff to put away. Surveyor also observed a hamper that was labeled soiled linen in the clean side of the laundry room near the folding area. On 5/20/25 at 12:45 PM, Surveyor interviewed DON-B who indicated clean laundry should never cross back into the dirty area and dirty items should not be on the clean side.

Based on observation, staff and resident interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R17) of 15 sampled residents. On 5/20/25, R17's call light was out of reach and not accessible to R17. Findings include: The facility's Call Lights: Accessibility and Timely Response policy, dated 3/6/25, indicates staff will ensure the call light is within reach of the resident and secured as needed. The call system will be accessible to the resident while in their bed or other sleeping accommodations within the resident's room. On 5/20/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R17's Minimum Data Set (MDS) assessment, dated 4/8/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 had intact cognition. The MDS assessment also indicated R17 had impairment on one side of the upper and lower extremities and required substantial/maximum assistance with rolling to the left and right sides and returning to lying on R17's back in bed. On 5/20/25 at 12:25 PM, Surveyor observed R17 in bed. Surveyor interviewed R17 who indicated R17 could not find the call light. R17 indicated R17 wanted to be repositioned and needed assistance. Surveyor observed a call light cord at the top of R17's bed on the left side under R17's pillow. When Surveyor informed R17 the call light was on the left side of R17's bed near the pillow, R17 attempted to reach the call light but could not. Surveyor informed R17 that Surveyor would ask staff to assist R17 with repositioning. On 5/20/25 at 12:33 PM, Surveyor notified Certified Nursing Assistant (CNA)-D that R17 required assistance with repositioning and could not reach the call light. CNA-D with the assistance of CNA-E entered R17's room. Surveyor observed CNA-E reach under R17's pillow, pull out the call light, and hand the call light to R17. CNA-E verified R17 could not reach the call light. CNA-D and CNA-E then repositioned R17. On 5/21/25 at 9:27 AM, Surveyor interviewed Director of Nursing (DON)-B who stated R17's call light should be within reach as indicated by the facility's call light policy.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 2 residents (R) (R8 and R11) of 15 sampled residents. On 5/19/25, Surveyor observed medication at R8's bedside hours after the morning medication pass. Staff did not return and check on R8 to ensure the medication was taken but documented the medication as administered. In addition, R8 did not have a quarterly self-administration of medication assessment. On 5/19/25, Surveyor observed Medication Technician (MT)-E prepare mediation for R11 and leave the medication at the bedside. R11 had an order to self-administer medication but did not have a current self-administration of medication assessment. Findings include: The facility's Resident Self-Administration of Medication policy, dated 4/9/25, indicates: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medication after the facility's interdisciplinary team has determined which medications may be self-administered safely. 1. Resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team .4. The results of the interdisciplinary team assessment are recorded on the medication self-administration assessment form which is placed in the resident's medical record .14. The care plan must reflect resident self-administration and storage arrangements for such medications . The facility's Medication Administration policy, dated 1/9/25, indicates: .17. Administer medication as ordered in accordance with manufacturer specifications .18. Observe resident consumption of medication .20. Sign Medication Administration Record (MAR) after administered .22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager . 1. On 5/19/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease, asthma, hypertension, anxiety, and depression. R8's Minimum Data Set (MDS) assessment, dated 5/8/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. On 5/19/25 at 12:18 PM, Surveyor interviewed R8 and noted a container of pudding that contained pills on R8's bedside table. Surveyor counted 14 pills visible on top of the pudding and noted other pills that appeared to have melted/disintegrated and others that were under the top of the pudding. Surveyor also noted a box of Effervescent antacid medication and a container of pain relief medication with an expiration date of 1/2023 on the bedside table. R8 indicated a nurse left the pills in the pudding earlier that morning around breakfast time and had not been back to check if R8 took the medication. R8 indicated the box of Effervescent antacid medication and container of pain relief medication were from home and the facility knew R8 had them. R8 indicated R8 had not taken any of R8's medications that morning and was not going to. On 5/19/25 at 4:13 PM, Surveyor observed R8's room and noted the container of pudding and pills was still on R8's bedside table. Surveyor counted 14 pills on top of the pudding and noted others that appeared to have melted/disintegrated and/or were under the pudding. Surveyor also noted the Effervescent antacid medication and container of pain relief medication with an expiration date of 1/2023 were still on the bedside table. R8's medical record contained the following physician's order: Okay to leave medications within reach at bedside table. Nurse to recheck in an hour to ensure medications are taken. If (R8) is not taking medications, please document. (Start date: 2/3/25). R8's medical record did not contain a self-administration of medication assessment. R8 also did not have a care plan that indicated R8 could self-administer medication or store medication at the bedside. Surveyor reviewed R8's MAR and noted 18 medications (not including medications that would not have been in pudding, i.e., insulin) were signed out as administered during the AM medication pass despite the fact some of the medications were refused by R8 and not taken. On 5/20/25 at 7:33 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-J who indicated staff who administer medication for R8 are supposed to go back and check if R8 took the medication. On 5/21/25 at 11:15 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated residents must have orders for all medication. DON-B indicated R8 should have had a self-administration of medication assessment to determine if R8 was capable to self-administer medication. DON-B indicated R8 should not self-administer medication without an assessment. DON-B indicated staff are required to go back after leaving medication at the bedside to check if the resident took the medication and should document accordingly. DON-B indicated staff should return within an hour to check on the resident. On 5/22/25 at 2:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated nursing staff are aware of and should follow the facility's medication administration and storage policies. NHA-A also indicated staff should follow standards of practice for medication and medication orders. 2. On 5/19/25 at 11:25 AM, Surveyor observed MT-E prepare mediation for R11 and leave the medication at R11's bedside. On 5/20/25, Surveyor reviewed R11's medical record. R11 had diagnoses including debility, cardiorespiratory conditions, urinary tract infection, neurogenic bladder, end stage renal disease, hypertension, diabetes mellitus, and anxiety disorder. R11's MDS assessment, dated 5/12/25, had a BIMS score of 15 out of 15 which indicated R11 had intact cognition. R11's plan of care indicated R11 had a physician's order for unsupervised self-administration of all medications and staff could leave the medication at the bedside. The care plan contained an intervention to assess R11's ability to safely self-administer medication on admission/readmission, quarterly, and with changes in condition. R11's MAR indicated R11 had an order (dated 2/16/23) to keep medication at the bedside. R11's medical record contained self-administration of medication assessments dated 2/17/23 and 12/23/24. On 5/20/25 at 12:45 PM, Surveyor interviewed DON-B who confirmed residents with a self-administration of medication order should have an assessment completed quarterly or with a change in condition. DON-B indicated if medication is left at the bedside for a resident to self-administer, staff who prepared the medication should check back to ensure the resident took the medication.

Based on observation, record review and staff interview, the facility did not ensure the resident environment remained as free of accident hazards as possible for 5 Residents (R) (R1, R9, R10, R11 and R12) of 5 residents reviewed. R1 was at risk for elopement and wore a Wanderguard (an electronic monitoring system where the resident wears a bracelet that triggers an alarm if the resident exits the facility.) R1 was placed on fifteen minute checks when the facility's Wanderguard system became disabled on 11/08/19. R1 eloped from the facility in freezing temperatures in the early morning hours of 11/12/19. R1's fifteen minute check sheet indicated R1 was in bed during the time R1 was missing from the facility. In addition, R1's fifteen minute checks weren't consistently completed. R9, R10, R11 and R12 were at risk for elopement and wore Wanderguards. R9, R10, R11 and R12 were placed on fifteen minute checks when the facility's Wanderguard system became disabled on 11/08/19. R9, R10, R11 and R12's fifteen minute checks weren't consistently completed. The facility's failure to prevent R1's elopement from the facility during freezing temperatures, and failure to provide fifteen minute checks for R1 and four other residents at risk for elopement when the facility's Wanderguard system became disabled, created a finding of Immediate Jeopardy (IJ) that began on 11/12/19. NHA was notified of the IJ on 11/14/19 at 4:00 PM. The IJ was removed on 11/14/19, however the deficient practice continues at a scope/severity of [NAME] as the facility continues to implement its action plan. Findings include: According to the National Institute of Health, Older adults are especially vulnerable to hypothermia, which can be deadly if not treated quickly.Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes (which this resident had) and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature. http://www.nih.gov/news/health/jan2009/nia-16.htm According to http://www.livescience.com/6008-person-freeze-death.html, A drop in body temperature prevents critical organs from working properly - including the brain and heart, according to the Mayo Clinic. Improper functioning of the heart results in reduced blood flow to many organs, putting the body in a state of shock and increasing the risk of conditions like liver failure and kidney failure . The very young and the very old are at greater risk for hypothermia because they generally have weaker heart muscles, he said. In addition, older people are more likely to take medications such as beta blockers that can slow heart rate, which further increases their risk of developing hypothermia in the cold .Symptoms of mild hypothermia, such as shivering, weakness and confusion, set in when core body temperature reaches about 95 F. After that, 'as you start dropping (in core body temperature), bad things happen .' Frostbite. The above source notes that fingers and toes are more prone to frostbite, because those areas will have reduced blood flow in cold temperatures, as your body tries to keep its core warm and that the length of time it takes for frostbite to develop depends on the conditions. According to the National Weather Service Wind Chill Chart, an individual could get frostbite in about 30 minutes at the temperature noted in the cite below. This could, however, occur sooner for someone who is elderly and who has diabetes. On 11/14/19, the Surveyor reviewed a complaint filed with the State Agency. The complaint stated R1 eloped from the facility on or about 11/11/19 in freezing temperatures. The complainant did not feel R1's Wanderguard was in place. On 11/14/19, the Surveyor reviewed a twenty-four hour report submitted to the State Agency on 11/12/19. The report stated a resident eloped from the facility and was found outside the building. The facility's five-day investigation, submitted on 11/19/19, stated on 11/12/19 at approximately 1:10 AM, CNA (Certified Nursing Assistant)-J observed R1 asleep in bed. At approximately 1:20 AM, CNA-J noted R1 was not in R1's room. CNA-J notified CNA-K and LPN (Licensed Practical Nurse)-[NAME] LPN-G, CNA-J and CNA-K searched the interior of the building as well as the outside perimeter and ensured all other residents were in their rooms. LPN-G called 911 at approximately 1:35 AM when they were unable to locate R1. NHA (Nursing Home Administrator)-A was notified that R1 was missing from the facility at approximately 1:40 AM. The Fond du Lac Police Department arrived at the facility and began a search. At approximately 2:10 AM, R1 was located inside a neighboring apartment building located across from the facility's parking lot. LPN-G completed a head-to-toe assessment. R1 denied pain and no injuries were visible. R1's POA (power of attorney) and hospice agency were notified. Residents at risk for elopement were reviewed by the IDT (interdisciplinary team). The IDT updated elopement assessments, plans of care and the facility's wander/elopement book. The facility purchased security alarms for exit doors. The alarms were activated from 10:00 PM and 6:00 AM and deactivated from 6:00 AM-10:00 PM. Staff education was provided on the elopement policy and to ensure knowledge of the new security system. The Surveyor noted the temperature in Fond du Lac between 12:00 AM and 6:00 AM on 11/12/19 ranged from 7-10 degrees Fahrenheit (F). The Surveyor reviewed R1's medical record. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent Quarterly MDS (Minimum Data Set), dated 9/06/19, indicated R1 exhibited wandering behavior, was cognitively impaired, required limited assistance of staff for transfers and extensive assistance of staff for most ADLs (activities of daily living.) R1 received hospice care and supplemental oxygen. R1's Altered Respiratory Status care plan stated R1 received oxygen due to difficulty breathing related to [MEDICAL CONDITION] and anxiety. R1's Elopement Risk care plan stated R1 was at risk for elopement due to a cognitive deficit and contained an intervention, dated 11/12/19, for fifteen minute checks. R1 had a physician's orders [REDACTED]. R1's MAR (medication administration record) indicated nursing staff were to document the completion of R1's fifteen minute checks. The Surveyor noted R1's fifteen minute checks were not documented as completed on 11/09/19, 11/10/19, 11/11/19 and 11/12/19. A progress note, dated 11/06/19, stated R1 was anxious and attempted to leave the building. A progress note, dated 11/08/19, stated the facility's Wanderguard system was not functioning and R1 was placed on fifteen minute checks. On 11/14/19, the Surveyor observed a communication sheet taped to the wall in the nurses' station. The sheet stated, Communication week of 11/3-11/8. Wanderguard not working! Fifteen minute checks on (R1), (R9) and (R10). Every resident must be checked on for safety at beginning of shift and rounds . During an interview with the Surveyor on 11/14/19 at 10:40 AM, CNA-L stated the facility's Wanderguard system broke approximately 1-1/2 weeks prior. CNA-L stated R1 wore a Wanderguard, but the Wanderguard didn't work when the system broke. During an interview with the Surveyor on 11/14/19 at 10:45 AM, DON (Director of Nursing)-B stated the front door was alarmed nightly at 10:00 PM. DON-B stated the alarm activated if a code wasn't entered within thirty seconds of opening the door. DON-B showed the Surveyor the Wanderguard system speaker located to the right of the front door. DON-B stated the speaker broke when a pen was used to disarm the alarm. DON-B stated the facility determined there was a problem with the alarm approximately two weeks prior when staff noticed a decrease in the speaker volume and staff couldn't hear the alarm from the back of the building. DON-B stated the door wasn't alarmed from 6:00 AM-10:00 PM because R1 eloped at night and there were enough staff to monitor residents' activities during the day. During an interview with the Surveyor on 11/14/19 at 11:10 AM, NHA-A stated, prior to 11/08/19, the facility's Wanderguard system was operational on the facility's front doors, a door behind the nurses' station and a door leading to the adjacent apartments. NHA-A stated all other exit doors in the building contained a separate alarm system that was still operational. NHA-A stated the facility discovered the Wanderguard system was broken on 11/08/19 when staff noticed residents with Wanderguards did not activate the alarm when in close proximity to doors equipped with the Wanderguard system. NHA-A stated, I'm working on getting the bids (to repair the system) .I've got the bid approved, but I'm not sure when (the installation company) is coming. There's a lag time of 4-6 weeks. NHA-A stated the facility purchased a home security system for the three doors without an alarm and educated staff that the doors were to be alarmed from 10:00 PM-6:00 AM. NHA-A stated the facility still conducted fifteen minute checks despite the addition of the home security system. During an interview with the Surveyor on 11/14/19 at 11:35 AM, DM (Director of Maintenance)-H stated, The fire department was here last week. (NHA-A) said (the system) wasn't working right. I was getting irregular readings. DM-H stated DM-H found out the system was obsolete and it was difficult to get parts and assistance. DM-H stated, (NHA-A) asked me to install (the home security system). I did a training on it with all staff. During an interview with the Surveyor on 11/14/19 at 1:15 PM, CNA-M stated CNA-M completed R1's fifteen minute checks on the AM shift and provided the Surveyor with a copy of the checks. The Surveyor noted the daily check sheet did not contain fifteen minute checks from the N[NAME] (night) shift. CNA-M stated CNA-M was unsure where the N[NAME] shift checks were recorded. On 11/14/19 at 1:30 PM, the Surveyor asked DON-B for R1's fifteen minute checks from 11/08/19-11/14/19. DON-B was initially unable to locate the check sheets and indicated staff usually put them in DON-B's mailbox. Without documentation, DON-B stated DON-B was unsure how the facility ensured the fifteen minute checks were completed. When DON-B provided R1's fifteen minute checks, the Surveyor noted R1's checks on 11/08/19 from 4:00 PM-12:00 AM, 11/11/19 and 11/14/19 from 12:00 AM-6:00 AM were missing. DON-B stated R9, R10, R11 and R12 also wore Wanderguards and were on fifteen minute checks. The Surveyor reviewed R9's medical record. R9 was admitted to the facility with [DIAGNOSES REDACTED]. R9's most recent Significant Change MDS, dated [DATE], indicated R9 was cognitively intact. R9's plan of care indicated R9 was an elopement risk due to impaired safety awareness and confusion. R9's Elopement Risk care plan contained an intervention, dated 11/13/19, for fifteen minute checks. The Surveyor reviewed R9's fifteen minute checks from 11/08/19-11/14/19 and noted R9's checks on 11/08/19, 11/10/19, and 11/11/19 were missing. The Surveyor reviewed R10's medical record. R10 was admitted to the facility with [DIAGNOSES REDACTED]. R10's Admission MDS, dated [DATE], indicated R10 was moderately cognitively impaired. R10's plan of care indicated R10 was an elopement risk due to impaired safety awareness. R10's Elopement Risk care plan contained an intervention, dated 11/13/19, for fifteen minute checks. The Surveyor reviewed R10's fifteen minute checks from 11/08/19-11/14/19 and noted R10's checks on 11/08/19, 11/10/19, and 11/11/19 were missing. The Surveyor reviewed R11's medical record. R11 was admitted to the facility with [DIAGNOSES REDACTED]. R11's most recent Annual MDS, dated [DATE], indicated R11 was severely cognitively impaired. R11's plan of care indicated R11 was an elopement risk due to disorientation and impaired safety awareness. R11's Elopement Risk care plan contained interventions, dated 11/13/19, for fifteen minute checks. The Surveyor reviewed R11's fifteen minute checks from 11/08/19-11/14/19 and noted R11's fifteen minute checks on 11/08/19, 11/10/19, 11/11/19, and 11/14/19 from 12:00 AM-6:00 AM were missing. The Surveyor reviewed R12's medical record. R12 was admitted to the facility with [DIAGNOSES REDACTED]. R12's most recent Quarterly MDS, dated [DATE], indicated R12 was severely cognitively impaired. R12's plan of care indicated R12 was an elopement risk due to wandering and confusion related to [MEDICAL CONDITION]. A wandering risk assessment, dated 11/12/19, stated R12 was a moderate risk for wandering. R12's Elopement Risk care plan contained an intervention, dated 11/13/19, for fifteen minute checks. The Surveyor reviewed R12's fifteen minute checks from 11/08/19-11/14/19 and noted R12's fifteen minute checks on 11/08/19, 11/10/19, 11/11/19, and 11/14/19 from 12:00 AM-6:00 AM were missing. During an interview with the Surveyor on 11/14/19 at 2:15 PM, DON-B stated the facility was unable to locate R1, R9, R10, R11 and R12's fifteen minute checks for the dates and times in question. DON-B verified the fifteen minute checks weren't an effective way to ensure resident safety if they weren't completed and again verified three doors in the building were not alarmed during the hours of 6:00 AM-10:00 PM. The failure to prevent R1's elopement from the facility during freezing temperatures, and failure to provide fifteen minute checks for R1 and four other residents at risk for elopement when the facility's Wanderguard system became disabled, created a finding of Immediate Jeopardy (I[NAME]) The facility removed the IJ on 11/14/19 when it completed the following: Resident 1 was located and returned to facility at approximately 2:20 am on 11/12/19, after staff discovered he was not in his room. Assessments completed on Resident 1 to include Skin Assessment and Vital Signs. MD notified of return with no new orders. Resident will be monitored for 24 hours every shift to identify if there is any change in level of consciousness. Resident's care-plan was reviewed, all interventions remain appropriate. The facility has armed the three doors that are not Wanderguard operational with a security system 11/14/19. This system is armed 24/7. All staff have been notified both in person and phone calls have been made to all current staff as of 11/14/19). Operation notes have been posted by the security system. Wanderguard system quote has been approved and sent to[NAME]on 11/14/19. Currently awaiting estimated installation date. On 11/14/19, the facility implemented a new procedure to arm all doors with sounding alarms. When each door is opened an alarm sounds notifying staff that someone is passing through. This update ensures all residents' safety as the system is operational 24 hours a day. All staff have been informed that when the alarm goes off it is their duty to respond to the alarm. Maintenance Director or Designee will check functioning Q (every) shift and PRN (as needed) until installation of new system. Education to all facility staff on door alarm procedures and responsibilities began on 11/14/2019. (100%) of all staff have been educated. Education to all facility staff on the elopement book and responsibilities and updating as necessary completed on 11/12/19. (100%) of all staff have been educated. Education to all facility staff on elopement procedures began on 11/12/19. (100%) of all staff have been educated. All residents were assessed for elopement risk and care plans/interventions have been updated as applicable. Elopement Assessments will be administered to all residents at least quarterly and with any change in cognition or new exit seeking behavior. Validated Elopement risk books and updated as applicable. Staff was advised during the education, that in the event it was determined they did not follow policy or the noted education, disciplinary action would occur up to and including termination.

Based on observation, staff and family interviews and record review, 1 (resident #5) of 5 residents reviewed for pain in a total sample of 13 residents did not receive the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. Resident #5 sustained a fractured right hip with resultant surgical repair on 10/27/10. The resident had a pain plan of care in place to include a goal to be pain free. Interventions on the plan of care directed staff to observe and administer pain medications as needed and to observe if pain was more severe for different positions. The resident displayed indicators of pain during cares and transfers. Staff were aware of the resident's pain indicators and did not stop activities, which were causing pain to the resident. Additionally, when the resident presented with indicators of pain during cares and transfers, staff did not alert licensed staff so initiation of pain assessments could be completed to determine what pain interventions would be implemented to relieve the resident's pain. Findings include: Resident #5's re-admission face sheet dated 11/4/10 indicated the resident had a history of [REDACTED]. The resident was assessed on 9/8/10 to be severely cognitively impaired. The resident's pain assessment tool, completed sometime after return to the facility after hospitalization on [DATE] (no date provided) indicated resident #5 had behaviors of vocal and non-verbal expressions of pain, facial grimaces and winces and restlessness with movement. The assessment also indicated the resident had no indications of the above pain indicators while at rest. The resident's pain plan of care initiated on 11/3/10 indicated a problem of pain management due to [MEDICAL CONDITION]. The goals of the plan included to be pain free or assist with coping mechanism. Interventions listed on the plan included to observe and administer medications as needed and to observe if pain was more severe for different positions. The resident had physician orders [REDACTED]. Nursing notes dated 11/3/10 to 11/27/10 indicated when resident #5 received as-needed pain medications, those medications were effective in reducing and/or relieving pain. On 11/29/10 at 7:25 a.m. surveyor # observed CNA (Certified Nursing Assistant)-Q and CNA-L provide pericare and transfers with the use of a Hoyer lift for resident #5. During turning in bed for pericare, during the transfer out of bed with the Hoyer lift and during clothing adjustment while the resident was seated in a wheel chair, resident #5 was observed to be grimacing and moaning. Staff did not discontinue cares and alert licensed staff when the resident displayed indicators of pain. The surveyor immediately interviewed CNA-Q regarding the above observations. CNA-Q stated, "Her (resident #5's) family won't let her have pain meds (medications) every four hours." Both CNA-Q and CNA-L verified during cares and transfers that morning resident #5 was in pain. The surveyor attempted to interview resident #5 regarding pain indicators, but the resident did not answer the surveyor when questioned. On 11/29/10 at 7:50 a.m. surveyor # interviewed MT (Medical Technician)-I regarding the above observations. MT-I verified resident #5 had last had pain medication administered at 8:00 p.m. on 11/28/10. MT-I stated, "It was reported by the night shift that after she (resident #5) got a pain med, she did pretty well without pain during routine repositioning throughout the night." On 11/29/10 at 9:30 a.m. surveyor # again interviewed MT-I regarding resident #5. MT-I stated, "She (resident #5) is in pain, so I will have the charge nurse assess her. On 11/29/10 at 9:40 a.m. LPN (Licensed Practical Nurse)-X entered resident #5's room where the resident was seated in her wheel chair. LPN-X spoke with the resident and stated, "She (resident #5) answered yes to her leg hurting. By her facial grimacing, I would say she was in pain, so I will have (MT-I) give her pain meds." MT-I verified to surveyor # she had administered two extra strength Tylenol to resident #5 at 9:45 a.m. on 11/29/10. On 12/1/10 at 7:10 p.m. surveyor # interviewed MT-I once more regarding resident #5. MT-I stated, "On 11/29/10 staff had not reported that she (resident #5) had been having pain with transfers and cares. The reason I had the charge nurse assess her that morning was because I saw her in the dining room, and I noticed facial expressions of pain. There is no directive on her MAR (Medication Administration Record) or her TAR (Treatment Administration Record) to evaluate her for pain during transfers and cares. I've never observed staff doing cares for her or transferring her." On 11/29/10 at 9:48 a.m. surveyor # observed CNA-Q and CNA-L transfer resident #5 back into bed. The resident was moaning throughout the transfer. The staff then performed pericare for the resident. As staff moved the resident from side-to-side in bed, the resident was moaning loudly. The resident received as-needed pain medication three minutes before being transferred back to bed and being moved from side-to-side in bed. Staff did not wait until the resident's indicators of pain diminished or subsided prior to the transfer and cares. On 11/29/10 at 10:00 a.m. surveyor # interviewed CNA-L regarding resident #5. CNA-L verified when resident #5 had indicators of pain during cares and again during transfer out of bed at 7:25 a.m. that morning, staff had not ceased cares and alerted licensed staff to the resident's indicators of pain. CNA-L also verified, "I didn't pass along the information that the resident (#5) was uncomfortable during cares and transfer this morning." On 11/29/10 at 10:05 a.m. surveyor # interviewed LPN-X regarding pain medications for resident #5. LPN-X stated, "Her ADPOAHC (Activated Durable Power of Attorney for Health Care) is concerned about side effects of pain meds. Right after her hip surgery, we were giving the resident [MEDICATION NAME], but then the ADPOAHC didn't want us to give that anymore. Tylenol is effective in relieving her pain. If she is in a lot of pain, then we just give her [MEDICATION NAME]. You will know because she will be yelling. She also has [MEDICATION NAME] as needed at bedtime. I was just made aware at 9:40 a.m. today that she was in pain. The family doesn't want her to be on scheduled pain medication. The staff didn't relay that she was moaning during cares and transfers today. I didn't know that or we would have given her something earlier. Her pain is most notable at meal times with moaning. I haven't observed cares or transfers with her; though if I would have known she was having pain during those times, I would have given her pain medication. I would expect staff to stop the transfer or cares and let me know of pain issues." On 11/29/10 at 10:10 a.m. surveyor # interviewed CNA-Q regarding resident #5. CNA-Q stated, "Normally I would have told someone if a resident is in pain, but I've gotten yelled at because they want her (resident #5) up even when she is obviously in pain. Both (LPN-X) and (DON (Director of Nursing)-A) have told us that. Everyday with transfers and cares since she broke her hip, she moans and grimaces. They are telling us that the family said she can't have pain meds every four hours." On 11/30/10 at 7:15 a.m. surveyor # again interviewed CNA-Q regarding resident #5. CNA-Q stated, "She (resident #5) had pain meds fifteen minutes before we got her up today. She did really well and wasn't moaning and had no pain. It was the first time that she hasn't had any pain when we transferred her or did cares for her since her fracture." On 11/30/10 at 11:30 a.m. surveyor # interviewed FM (Family Member)-FF regarding pain medications for resident #5. FM-FF indicated she was resident #5's secondary ADPOAHC. FM-FF stated, "I've noticed her moaning during transfer with that sling. I think that sling pushes on her leg and causes pain. She was on [MEDICATION NAME] right after she fractured her hip, but she was too sedated. We were okay with giving her the [MEDICATION NAME] or Tylenol as needed. We were okay with staff assessing her and giving her medication for pain when she needs it. She needs it an hour before transfers or therapy, because I noticed those were the times she would have pain."

Based on observation, family and staff interviews and record review, the facility did not ensure 3 (residents #4, #5 and #13) of 6 residents reviewed for falls in a total sample of 13 residents received adequate supervision and assistance devices to prevent accidents. Resident #4 had a history of [REDACTED]. Interventions on resident #4's plan of care indicated resident #4 was not be left unattended when toileting; a pressure pad alarm that was integrated into the call light system was to be used while the resident was in bed; a tabs alarm was to be used while the resident was in bed and a motion sensor alarm was to be used while the resident was in bed. The plan of care interventions were not consistently implemented. Resident #5 was assessed to be at high risk for falls due to dementia, balance problems and decreased muscular coordination. The resident's CNA (Certified Nursing Assistant) care card dated March 2010 indicated the resident was a one to two assist for transfer. On 10/27/10 CNA-GG, without assistance from another staff, transferred resident #5 from a bath chair to a wheel chair, at which time the resident lost her balance and fell . The fall resulted in a right trochanteric hip fracture, which required hospitalization and surgical repair. Resident #13 had a history of [REDACTED]. A care plan intervention to include the use of a floor motion detector while the resident was in bed was not consistently implemented. Findings include: The Long Term Care Facility Resident Assessment Instrument User's Manual Version 2.0 dated 6/06 indicated the definition of transfer was how the resident moved between surfaces- i.e., to/from bed, chair, wheel chair, standing position. 1. Resident #5's re-admission face sheet dated 11/4/10 indicated the resident had a history of [REDACTED]. The resident was assessed in July 2010 to be at high risk for falls due to confusion, balance problems while standing and walking, impaired vision, decreased muscle coordination and jerking or unstable movements while making turns. The resident was assessed on 9/8/10 to be severely cognitively impaired and required extensive assistance to transfer. The resident's September 2010 MDS (Minimum Data Set) indicated the resident was unable to do a balance-while-standing test without physical help. The resident's potential for falls plan of care dated 12/14/09 indicated interventions (same date) to observe, record and report all unsafe conditions and situations. Encourage to ask for assistance. Instruct resident in use of adaptive equipment. Anticipate falls times. Instruct on safety. The resident's CNA care card dated 3/16/10 indicated resident #5 was at risk for falls, required one to two assist for transfers and was not to be left in a wheel chair when alone in her room. There had been no changes made to the care card regarding the resident's level of assistance for transfers from 3/16/10 to 10/27/10 despite staff interviews that indicated resident #5 required two assist for all transfers due to unpredictable and unreliable behaviors during transfers. On 11/29/10 at 11:10 a.m. surveyor # interviewed LPN (Licensed Practical Nurse)-X and MT (Medication Technician)-I. Both staff verified resident #5 was a two assist with standing and transfers due to decline prior to sustaining the fall on 10/27/10. On 11/29/10 at 1:00 p.m. surveyor # interviewed CNA-HH regarding transfers for resident #5. CNA-HH verified resident #5 was a two staff assist and the use of a gait belt with all transfers prior to sustaining the hip fracture and stated, "She (resident #5) wouldn't always hang onto the walker, so one staff would stand in front of her and hold onto her hands and walker. It wasn't safe to transfer her alone. You never knew when her legs would start to give out. The usual bath girl always asked me to assist when transferring her (resident #5) from the bath chair to the wheel chair." On 11/29/10 at 1:45 p.m. surveyor # interviewed CNA-Q regarding transfers for resident #5. CNA-Q stated, "She (resident #5) was a two assist for all transfers. She is unpredictable and sometimes won't stand and sometimes will just not stay standing. It's just not safe to transfer her without two people." On 11/29/10 at 2:00 p.m. surveyor # interviewed CNA-II regarding transfers for resident #5. CNA-II stated, "She (resident #5) was definitely a two assist and a gait belt to transfer prior to her fracture. She was unsteady, unreliable and unpredictable." The facility's fall assessment documented on 10/27/10 at 5:40 a.m., after giving the resident a bath, CNA-GG assisted resident #5 to stand and transfer from a tub chair to a wheel chair. The resident lost her balance and fell . The fall resulted in a right trochanteric hip fracture which required surgical repair and a hospital stay from 10/27/10 to 11/3/10. On 11/29/10 at 11:00 a.m. surveyor # interviewed CNA-GG regarding the fall resident #5 sustained on 10/27/10. CNA-GG verified she had been assisting resident #5 to transfer from the tub chair to the wheel chair on 10/27/10 at 5:40 a.m. when the fall occurred. CNA-GG stated, "I had her (resident #5) stand with a gait belt on and pulled her pants up. I moved the tub chair in order to get the wheel chair behind her, so she could sit down; and she fell backwards. I called the nurse four times on the walkie talkie for assistance with the resident before the transfer, but no one ever came to help me...The resident was alert that morning. She was just standing not transferring, so I only used one to help her move from the bath chair to the wheel chair." On 11/29/10 at 11:05 a.m. surveyor # interviewed DON (Director of Nursing)-A. When the surveyor asked DON-A who made the decision if resident #5 was to be transferred with one assist or two assist, DON-A stated, "One assist in the morning and two assist in the afternoons and evenings when the resident was more fatigued. The CNAs make that call." During the 11/29/10, 11:00 a.m. interview with surveyor # , CNA-GG indicated the nurse did speak with her about the unsafe transfer and reiterated resident #5 was a two assist with a gait belt. On 11/30/10 at 8:00 a.m. surveyor # interviewed DON-A regarding any training provided to staff following the 10/27/10 fall sustained by resident #5. DON-A stated, "We didn't recognize it (resident #5's fall) as a transfer, so we didn't specifically talk about that transfer issue in the general staff inservice on 11/10/10. On 11/30/10 at 7:55 a.m. surveyor # again interviewed CNA-GG regarding the fall resident #5 sustained on 10/27/10. CNA-GG stated, "I called for assistance at least three times before I stood the resident (#5) up. Her pants were up. I was just switching her from the tub chair to her wheel chair. I had one hand on her gait belt and one hand I used to switch out the chairs. I transferred her alone because no one came to help me." On 11/30/10 at 11:30 a.m. surveyor # interviewed FM (Family Member)-FF regarding the fall resident #5 sustained on 10/27/10. FM-FF was resident #5's secondary ADPOAHC (Activated Durable Power of Attorney for Health Care). FM-FF stated, "They told me that she (resident #5) fractured her hip during a bath. She was already clothed and was sitting on a tub chair. They transferred her from one chair to another, and her leg gave out when standing. She was lowered to the floor. They always used two staff to transfer her due to a decline in strength in the last year and due to the progression of her Alzheimers. I'm here twice a week and that's what I see them doing." An addendum dated 11/30/10, which was added to resident #5's fall assessment completed on 10/27/10, indicated, "...Late entry. CNA assisted resident to stand up to change chairs behind her. Resident's feet never moved. Gait belt and walker were used. Upon standing, resident collapsed to her right. CNA assisted resident to floor and called for assist." 2. Resident #4's face sheet, contained within the medical record and dated 10/6/10, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] indicated resident #4 had short and long-term memory problems and was independent with cognitive skills for daily decision making. Resident #4 required extensive assistance with transfers and had fallen in the past 30 days and past 31-180 days. The nurses' notes dated 9/23/10 at 10:40 p.m. indicated a tabs alarm was put into place for resident #4 due to agitation and restlessness. The nurses' notes dated 9/24/10 at 7:15 a.m. indicated resident #4 attempted several times to transfer herself out of bed without requesting assistance from nursing staff. The nurses' notes dated 9/24/10 at 9:51 a.m., as a late entry for 9/24/10 9:00 a.m., indicated resident #4 was observed on the floor in the bathroom. The resident was alert and oriented to self, but confused, which was within normal limits for the resident. Resident #4 complained of pain in the right hip, right arm and right side of face. Resident #4 was transferred to the emergency room . The emergency room notes indicated resident #4 sustained a contusion (a bruise with swelling and some bleeding under the skin) of the right hip and returned to the facility on [DATE]. The nurses' notes dated 9/24/10 at 7:30 p.m., as a late entry for 9/24/10 8:00 a.m., indicated the writer (unknown) spoke with resident and staff regarding incident. Resident #4 did indicate that she requested staff to leave the bathroom while she voided. Staff indicated she left the bathroom per resident request. The resident did have the call light and did indicated she would use it when finished in the bathroom. Upon staff return, the resident was observed on the floor. On 12/1/10 at 11:39 a.m. surveyor # interviewed DON-A regarding resident #4. DON-A confirmed resident #4 had a history of [REDACTED]. DON-A also stated she educated the CNA who left resident #4 in the bathroom alone on 9/24/10. The DON indicated, "No one else was educated." DON-A indicated she did tell other staff informally when they were coming and going (arriving at and leaving work) that it was not the best practice to leave residents in the bathroom unattended when they were at risk for falls. The DON indicated she told staff "...before making that choice, talk to the nurse and don't let the resident talk you in to something." The nurses' notes dated 10/29/10 at 3:36 a.m. indicated resident #4 climbed out of bed unassisted at 12:15 a.m. Staff found the resident down with no apparent injury. Devices in use were a pressure sensor alarm, which was not attached to the bed, a tabs unit clip alarm that was not attached and a motion sensor alarm. The resident was instructed on safe use of assistive device and safe transfer techniques. The Fall Prevention and Assessment Meeting Form dated 10/29/10 indicated resident #4 was impulsive and not aware of her own safety. The documentation indicted the call light was within reach when the resident was in bed and was not on at time of the observation. The follow up plan was to implement a pressure pad integrated into the call light system. The facility provided no further information to surveyor # regarding the incidents on 9/24/10 and 10/29/10. Resident #4's current plan of care, dated 10/6/10, indicated the resident had a potential for trauma/falls related to a decline in cognitive status manifested by a history of falls. The approach was dated 10/31/10 and indicated resident #4 was encouraged to ask for assistance, call light in reach, do not leave unattended when toileting, toilet approximately every two hours and as needed, lipped mattress, pressure pad integrated into the call light system in bed. On 11/18/10 the approach of a floor mat was added to the care plan. The current CNA care plan dated 10/31/10 indicated the resident was alert and confused, was at risk for falls and safety needs were as follows: floor mat, tabs alarm in wheel chair and pressure pad in bed. The CNA care card did not include the interventions of encouraging the resident to ask for assistance, call light in reach, do not leave the resident unattended when toileting, toilet approximately every two hours and lipped mattress. On 11/29/10 at 9:28 a.m. surveyor # observed resident #4 in bed. Surveyor # walked in front of a motion sensor alarm, which was positioned on the floor mat near the foot of the bed. The motion sensor alarm did not alarm. On 11/29/10 at 9:35 a.m. surveyor # observed resident #4 sitting up on the bed with the tabs clip alarm unattached. The resident was attempting to stand. The call light was positioned at the foot of the bed, and the motion sensor alarm on the floor at the foot of the bed was not alarming. Surveyor # pushed the call light for assistance and stayed with the resident, who sat back down on the bed. Resident #4 indicated she needed to use the bathroom. Surveyor # walked past resident #4's door and was able to monitor the resident while surveyor # went to get staff to assist the resident. RN (Registered Nurse)-B and CNA-HH came in to the room to assist the resident. CNA-HH assisted resident #4 to the bathroom and on to the toilet. At 9:39 a.m. CNA-HH left the resident unattended in the bathroom and went to the sink in resident #4's room to wash her hands. CNA-HH was unable to visualize the resident in the bathroom. CNA-K entered resident #4's room. CNA-HH left resident #4's room and at 9:41 a.m. CNA-K went in to the bathroom with resident #4. CNA-K then assisted resident #4 back to bed. On 11/29/10 at 1:10 p.m. surveyor # interviewed resident #4. The motion sensor alarm did not alarm when surveyor # walked past it twice during the interview. At 1:17 p.m. CNA-K entered resident #4's room; and when asked about the motion sensor alarm, placed her hand in front of the alarm in a waving motion. The motion sensor alarm did not alarm. CNA-K verified the motion sensor alarm was not working properly. CNA-O entered resident #4's room and stated the motion sensor alarm was "...delayed, and she has a clip alarm and pressure alarm." CNA-K stated the motion sensor alarm was in the chime position, which is why it did not sound. On 11/29/10 at 1:24 p.m. surveyor # observed CNA-K assist resident #4 to the bathroom. When CNA-K assisted resident #4 from the bed to a standing position, the pressure alarm on the bed did not sound. CNA-K placed the resident on the toilet. At 1:27 p.m. CNA-K stated to resident #4, "I'll be right back" and left resident #4 unattended in the bathroom. The CNA went to wash her hands at the sink in resident #4's room. CNA-K was unable to visualize the resident. CNA-K returned to the resident in the bathroom at 1:28 p.m. CNA-K then assisted resident #4 back to bed, and the pressure alarm on the bed did not sound. Surveyor # interviewed CNA-K related to the bed pressure alarm. CNA-K stated, "It didn't sound when she got up, so it must be (used) in the chair only." CNA-K verified there was a pressure pad alarm on the chair, and it was plugged in to the box on the side of the chair. On 11/30/10 at 11:01 a.m. surveyor # observed resident #4 laying in bed. The tabs alarm box was laying near the resident's shoulder attached to the resident's shirt, and the motion sensor alarm was on the nightstand, not turned on. On 11/30/10 at 11:13 a.m. surveyor # interviewed CNA-K, who verified the tabs alarm was laying on the bed next to the resident, and the motion sensor alarm was not turned on. CNA-K stated, "The motion sensor is not working, and the tabs alarm should be attached to something." CNA-K turned the motion sensor alarm on and attached the tabs alarm box to the nightstand. On 11/30/10 at 3:35 p.m. surveyor # interviewed DON-A who stated resident #4 "...uses pressure pad on bed...it is integrated in to the call light system." On 11/30/10 at 4:29 p.m. surveyor # and DON-A went in to resident #4's room to look at the pressure pad on the bed. DON-A demonstrated the use of the pressure pad on the recliner and stated, "It beeps when you move/stand up, and the call light comes on." On demonstration the call light did not turn on outside of resident #4's room. The motion sensor alarm was not working at that time. DON-A stated, "Maybe it needs new batteries." On 12/1/10 at 7:35 a.m. surveyor # observed CNA-M assist resident #4 from the bed to the bathroom and on to the toilet. The pressure alarm did not sound when the resident stood up from the bed. CNA-M left the resident unattended in the bathroom for two minutes to wash her hands at the sink in resident #4's room. CNA-M then returned to the bathroom. CNA-M then left the resident unattended in the bathroom to go near resident #4's sink to get a pair of gloves and wash cloths/towels. CNA-M then wet the wash cloths at the sink. Resident #4 yelled from the bathroom, "When can I get up?" CNA-M placed soap on the wash cloths and went back in the bathroom to assist resident #4. CNA-M then assisted resident #4 back to the bed, and the pressure alarm did not sound. There was not a motion sensor in resident #4's room at the time of the observation. On 12/1/10 at 7:49 a.m. surveyor # interviewed CNA-M, who confirmed staff were "...not supposed to leave (resident #4) alone in the bathroom, but I had to get the towels. It was only for two seconds." CNA-M also indicated resident #4 only had a pressure pad in the recliner or wheel chair, none in the bed. CNA-M verified the pressure pad was on the chair and plugged into the box on the side of the recliner. On 12/1/10 at 7:52 a.m. surveyor # interviewed CNA-W related to resident #4's motion sensor not being in the room. CNA-W confirmed resident #4 was supposed to have a motion sensor alarm. CNA-K then entered resident #4's room and verified the motion sensor alarm was not in resident #4's room. CNA-K left resident #4's room to obtain a motion sensor alarm, placed the alarm on the nightstand and stated "...had to get new batteries for it." On 12/1/10 at 9:10 a.m. surveyor # and RN-B entered resident #4's room. The motion sensor alarm was on the nightstand. The alarm did not sound when surveyor # walked in front of it. RN-B verified the alarm did not sound and stated, "It should. It's a sensor. I'll have to ask." At 9:13 a.m. surveyor # observed the sensor pressure pad for resident #4 was not plugged in for the bed, but the sensor pressure pad was plugged in for the chair. At 9:28 a.m. surveyor # interviewed RN-B, who showed surveyor # the pressure pad on the bed and verified the sensor pressure pad needed to be used for resident #4 and was plugged in for the chair not the bed. RN-B left resident #4's room without turning the motion sensor alarm on. On 12/1/10 at 9:35 a.m. surveyor # interviewed CNA-K, who verified the motion sensor alarm was not turned on in resident #4's room while the resident was in bed. CNA-K turned the motion sensor alarm on before leaving the room. On 12/1/10 at 10:00 a.m. surveyor # interviewed LPN-X related to resident #4's sensor pressure pad. LPN-X indicated staff didn't use the pressure detector on the bed, because resident #4 would throw it off. The LPN indicated the pressure detector was only used in the chair. LPN-X verified the pressure pad was plugged in to the box for the chair, not the bed. On 12/1/10 at 1:28 p.m. surveyor # interviewed CNA-K related to leaving resident #4 unattended in the bathroom. CNA-K stated staff could leave resident #4 in the bathroom, but could not leave the room. CNA-K indicated, "It is okay to wash your hands and get gloves." 3. Resident #13's readmission face sheet dated 9/27/10 indicated the resident had just returned from the hospital following a UTI (Urinary Tract Infection) with MRSA (Methicillin Resistant Staph Aureus) sepsis. The resident had additional [DIAGNOSES REDACTED]. The resident was assessed on 10/5/10 to be moderately cognitively impaired and required total assistance from staff to perform transfers. Nurses' notes housed in the resident's medical record indicated the resident sustained [REDACTED]. Changes in the resident's plan of care were initiated after each fall incident. The resident's plan of care for falls dated 9/10/10 indicated a motion sensor would be utilized. The resident's CNA care card dated 9/16/10 indicated the resident was at risk for falls and was to be utilizing a motion sensor. On 12/1/10 at 11:15 a.m. surveyor # observed CNA-Q and CNA-GG assist resident #13 back into bed. The staff covered the resident, put a tabs alarm on the resident, placed a fall matt on the right side of the bed and exited the room. A motion sensor alarm was sitting on the resident's bedside table in the off position. The surveyor stood in the hallway and observed the resident continuously. At 11:35 a.m. MT-I entered the room, gave resident #13 pain medication and exited the room without activating the motion sensor. The resident remained in bed with his motion sensor not activated until 11:45 a.m. when surveyor # alerted CNA-Q to the observations. CNA-Q verified resident #13's motion sensor was to be on per the resident's plan of care. The CNA immediately went into the resident's room and placed the activated motion sensor on the floor near the resident's bed.

Based on observation, staff interview and record review, the facility did not ensure 1 (resident #6) of 7 sampled residents reviewed for falls, received adequate supervision and assistance devices to prevent accidents. Resident #6 had a history of [REDACTED]. The intervention on resident #6's CNA (Certified Nursing Assistant) care plan/assignment card directed staff not to leave resident alone in the bathroom. Resident #6 was left alone on the toilet in the bathroom. Findings include: Resident #6's face sheet, contained within the medical record and dated 12/1/10, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS (Minimum Data Set) dated 7/23/10 indicated resident #6 had short and long-term memory problems and was moderately impaired with cognitive skills for daily decision making. Resident #6 required extensive assistance with transfers and had fallen in the past 31-180 days. A Fall Prevention and Assessment Meeting Form dated 1/11/11 indicated resident #6 attempted to get out of bed herself. The motion sensor alarm was sounding, and resident #6 was observed next to the bed. Resident #6 was sent to the emergency room for evaluation due to a skin tear and a small hematoma on the back of the head. A pressure pad alarm was then placed on resident #6's bed and integrated into the call light system. Resident #6's current CNA care plan/assignment card, dated 7/29/10 and revised on 11/23/10, indicated the resident had a potential for trauma-falls. The care plan indicated resident #6 was not to be left alone in the bathroom. The facility conducted an in-service for direct care staff on 12/10/10 related to falls. On 1/27/11 at 3:40 p.m. surveyor # interviewed DON (Director of Nursing)-G related to the in-service, and DON-G verified CNA-P and CNA-Q attended the falls review in-service. On 1/27/11 at 9:32 a.m. surveyor # observed CNA-P and CNA-Q transfer resident #6 to the bathroom. At 9:35 a.m. CNA-P and CNA-Q left resident #6 in the bathroom alone, sitting on the toilet. The CNAs went to the sink to wash their hands. The door was left partially open; however, CNA-P and CNA-Q were unable to visualize resident #6 on the toilet at that time. At 9:38 a.m. CNA-Q went back into resident #6's bathroom. On 1/27/11 at 1:35 p.m. surveyor # interviewed CNA-P and CNA-Q regarding the above observation. The CNAs verified resident #6 was left in the bathroom alone while they washed their hands. The CNAs further confirmed they could not visualize resident #6 while the resident was on the toilet and they were washing their hands. CNA-P and CNA-Q both stated resident #6 "...was not supposed to be left alone in the bathroom per the family." On 1/27/11 at 1:38 p.m. surveyor # interviewed DON-G related to resident #6 being left unattended in the bathroom. DON-G stated, "I am not sure why the family doesn't want (resident #6) left alone in the bathroom...she has anxiety?" On 1/27/11 at 2:18 p.m. surveyor # interviewed MT (Medication Technician)-N and LPN (Licensed Practical Nurse)-O regarding resident #6. MT-N stated resident #6 could not be left in the bathroom unattended, because the resident "...gets up." LPN-O stated resident #6 was a fall risk, and staff did not leave her unattended. On 1/27/11 at 2:43 p.m. surveyor # interviewed CNA-R regarding resident #6. CNA-R verified resident #6 should not be left unattended in the bathroom and stated, "The family requested (resident #6) not be left alone in the bathroom...has falls...believe (resident #6) had a fall in the bathroom." On 1/27/11 at 3:15 p.m. surveyor # interviewed DON-G and requested a copy of the facility's current fall risk assessment for resident #6. DON-G indicated she was unable to locate a fall risk assessment for the resident #6. As of 2/7/11 surveyor # had not received a fall risk assessment for resident #6.