Every finding on record at Edenbrook Rochester West

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were available to meet resident needs for 2 of 3 residents (R3 and R2), resulting in a pattern of delayed toileting assistance and care needs.Findings include:R3's Face sheet printed 5/13/26, identified diagnoses including Parkinsonism, polyneuropathy, chronic pain syndrome, urge incontinence, Crohn's disease, chronic kidney disease stage 3b, protein-calorie malnutrition, and attention to ileostomy (opening in the abdomen for stool drainage into a bag).R3's 5-day Prospective Payment System (PPS) Minimum Data Set (MDS) dated [DATE], indicated R3's cognition was intact, had impaired range of motion (ROM) in both upper and lower extremities, was dependent for toileting hygiene and transfers, required partial to moderate assistance with rolling in bed, substantial to maximal assistance with lower body dressing, and required a mechanical lift for transfers and a wheelchair for mobility. The MDS further identified R3 had an ostomy appliance and was frequently incontinent of bladder.R3's care plan revised 4/29/26, identified a focus of an activity of daily living (ADL) self-care deficit related to dementia, obesity, limited mobility, and pain. The care plan identified R3 did not walk, pick up objects, or independently propel a wheelchair for 150 feet. An intervention revised 3/27/26 indicated R3 required assistance of two staff for toileting every 2 to 3 hours and as needed (PRN). A separate care plan focus revised 3/24/26, identified mixed bladder incontinence related to impaired mobility, need for assistance with toileting, recurrent cystitis, and dementia. Interventions initiated 6/24/25, indicated staff were to check and offer toileting every 2 hours, provide incontinent care with each episode of incontinence, and change clothing as needed following incontinence episodes.During an observation and interview on 5/13/26 at 1:38 p.m., R3 was observed seated upright in her wheelchair in the dining room. R3 stated staff were respectful, but the facility needed more staff. R3 currently required extensive assistance due to weakness and low blood pressures causing dizziness and passing out. R3 stated it took two staff to assist her with bed mobility and use of the bedpan and required two staff with a mechanical lift to transfer out of bed into her wheelchair. R3 stated call light response times were poor throughout the day and night and she had been left on the bedpan for prolonged periods of time, causing pain to her buttocks. Staff frequently told R3 they did not have enough staff and would answer the call light, turn it off, say they would return, and then not come back for prolonged periods of time. R3 stated she had episodes of urinary incontinence because she had to wait too long for assistance. The issues with delayed call light response had been ongoing for a long time and were very frustrating. R3 stated she did not feel staff were able to respond timely to resident needs.R3's call light log report was reviewed from 5/6/26 through 5/13/26 (7 days) and identified R3's call light remained active for longer than 15 minutes on 36 occasions. Multiple prolonged delays occurred throughout the day and night, including early morning, daytime, evening, and overnight hours. Review identified repeated wait times ranging from 16 minutes to over 2 hours, including delays of 1 hour or longer on 8 occasions. The longest documented wait times included 2 hours and 17 minutes on 5/8/26 and 2 hours and 18 minutes on 5/9/26. Additional prolonged wait times included 1 hour and 30 minutes, 1 hour and 24 minutes, 1 hour and 10 minutes, 1 hour and 8 minutes, 1 hour and 3 minutes, and 1 hour.Tuesday, 5/6/26:-12:37 p.m. to 1:37 p.m., for a total wait time of 1 hour.-1:41 p.m. to 2:00 p.m., for a total wait time of 19 minutes.-2:07 p.m. to 2:25 p.m., for a total wait time of 18 minutes.-10:55 p.m. to 12:25 a.m., for a total wait time of 1 hour and 30 minutes.Wednesday, 5/7/26:-7:00 a.m. to 7:24 a.m., for a total wait time of 24 minutes.-12:07 p.m. to 12:49 p.m., for a total wait time of 42 minutes.-1:11 p.m. to 1:53 p.m., for a total wait time of 42 minutes.-2:02 p.m. to 2:21 p.m., for a total wait time of 19 minutes.-8:47 p.m. to 9:11 p.m., for a total wait time of 24 minutes.Thursday, 5/8/26:-7:48 a.m. to 8:35 a.m., for a total wait time of 47 minutes.-1:56 p.m. to 2:12 p.m., for a total wait time of 16 minutes.-4:39 p.m. to 6:56 p.m., for a total wait time of 2 hours and 17 minutes.-8:35 p.m. to 9:38 p.m., for a total wait time of 1 hour and 3 minutes.-10:03 p.m. to 10:34 p.m., for a total wait time of 31 minutes.Friday, 5/9/26:-1:57 a.m. to 2:15 a.m., for a total wait time of 18 minutes.-9:00 a.m. to 9:29 a.m., for a total wait time of 29 minutes.-6:53 p.m. to 7:13 p.m., for a total wait time of 20 minutes.-7:52 p.m. to 10:10 p.m., for a total wait time of 2 hours and 18 minutes.Saturday, 5/10/26:-9:48 a.m. to 10:18 a.m., for a total wait time of 30 minutes.-2:21 p.m. to 2:39 p.m., for a total wait time of 18 minutes.-2:51 p.m. to 3:10 p.m., for a total wait time of 19 minutes.-4:57 p.m. to 6:21 p.m., for a total wait time of 1 hour and 24 minutes.-6:23 p.m. to 6:41 p.m., for a total wait time of 18 minutes.-8:06 p.m. to 8:29 p.m., for a total wait time of 23 minutes.-8:53 p.m. to 9:37 p.m., for a total wait time of 44 minutes.-9:42 p.m. to 10:23 p.m., for a total wait time of 40 minutes.Sunday, 5/11/26:-3:33 a.m. to 3:52 a.m., for a total wait time of 19 minutes.-5:41 a.m. to 6:49 a.m., for a total wait time of 1 hour and 8 minutes.-8:23 a.m. to 8:46 a.m., for a total wait time of 23 minutes.-11:16 a.m. to 12:26 p.m., for a total wait time of 1 hour and 10 minutes.-4:39 p.m. to 5:07 p.m., for a total wait time of 28 minutes.-7:08 p.m. to 7:28 p.m., for a total wait time of 20 minutes.-10:11 p.m. to 10:37 p.m., for a total wait time of 26 minutes.Monday, 5/12/26:-11:58 a.m. to 12:17 p.m., for a total wait time of 19 minutes.-8:50 p.m. to 9:08 p.m., for a total wait time of 18 minutes.Tuesday, 5/13/26:-10:30 a.m. to 10:47 a.m., for a total wait time of 17 minutes. R2's face sheet printed 5/13/26 identified R2 had diagnoses including chronic diastolic congestive heart failure, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, morbid obesity, unsteadiness on feet, generalized muscle weakness, diabetic neuropathy, chronic kidney disease stage 3b, atrial fibrillation, urinary retention, and dependence on supplemental oxygen.R2's quarterly MDS dated [DATE], indicated R2's cognition was intact, required substantial to maximal assistance with toileting hygiene and toilet transfers, used a wheelchair for mobility, and had impaired range of motion in both upper and lower extremities. R2 was frequently incontinent of bladder, continent of bowel, and received a diuretic medication.R2's care plan revised on 4/6/25, identified a focus of an activities of daily living (ADL) self-care performance deficit related to weakness. The care plan identified R2 required an EZ stand lift for transfers and did not ambulate. An intervention initiated on 4/6/25 identified R2 required toilet use assistance of one staff member. Separate care plan focuses revised on 4/6/25 and 11/24/25 identified limited physical mobility related to weakness and functional bladder incontinence related to impaired mobility and urinary retention. Interventions initiated on 4/6/25 identified R2 required bed mobility assistance of one staff member, transfer assistance of two staff using a stand-up lift from wheelchair to bed and bedside commode, placement of a urinal and bedpan within reach, assistance with toileting, and incontinent care as needed.During an interview on 5/13/26 at 10:53 a.m., R2 stated staff were good, but the facility needed more staff. R2 used a bedside commode for toileting and required use of an EZ stand lift with assistance from two staff members. Staff sometimes left R2 sitting on the commode for up to an hour, causing soreness to his buttocks. R2 stated he had episodes of bowel incontinence because he could not wait long enough for staff to assist him with toileting. Call light response times were horrendous and estimated average wait times were approximately 30 minutes, with waits at times lasting up to an hour. The delays were ongoing and were not limited to a certain time of day. R2 further stated he took a water pill and was up multiple times overnight urinating and had to call staff because all three of his urinals were full.R2's call light log report was reviewed from 5/6/26 through 5/13/26 (7 days) and identified R2's call light remained active for longer than 15 minutes on 7 occasions. Review identified prolonged wait times occurring during daytime, evening, and overnight hours, with delays ranging from 17 minutes to 47 minutes. The longest documented wait times included 47 minutes on 5/10/26, 42 minutes on 5/8/26, and 31 minutes on 5/10/26. Additional prolonged wait times included 29 minutes, 23 minutes, 19 minutes, and 17 minutes.Thursday, 5/8/26:-11:02 a.m. to 11:21 a.m., for a total wait time of 19 minutes.-9:11 p.m. to 9:53 p.m., for a total wait time of 42 minutes.Saturday, 5/10/26:-5:40 p.m. to 6:11 p.m., for a total wait time of 31 minutes.-6:49 p.m. to 7:36 p.m., for a total wait time of 47 minutes.-9:01 p.m. to 9:30 p.m., for a total wait time of 29 minutes.Sunday, 5/11/26:-11:18 a.m. to 11:41 a.m., for a total wait time of 23 minutes.Monday, 5/12/26:-4:51 a.m. to 5:08 a.m., for a total wait time of 17 minutes. During an interview on 5/13/26 at 12:27 p.m., staffing coordinator (SC)-A stated the south hall had 17 residents, including four residents who required assistance of two staff members with a mechanical lift and an additional resident who required assistance of two staff members for transfers. The north hall had 9 residents, including four residents who required assistance of two staff members with a mechanical lift. Nursing assistants did not currently have radios, requiring staff to leave resident rooms to locate another staff member when two-person assistance was needed. SC-A stated delays in responding to resident needs were more difficult when a float aide was not scheduled. SC-A stated the facility was currently staffing at approximately 3.2 hours per patient day (PPD) and acknowledged staffing should be approximately 3.5 PPD based on resident acuity. Ideal staffing would include two nursing assistants, two nurses, and a float aide on day and evening shift and one nursing assistant and one nurse on night shift; however, if staffing strictly reflected resident acuity, three nursing assistants would be needed on day and evening shifts and two nursing assistants on night shift. SC-A further stated she was working with corporate to obtain approval for additional staffing.Review of the staffing schedules from 5/6/26 through 5/13/26 identified multiple shifts where no designated float nursing assistant (NA) was scheduled. The schedules identified:5/6/26: No designated float aide scheduled for evening shift.5/7/26: No designated float aide scheduled for evening shift.5/8/26: No designated float aide scheduled for day or evening shift.5/9/26: No designated float aide scheduled for evening shift.5/10/26: No designated float aide scheduled for evening shift.5/11/26: No designated float aide scheduled for day or evening shift.5/13/26: No designated float aide scheduled for evening shift. During an interview on 5/14/26 at 11:02 a.m., nursing assistant (NA)-A stated staff did their best to answer call lights timely; however, when only one nursing assistant was scheduled on the hall, delays occurred because several residents required assistance of two staff members due to use of mechanical lifts. NA-A stated staff frequently had to locate another aide from a different hall to assist with transfers and toileting, which could take additional time, particularly during morning care. Call lights were answered more timely when a float staff member was available.During an interview on 5/13/26 at 1:56 p.m., registered nurse (RN)-A stated resident call lights should generally be answered within 15 minutes and acknowledged response times during busy periods, such as mealtimes, may increase to approximately 20 minutes. Residents should not have to wait an hour for assistance. RN-A further stated when only two nursing assistants were scheduled in the building, response times could take longer, and the facility needed enough staff to meet resident needs timely.During an interview on 5/13/26 at 1:59 p.m., the director of nursing (DON) stated she recently became aware of prolonged call light response times and increased resident complaints regarding delays in assistance, however, had not completed recent call light audits. The facility currently had an increased number of residents requiring mechanical lifts, which required additional staff assistance for transfers and toileting. DON stated the facility needed a float nursing assistant on day and evening shift to assist staff in meeting resident needs timely. DON further stated the facility previously staffed at approximately 4.0 hours per patient day (PPD), was currently staffing at approximately 3.2 PPD, and she planned to advocate for increased staffing. The goal for call light response times should be approximately 10-15 minutes. The DON was unaware that R2 and R3 had experienced episodes of incontinence due to delayed response times.During an interview on 5/13/26 at 2:20 p.m., regional director of clinical services (RDCS)-A stated the facility goal was for staff to answer resident call lights within 15 minutes and acknowledged residents should never wait over an hour for assistance. RDCS-A further stated the facility needed to staff according to resident acuity.The facility assessment dated [DATE], identified the facility population included residents with complex medical conditions requiring extensive assistance with activities of daily living (ADLs), transfers, toileting, mobility, incontinence care, ostomy care, and mechanical lift assistance. The facility assessment further identified 26 residents required assistance of one to two staff members for transfers and toileting. The assessment identified bowel and bladder care included responding promptly to resident requests for assistance to the bathroom or toilet in order to maintain continence and promote resident dignity. The assessment further identified nursing staffing needs were to be based upon resident acuity and adjusted as needed to meet resident care needs.Facility policy Call Light Use and Response, revised 7/18/23, identified the purpose of the policy was to respond promptly to resident's call for assistance. The policy further identified facility personnel were to be aware of resident call lights and answer all call lights in a prompt, calm, courteous manner.Facility policy Sufficient Staffing, revised 10/19/23, identified the facility would have sufficient nursing staff with the appropriate competencies and skill sets to provide services necessary to assure resident safety and maintain each resident's highest practicable well-being considering the number, acuity, and diagnoses of the facility's resident population. The policy further identified nursing direct care staffing ratios would be recalculated based on census and level of care needs and staffing patterns would be reviewed daily by the scheduler, human resources (HR), administrator, and director of nursing (DON).

Based on observation, interview, and document review, the facility failed to ensure physician orders were in place to provide treatment and monitoring for an ostomy (ileostomy) (opening to allow waste to exit the body and be collected in a pouch) for 1 of 1 resident (R5) reviewed for ostomy care. The facilities failure resulted in harm for R5 who continued to exhibit symptoms of redness, severe pain, excoriation (abrasion, breakdown) and infection requiring two courses of antibiotics.Findings include:R5 was admitted to the facility on [DATE]R5's Minimum Data Set (MDS) assessment, dated 09/12/25, identified no cognitive impairment, had limited range of motion of both her upper and lower extremities and R5 required substantial to maximal assistance with personal hygiene. In addition, R5 had an ileostomy to manage her fecal excretion.R5's care plan dated 6/24/2025, had an alteration in elimination; interventions listed included, ileostomy care as ordered. R5's care plan lacked direction or interventions of how to care for the ileostomy .R5's admission orders included call MD (medical doctor) with any excessive bleeding, pus, foul smelling drainage, stoma that is recessing into the belly, bulging skin around the stoma, change in stoma color, chills, nausea/vomiting, increased pain in the belly or around the stoma, no gas or stool in 24 hours every shift for monitoring; Change ostomy flange and bag every 3 days and PRN; Empty ostomy pouch every shift or when 1/3 full. Cleanse area after emptying with warm water and gentle soap. Apply skin prep after cleansing every shift for monitoring; Ostomy cares: as needed bag size and change, skin prep: wafer size and change.R5's above mentioned orders were ended on 8/1/25. R5's orders lacked any additional updates or orders to care for the ostomy.R5's orders dated 9/9/25, was to vent ostomy bag and empty every 4 hours while awake.R5's provider assessment dated [DATE], noted a history of Crohn's disease with a surgical ileostomy. Provider assessment lacked specific appliance change instructions (i.e., bag type, bag size, skin protectants, skin barriers, and bag removal).R5's hospital stays dated 7/24/25 and 8/6/25, included provider assessments, lacked specific appliance change instructions (i.e., bag type, bag size, skin protectants, skin barriers, and bag removal).R5's provider evaluation dated 7/16/25, indicated R5's stoma was reddened, painful, and swollen with what appeared to cellulitis (a common bacterial skin infection of the deeper layers of skin and tissue, most often caused by group A streptococcus or Staphylococcus bacteria entering through a break in the skin). R5 was started on an antibiotic to treat the infection. No new ostomy orders were initiated.R5's provider evaluation dated 9/24/25, indicated R5's stoma was reddened, painful, and swollen with what appeared to be cellulitis. R5 was started on an antibiotic to treat the infection. R5's orders lacked additional ostomy cares. R5's nursing skin assessments indicated:-6/27/25 noted no new skin issues.-7/4/25 noted ileostomy area a little red-7/18/25 noted area around ileostomy is quite reddened-8/11/25 noted ileostomy changed 3 times today due to leaks lower right side of stoma, red in color and resident stated painful-9/1/25 noted area around stoma is reddened-9/10/25 noted area around stoma is quite reddened-9/15/25 noted skin irritation and erosion around stoma-10/7/25 noted redness around ileostomy-10/14/25 noted redness around ileostomy-10/21/25 noted redness around stoma-10/28/25 noted no assessment of ileostomy-11/4/25 noted area around stoma is quite reddened with opening approximately 3 cm (centimeters) circle-11/11/25 noted stoma area is reddened-11/18/25 noted redness around her ileostomyR5's progress note dated 10/15/25, indicated the stoma area was red and bleeding, R5 rated pain 8/10 (8/10 indicates severe pain on the pain rating scale) and required pain medication to get comfortable.During observation and interview on 11/18/25 at 3:19 p.m., R5 stated her ileostomy was leaking and needed to be changed. R5 stated the area around her ostomy is reddened and has a burning sensation almost all the time. R5 stated the condition of her ostomy causes her pain and she gets anxious because she feels the facility isn't doing enough to reduce her pain and discomfort. Registered nurse (RN)-B in the room stated R5 does not have orders for specific ostomy supplies or dressing changes. RN-B stated R5 requires frequent, almost daily dressing changes. RN-B stated staff use whatever supplies are in the room. RN-B stated R5 has not seen a dedicated wound/ostomy nurse; however, this would be beneficial, to know what appliance/supplies work best for the resident. RN-B washed the ostomy site with warm water and dried using a washcloth. She waited approximately two minutes before applying a light sprinkle of Adapt Stoma Powder; then applied the Steawoce Colostomy Bag.During an interview on 11/18/25 at 4:24 p.m., the director of nursing (DON) confirmed R5 does not have orders or an established ostomy care plan indicating specific supplies to use because the facility has been trialing new ostomy supplies since R5's readmission to the facility on 8/6/25. The facility planned to enter those orders once they found a set of supplies that worked. On 8/12/25, the facility received the June hospital recommendations from the hospital wound-ostomy nurse that included:-Coloplast Sensura Fecal #820306-Small convex oval ring #816983-Stomahesive powder #007639-Cavilon No Sting Barrier film #135096The DON stated the 8/12/25 orders were not documented because I think we tried the supplies, but they did not work. The DON confirmed there is no documentation the facility tried the recommended supplies, or the supplies did not work. Currently, the facility is using:-Steawoce Ostomy Bag, Model A42-E Lot 250506-Ostomy Barrier Rings, Atwlux 20 pieces, 2.0mm, X004NL5ROL-Medline Sure Prep Rapid dry spray-Adapt Stoma Powder, [NAME] 7906-Adapt Medical adhesive remover [NAME] 7733R5's weekly skin assessments were reviewed and the DON confirmed R5 had ongoing redness, pain, and swelling leading to two separate courses of antibiotics for cellulitis. The DON stated she was not sure if using ill-fitting appliances would cause the above complications, but it is important to follow ostomy recommendations to ensure a proper fit.During interview and observation on 11/20/25 at 7:48 a.m., registered nurse (RN)-A stated R5 does not have specific orders for ostomy supplies and dressing changes. RN-A stated when he changes the ostomy, he uses the supplies that are in the room. RN-A stated R5 requires frequent appliance changes due to leakage. RN-A washed the ostomy site with warm water and dried using a washcloth. He waited approximately two minutes before applying a light sprinkle of Adapt Stoma Powder; then applied the Steawoce Colostomy Bag.During interview 11/19/25 at 8:53 a.m., wound-ostomy care registered nurse (RN)-C stated R5 was seen while R5 was in the hospital 8/2025. Recommendations at the time were:-[NAME] 8531 one piece with putty ring-Stoma powderRN-C stated recommendations are based on assessment of the stoma, contour of the area around the stoma, and a skin assessment. It is important the recommended supplies are used to prevent skin breakdown. RN-C stated it is abnormal for ostomy supplies to require changing more than 3 times per week. Frequent changes, burning, pain, infections could be complications from ill-fitting ostomy supplies. During a follow up interview on 11/19/25 at 10:19 a.m., the DON stated the facility did not order the recommended ostomy supplies from the August hospitalization because they didn't think they would work. The facility continued to trial other supplies. The DON confirmed it was possible using the incorrect supplies could lead to complications R5 experienced. During interview on 11/19/25 at 10:26 a.m., the facility medical director (MD) stated he was familiar with R5's ileostomy due to a history of Crohn's disease. MD stated he was aware R5 had been treated twice for cellulitis and was the treating provider for the 9/2025 infection. MD stated he would expect to be notified if R5 was continuing to have complications related to her ostomy. MD confirmed R5 did not have orders for ostomy appliance changes (size and type of appliance and treatment procedure). He stated it is the provider's responsibility to ensure treatment orders are written post-hospitalization and those orders should have been entered upon R5's return from the hospital August 2025. A facility policy titled Colostomy and Ileostomy Care dated 1/28/25, the purpose of ileostomy care is to prevent infection and skin irritation.

Based on observation and interview the facility failed to ensure infection control practices were maintained by wearing a hair net and beard cover while in the kitchen. Additionally, the facility failed to ensure a commercial dishwasher was adequately monitored (i.e., every shift). Last, the facility failed to ensure food stored in the refrigerators and freezers were labeled, dated and discarded properly. These deficient practices had the potential to affect all 29 residents, staff and visitors who received food from facility kitchen. During the initial kitchen tour on 11/17/25 at 10:58 a.m., dietary (D)-C greeted surveyor inside the kitchen; after introductions D-C exited the kitchen with surveyor and applied a hairnet, returning to stove side to finish cooking lunch vegetables. D-C stated he should have put his hairnet on before coming into the kitchen. D-C did not have a beard cover while at stove side. Dietary (D)-B assisted surveyor with kitchen tour since dietary manager was not at the facility. The kitchen had one commercial dishwasher, staff indicated this was new and had only been in the building for a few weeks. The commercial dishwasher lacked a temperature tracking sheet, with D-C and D-B stating they had not monitored dishwasher temperatures since the dishwasher was installed. The following items were observed in the fridge and freezer expired, undated food, and uncovered food:-Frozen omelets in opened undated bag with crystalizing ice on food product-Uncovered, prepped ice cream-Pudding dated 10/31-Cranberry Sauce dated 11/4-Undated, thawing chicken-Undated Mayonnaise-Undated Bag of lettuce (turning brown)-Undated Ham-Undated SausageDuring second kitchen walk through on 11/17/25 at 11:31 a.m., dietary manager (D)-A confirmed it is an expectation that everyone entering the kitchen applies a hairnet and beard cover if applicable. D-A confirmed the commercial dishwasher was new; was an expectation the temperature monitoring be completed every shift. Additionally, conferred with staff, no one had monitored new commercial dishwasher because none of them had been trained to perform temperature monitoring. During interview on 11/17/25 at 11:51 a.m., administrator stated all staff entering the kitchen should have a hairnet and beard cover. The administrator also confirmed the dishwasher was new and had been installed a couple weeks prior. The administrator confirmed staff should be following facility equipment monitoring procedures. The administrator stated the dietary staff are expected to follow the facility food safety policy to accurately date and dispose of food items. A facility policy titled Food Safety Requirements Policy and Procedure dated 11/26/17, facility staff will follow proper food handling practices to include hair and beard coverings, proper labeling and dating of food items, food covering, and equipment monitoring.

Based on interview and document review the facility failed to ensure all staff working in the dietary department had training on use of equipment, safe temperatures to ensure food safety and sanitation processes. This had the potential to affect all 29 residents in the facility. Findings include:During the initial kitchen tour on 11/17/25 at 10:58 a.m., dietary aide (D)-C met surveyor inside main kitchen entrance; exited the kitchen, putting on hair net and returning to the kitchen. Returned to stove side, D-C lacked a beard cover. Dietary aide (D)-B offered to escort surveyor since the dietary manager was not in the building yet. At the conclusion of the initial tour, D-B could not state the normal temperature ranges for the facility refrigerators and freezers. Further, D-B could not state how to complete temperature checks for the new dishwasher. Additionally, D-B stated it was acceptable to serve uncovered food from the freezer to residents, food in the refrigerators doesn't need a labeled expiration date because they use it so fast, and it was acceptable to have staff beverages in the main kitchen refrigerators. During the follow up kitchen tour on 11/17/25 at 11:31 a.m. with dietary manager (DM), stated she was unsure what education the dietary aides and cooks were required to complete. DM stated she had been hired at the facility for two weeks and had not verified the educational backgrounds of the current staff. DM confirmed her credentials were certified food protection manager (CFPM) and food service manager (FSM). DM stated dietary staff should have education about proper food handling, requirements for covered containers, proper labeling, normal temperatures for refrigerators and freezers, and should know how to check the temperature of the dishwasher. During an interview on 11/17/25 at 11:42 a.m., D-C stated the dishwasher was purchased a couple weeks prior and staff had not been shown how to verify temperatures yet. D-C stated the facility also doesn't have the temperature strips but is sure they will get them once they teach us how to temp the dishwasher. During an interview on 11/17/25 at 11:51 a.m., administrator stated dietary staff complete food safety education at hire, annually, and when updates are needed. The administrator stated this education would include food safety, infection control, appropriate temperatures, food storage, and how to use and measure temperature on the new dishwasher. Requested dietary staff education and competencies but did not receive. Facility policy titled Food Safety Requirements Policy and Procedure dated 11/26/2017, dietary staff will be educated on safe food handling including, proper food handling to prevent foodborne illness, requirements for covered containers or secure wrapping, proper labeling and dating of items, storage temperatures for refrigerators and freezers, dietary equipment use.

Based on observation, interview and document review, the facility failed to ensure direct-care nursing staff were appropriately trained and competent in the assessment and care of ostomies for 1 of 1 (R5) resident reviewed for ostomy care.Findings include:R5 was admitted to the facility on [DATE] R5's Minimum Data Set (MDS) assessment, dated 09/12/25, identified no cognitive impairment, had limited range of motion of both her upper and lower extremities and R5 required substantial to maximal assistance with personal hygiene. In addition, R5 had an ileostomy to manage her fecal excretion. R5's care plan dated 6/24/2025, had an alteration in elimination; interventions listed included, ileostomy care as ordered. R5's care plan lacked direction or interventions of how to care for the ileostomy. During an interview on 11/18/25 at 3:19 p.m., registered nurse (RN)-B stated R5 does not have orders for specific ostomy supplies or dressing changes. RN-B stated the R5 requires frequent, almost daily dressing changes. RN-B stated staff use whatever supplies are in the room. RN-B stated she might have completed some sort of ostomy training when she started. RN-B stated she isn't sure if ostomy care was an annual competency. During an interview on 11/19/25 at 10:19 a.m., RN-A stated R5 does not have orders for specific ostomy supplies or dressing changes. RN-A stated staff use whatever supplies R5 has in her room. RN-A stated, I think there was education, I don't remember any specific training. Further, I'm sure we've had some education, I don't know when exactly. During interview on 11/19/25 at 10:25 a.m., licensed practical nurse (LPN)-B stated, I don't know if there is any specific Relias (online training company) training for ostomy care. LPN-B is unsure if she had completed any recent training on ostomy care. During interview on 11/19/25 at 10:19 a.m., director of nursing (DON) stated the facility does not have specific ostomy training. DON confirmed staff have not had specific training about how to assess and care for R5's ostomy. The Facility assessment dated [DATE], the facility could provide specialized treatment and care for ostomies. However, the facility assessment does not include ostomy care in the standard list of in-services and required competencies for nursing staff. Nurse staff competency transcripts (training and education) were request but not received.

Based on interview and document review, the facility failed to ensure a resident had physician orders for the care and treatment for 1 of 1 (R5) resident reviewed for ostomy care.Findings include:R5's Minimum Data Set (MDS) assessment, dated 09/12/25, identified no cognitive impairment, had limited range of motion of both her upper and lower extremities and R5 required substantial to maximal assistance with personal hygiene. In addition, R5 had an ileostomy to manage her fecal excretion. R5's care plan dated 6/24/2025, had an alteration in elimination; interventions listed included, ileostomy care as ordered. R5's care plan lacked direction or interventions of how to care for the ileostomy.R5 was initially admitted on [DATE]. R5's admission orders included call MD (medical doctor) with any excessive bleeding, pus, foul smelling drainage, stoma that is recessing into the belly, bulging skin around the stoma, change in stoma color, chills, nausea/vomiting, increased pain in the belly or around the stoma, no gas or stool in 24 hours every shift for monitoring; Change ostomy flange and bag every 3 days and PRN; Empty ostomy pouch every shift or when 1/3 full. Cleanse area after emptying with warm water and gentle soap. Apply skin prep after cleansing every shift for monitoring; Ostomy cares: as needed bag size and change, skin prep: wafer size and change.R5's above mentioned orders were ended on 8/1/25. R5's orders lacked any additional updates or orders to care for the ostomy. During an interview on 11/18/25 at 3:19 p.m., registered nurse (RN)-B stated R5 does not have orders for specific ostomy supplies or dressing changes. RN-B stated R5 requires frequent, almost daily dressing changes. RN-B stated staff use whatever supplies are in the room. During an interview on 11/18/25 at 4:24 p.m., the director of nursing (DON) confirmed R5 did not have active orders or an established ostomy care plan. The facility planned to enter those orders once they found ostomy supplies that worked. During interview on 11/19/25 at 10:26 a.m., the facility medical director (MD) stated he was familiar with R5's ileostomy due to a history of Crohn's disease. MD also confirmed R5 did not have orders for ostomy appliance changes (size and type of appliance and treatment procedure). He stated it is the provider's responsibility to ensure treatment orders are written post-hospitalization and those orders should have been entered upon R5's return from the hospital August 2025. A facility policy titled Physician Services and dated 2/26/22, the resident's physician is responsible for prescribing new treatments and cares to ensure that the resident receives quality care and medical treatments.

Based on observation, interview, and document review the facility failed to provide professional standards of practice when staff completed treatments and later entered orders in the medical administration record without verification from a physician for 1 of 1 resident (R5) reviewed for ostomy cares.Finding include:R5's Minimum Data Set (MDS) assessment, dated 09/12/25, identified no cognitive impairment, had limited range of motion of both her upper and lower extremities and R5 required substantial to maximal assistance with personal hygiene. In addition, R5 had an ileostomy to manage her fecal excretion. R5's care plan dated 6/24/2025, had an alteration in elimination; interventions listed included, ileostomy care as ordered. R5's care plan lacked direction or interventions of how to care for the ileostomy . R5's treatment administration record (TAR) and medication administration record (MAR) lacked ostomy change orders, ostomy site assessments, ostomy supplies, dates and times of appliance changes, and staff completing ostomy appliance changes. During an interview and observation on 11/18/25 at 3:19 p.m., registered nurse (RN)-B stated R5 does not have orders for specific ostomy supplies or dressing changes. RN-B stated R5 requires frequent, almost daily dressing changes. RN-B stated staff use whatever supplies are in the room. When asked how RN-B charts the ostomy change, RN-B replied since there isn't an order, sometimes staff will do a progress note. When asked how she knows what to use without an order; RN-B stated since there isn't an order, they use whatever supplies are in the room. According to the American Nurses Association (ANA) an RN's scope of practice is to implement orders, not to create them. The authority to create orders rests with authorized prescribers like physicians and nurse practitioners. Further, RN's need a provider's order to provide medical treatment, such as ostomy site care. During an interview and observation on 11/18/25 at 4:24 p.m., director of nursing (DON) confirmed R5 had one order to care for her ostomy. DON confirmed this order was not sufficient to care for her ostomy. Without conferring with an authorized prescriber, the DON created and entered ostomy care and treatment orders. During a follow up interview on 11/19/25 at 10:19 a.m., DON confirmed she had created and entered ostomy care orders the previous evening. When asked how she knew what to order, DON stated she just entered generic ostomy-care orders. DON confirmed she did not get resident-specific orders from a provider until she saw the provider earlier that morning. During an interview on 11/19/25 at 10:26 a.m., medical director (MD) confirms a provider writes orders for resident care; to include ostomy care orders. MD confirms R5 did not have orders for ostomy care. MD stated he knew staff at the facility had been changing the ostomy dressing frequently due to leakage. MD stated this probably couldn't be confirmed due to the lack of orders; thus, lacking a place to chart the ostomy dressing changes. A document titled Registered Nurse Job Description dated 8/2/23, registered nurses will safeguard the health, safety, and welfare of all guests under their care by following applicable laws, regulations, and established nursing policies and procedures.

Based on observation, interview, and document review, the facility failed to ensure respiratory equipment was properly maintained for 2 of 2 residents (R27 and R2) reviewed for respiratory care. Findings include: R27 R27's admission minimum data set (MDS) assessment dated [DATE] indicated R27 was cognitively intact with no behaviors, independent with ADL's and uses oxygen. R27's care plan included a respiratory care plan indicating saddle embolus and OSA [obstructive sleep apnea] with interventions that included oxygen per MD (medical doctor) order R27's provider orders included: oxygen 2 liters per nasal cannula at rest, 4 liters with activity. CPAP [a machine used to treat sleep apnea] pressure setting as settings stored. Change distilled water daily During observation on 11/17/25 at 12:23 p.m., an oxygen concentrator was observed in R27's room next to the bed. The plastic housing where the oxygen tubing connects to the machine was broken with sharp edges. A nasal cannula was attached to one end of a metal connector. The connector was hanging outside the machine approximately 8 centimeters. The other end of the connector was attached to a green tubing that was coming from inside the machine. During observation on 11/18/25 at 8:32 a.m., R27's oxygen concentrator remained broken with the connector hanging out of the machine and the green internal tubing visible. During observation on 11/18/25 at 1:42 p.m., oxygen tubing was rolled up on top of the concentrator. The metal connector continued to hang out of the machine with the internal green tubing visible. Plastic housing remains broken. During interview on 11/18/25 at 3:35 p.m., the customer service representative (CSR) for the oxygen supply company stated oxygen concentrators are serviced every 6 months and as needed. The CSR stated oxygen concentrators are assigned to specific residents and there was no documentation the facility requested a new concentrator for R27. The CSR stated the expectation is for the facility to report any issue with the concentrators and if there are broken parts, the machines should be replaced. During observation and interview on 11/18/25 at 4:02 p.m., R27 was sitting on the edge of the bed wearing oxygen tubing attached to the concentrator. R27's family member (FM)-A stated the concentrator has been broken since R27 admitted on [DATE]. During observation on 11/18/25 at 4:15 p.m., the oxygen supply room contained several cylinders of oxygen and two oxygen concentrators. One of the concentrators had a sign stating not working taped to it. During interview on 4/18/25 at 4:23 p.m., registered nurse (RN)-D stated R27's concentrator has been that way for a while however was not working the day the plastic housing broke. During observation on 11/19/25 at 1:00 p.m., the oxygen concentrator remained broken. During observation on 11/20/25 at 8:30 a.m., the concentrator remained broken. R2 R2's annual MDS assessment dated [DATE] indicated R2 had mild cognitive impairment with no behaviors, no upper or lower body impairment, independent with all activities of daily living, independent with transfers and ambulating short distances, supervision for ambulating for long distances. It also indicated R2 uses oxygen therapy. R2's provider orders included the following:-change oxygen tubing and humidifier bottles weekly. Date tubing every night shift every Sunday.-check oxygen saturation weekly on room air every night shift every Sunday for monitoring.-respiratory assessment every Wednesday day shift and Saturday evening shift-oxygen at 2 lpm (liters per minute) via nasal cannula to keep saturations at or above 90% for respiratory distress. Check SPO2 (measurement of oxygen saturation in blood) every shift for oxygen and as needed R2's care plan included congestive heart failure and asthma. Interventions included administer oxygen as ordered, elevate head of bed to ease shortness of breath, evaluate lung sounds and vital signs as needed, obtain oxygen saturation. During observation and interview on 11/19/25 at 12:59 p.m., R2 was observed lying in bed wearing nasal cannula. An oxygen concentrator was observed on the floor near R2's bed running at 2 lpm. R2's oxygen tubing was connected to a bottle containing clear fluid. The bottle was connected to the concentrator via tubing. The plastic casing of the concentrator was broken at the area the bottle was attached. A bright pink object was observed protruding from the concentrator and was holding the bottle in place. Upon closer inspection, the bright pink object had a rough texture and a similar object white in color was below the pink object, also protruding from inside the concentrator. R2 was asked if she knew what the bright pink object was and stated the objects were emery (nail filing) boards. R2 stated she placed them in the opening of the machine to keep the water bottle in place. When asked if the facility staff were aware the files were in there, R2 stated they must know because they change the tubing and do the water. R2 could not recall how long the files have been in there and reiterated the nurses come in and fill the humidifier bottle. During the observation and interview, licensed practical nurse (LPN)-A entered the room delivering R2's lunch. LPN-A was asked about R2's concentrator. LPN-A indicated they were not aware the concentrator casing was broken and did not know what the bright pink object protruding out of the machine was. LPN-A left the room. The emery boards remained in place. During observation and interview on 11/19/25 at 1:07 p.m., registered nurse (RN)-A stated R2 preferred to stay in her room. RN-A stated the humidifier bottle on R2's oxygen concentrator is filled every night or when it gets close to being empty. RN-A was brought to R2's room and observed R2's oxygen concentrator. RN-A stated, all that is broken is plastic, so it is functioning. RN-A stated the oxygen supply company was made aware of the broken concentrator however was unsure when. RN-A visualized the emery boards and stated R2 used them as a [NAME] to keep the water bottle in place. RN-A then left the room. The emery boards remained in place. During observation on 11/20/25 at 8:32 a.m., R2 was lying in bed awake speaking to a staff member. R2's oxygen concentrator continued to have the broken casing and emery boards holding the humidifier bottle in place. During observation and interview on 11/20/25 at 8:50 a.m., the director of nursing (DON) was brought to R2's room. The DON visualized the broken oxygen concentrator and asked R2 what the two objects were. R2 informed the DON she placed the emery boards in the machine to keep the oxygen bottle in place. The DON informed R2 a new concentrator would be obtained. The DON was taken to R27's room and observed the plastic housing on the concentrator broken. The DON stated she was not aware R27's concentrator was also broken. The DON stated if equipment is broken, she would expect staff to obtain a replacement concentrator and lock-out the broken concentrator so others cannot use it. She would expect to be informed if there is an issue with the oxygen concentrators. A contract dated 11/1/24 between the oxygen supply company (company) and the facility titled Medical Oxygen, DME [durable medical equipment] products and Services Agreement indicated, Equipment Maintenance and Use. [Company name] assumes full responsibility for proper maintenance and repair of all oxygen equipment rented to facility and [facility name] assumes responsibility for appropriate use and care of equipment while rented to [facility name]. A policy titled Oxygen Administration and storage revised 6/15/25 did not provide direction in the event of broken equipment.

Based on interview and record review, the facility failed to ensure appropriate information was communicated to the receiving facility, and obtain provider orders prior to discharge for 1 of 1 residents (R37) reviewed for discharge. Finding includeR37's discharge minimum data set (MDS) assessment dated [DATE], indicated R37 was admitted [DATE] after a short-term hospital stay with plans to return home/community. No long- or short-term memory issues and no behaviors. R37 was independent with eating, set up for oral hygiene, partial assist for bathing and upper body dressing, substantial assist with toilet and personal hygiene, and lower body dressing. R37 was dependent on staff for applying and removing footwear and required partial assist with bed mobility and transfers. R37 was diabetic and received insulin. R37's diagnoses list included respiratory failure, diabetes, obstructive pulmonary disease, depression, sleep apnea, heart failure, kidney disease, long term use of insulin, dependence on oxygen. R37's medication administration (MAR) record at the time of discharge included the following types of medications cholesterol medications, antidepressants, multiple vitamin supplements, thyroid, blood thinners, pain medications, diuretics, stool softeners, respiratory inhalants, and antihistamines. In addition, R37 was receiving insulin on a scheduled basis including sliding scale insulin (insulin dosing based on blood sugar value). R37 also had wound care orders, oxygen orders, and used a CPAP (continuous positive air pressure machine-used to treat sleep apnea).Care conference notes dated 8/7/25 indicated R37, R37's family, director of nursing (DON), assistant director of nursing, therapy staff and social worker were in attendance. The notes indicated R37 planned to discharge back to previous assisted living apartment. The notes indicated R37 would like scripts for a hospital bed and bariatric shower chair. The notes also indicated a voicemail was left with the director of nursing at the assisted living to determine what R37 will need to return. Progress notes dated 8/13/25 indicated R37 was packing up belongings stating she was planning to leave Friday (8/15/25).Progress notes dated 8/20/25 indicated R37 discharged from the facility at 4:25 p.m. with 2 grandchildren. Scheduled insulin and a pain medication were administered. Insulin pen was given to a family member for R37. The notes indicated R37 stated she signed her papers etc. this morning. During interview on 11/19/25 at 2:24 p.m., the receiving assisted living director (ALD)-A stated she performed an in-person admission assessment with R37 a day or two prior to R37 admitted to their facility. After the assessment, ALD-A and R37 went to the facility social worker's office to discuss what was needed prior to discharge. When R37 re-admitted to the assisted living facility, R37 arrived with no provider orders for medications or treatments. ALD-A stated she had to scramble to get orders from R37's primary provider, which was difficult because the primary provider had not seen R37. ALD-A stated the facility also did not send R37's medications with her. When asked what specific orders were required, ALD-A stated they needed discharge orders for medications, therapy orders, orders for cpap, wheelchair, and an order for a hospital bed. R5's progress notes provided by the assisted living facility indicated as follows:-8/11/25 at 2:07 p.m. ALD-A spoke with facility social worker regarding R37's possible return. Social worker to contact receiving facility in coming days regarding expected discharge date to schedule a re-evaluation.-8/19/25 at 12:45 p.m. ALD-A noted R37 was expected to return during the week pending provider discharge orders and hospital bed.-8/20/25 at 8:27 p.m. ALD-A noted, R37 returned from rehabs stay. R37 returned to facility without medications, paperwork, and requested tasks completed. Requests included: discontinue sliding scale insulin, hospital bed, and doctor's orders.-8/21/25 12:42 p.m., phone call placed to [clinic name] provider line to obtain orders for resident due to prior facility neglectfully completing tasks.During an interview on 11/20/25 at 10:06 a.m., facility social worker (SW)-A stated if a resident is planning to discharge to an assisted living facility, the facility will determine level of independence required, need for re-evaluation, type of paperwork required, any therapies needed post discharge. The nursing department sets up a discharge visit with the provider. SW-A stated she opens the recapitulation of stay documentation screen for individual departments to provider their documentation. The nursing department gathers discharge paperwork faxed or emailed over to the receiving facility. SW-A stated ALD-A did an in-person re-evaluation on 8/19/25 and determined R37 was appropriate for readmission. SW-A also stated R37 had a discharge provider visit on 8/19/25. SW-A stated the discharge information was faxed to the assisted living facility and R37 discharged on 8/20/25. During interview on 11/20/25 on 10:30 a.m., the director of nursing (DON) stated R37 was eager to discharge back to her previous assisted living facility. The director of nursing stated R37 wanted a hospital bed however there was an issue with insurance coverage and gave options for R37's daughter to obtain a hospital bed. The DON confirmed R37 mentioned on admission a prescription for a hospital bed was required however, R37 did not mention needing a prescription for a hospital bed when she discharged . The DON stated there was not an established discharge date set. The assisted living director of nursing did a re-evaluation assessment a day or two prior to R37's discharge and the facility nurse practitioner did see R37 on 8/19/25. Email communication between the facility and the assisted living facility indicated as follows: -8/19/25 at 11:36 a.m., SS-A to DON indicated ALD-A had authorized R37's return to the assisted living and requested a script for a bariatric hospital bed. -8/20/25 at 10:56 a.m., SS-A to ALD-A indicated This is all I have for now. Once we get the rest of the paperwork, I will get it over to you. Attached to the email was a history and physical from the nurse practitioner visit on 8/19/25 and provider order adjusting R37's insulin dosages, including sliding scale insulin. The attached history and physical dated 8/19/25 indicated R37 was seen for wound and diabetes follow-up. It also indicated [R37] notes that she will be discharging home with husband in a day or 2. Still waiting to hear back from the facility's staff to either confirm or deny her claim -8/20/25 at 5:31 p.m. ALD-A to SS-A and DON indicated R37 returned to the facility but did not have things that were discussed including paperwork/provider orders for any medications, wound care orders, order for hospital bed, and discontinuation of sliding scale insulin as the assisted living is unable to accommodate. -8/20/25 at 7:22 p.m., from DON to ALD-A indicated the facility social worker sent all this out and I won't be back in the office until tomorrow. -8/21/25 at 7:28 a.m., from SS-A to DON and ALD-A indicated I had sent over what we had at the time, The rest of the paperwork did not get completed by medical provider until after 4 p.m., I was gone for the day by then. I have attached the paperwork that came in after 4:00 p.m. If there is anything else needed, a medical provider will need to be contacted for follow up. Both [DON] and I did ask [provider] many times yesterday to get us the paperwork before 4:00 p.m. Attached to the email was a history and physical dated 8/19/25 that indicated R37 was seen today for a skilled nursing facility discharge visit. Section #23 titled Disposition indicated Patient is discharging to her assisted living facility with husband and family support. DME (durable medical equipment) ordered- N/A During follow-up interview on 11/20/25 at 1:39 pm., the DON stated her only communication with ALD-A was the email response after business hours on 8/20/25. She did not ever speak to ALD-A. The DON stated discharge orders for R37 were faxed to the assisted living however the facility is unable to provide proof of the fax transmission and confirmed R37's medical record does not contain signed provider orders. The DON confirmed a DME order for the hospital bed was not written. A policy titled Discharging a Resident revised 11/11/20 indicated The resident's attending physician is required to write a discharge order to include medication disposition. It continues, The discharge summary contains necessary medical information that the facility must furnish at the time the resident leaves the facility, to the receiving provider assuming responsibility for the resident's care after discharge. Further, the policy indicated the summary will include but is not limited to, the following:A. a recapitulation of the resident's stay that includes. bu8t is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.B. A final summary of the resident's status to include items: .medications, special treatments and procedures.C. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter)

Based on observation, interview and document review, the facility failed to comprehensively assess and initiate a plan of care for 1 of 1 (R5) resident who was reviewed for ostomy care.Findings include:R5's Minimum Data Set (MDS) assessment, dated 09/12/25, identified R5 had no cognitive impairment, and R5 had an ileostomy to manage her fecal excretion. R5's care plan dated 6/24/2025, identified R5 had an ileostomy and alteration in elimination; interventions listed included, ileostomy care as ordered. R5's care plan lacked direction or interventions of how to care for the ileostomy . During observation and interview on 11/18/25 at 3:19 p.m., R5 stated her ileostomy is leaking and needed to be changed. R5 stated the area around her ostomy is also reddened and has a burning sensation almost all the time. R5 stated the condition of her ostomy causes her pain and she gets anxious because she feels the facility isn't doing enough to reduce her pain and discomfort. Registered nurse (RN)-B stated the resident has had her ostomy appliance changed 3 times in the last 12 hours. RN-B began to change the ostomy appliance, stated she just used whatever supplies were in the resident's room. RN-B confirmed the resident did not have active orders specifically for ostomy supplies and did not have a care plan detailing how to care for her ostomy. During interview on 11/18/25 at 4:24 p.m., director of nursing (DON) stated R5 does not have current orders for specific ostomy supplies; further stating the resident does not have an active care plan specifically for her ostomy care. DON stated nursing staff was actively trialing new ostomy supplies and they would enter orders and initiate a complete care plan once they found supplies that worked. DON confirmed it is essential staff use the correct supplies; this would prevent irritation and breakdown of the ostomy. DON confirmed staff would normally look at the care plan to know what supplies were being used for each resident. DON confirmed she should have done an ostomy-specific care plan to ensure staff used the correct supplies. Further, the care plan should have outlined what is normal or abnormal for R5's ostomy. During interview on 11/19/25 at 10:26 a.m., medical director (MD)-A confirmed he was familiar with R5 and her diagnosis of needing an ileostomy due to Crohn's disease. MD-A confirmed he would expect nursing to notify him if the ileostomy had complications (i.e., redness, pain, swelling). MD-A confirmed R5 did not have current orders for ostomy appliance changes (i.e., bag type, bag size, skin protectants, skin barriers, and bag removal) and R5 did not have a care plan for her ostomy. A facility policy titled Colostomy and Ileostomy Care dated 1/28/25, the purpose of ileostomy care is to prevent infection and skin irritation.

Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 1 of 5 residents (R5) reviewed for unnecessary medications.Findings include:R5's Minimum Data Set (MDS) assessment, dated 09/12/25, identified R5 no cognitive impairment, had limited range of motion of both her upper and lower extremities and diagnosis included: metabolic encephalopathy (diffuse brain dysfunction), lewy body dementia (protein deposits in the brain leading to cognitive decline), parkinsonism (movement disorder), psychotic disturbances, major depressive disorder and moderate anxiety. R5's medication orders included:Cyanocobalamin 1000mg Oral Daily: Start date 8/4/25Diclofenac Sodium External Gel 1% Topical, apply to right chest arms four times per day: Start Date 8/4/25 Pharmacy recommendations included:8/30/25Cyanocobalamin 1000mg Oral Daily - CHANGE TO Cyanocobalamin 1000mcg Oral DailyDiclofenac Sodium External Gel 1% Topical, apply to right chest arms four times per day - CHANGE TO Diclofenac Sodium External Gel 1% Topical, apply 2g to right chest arms four times per dayClobetasol Propionate External Solution0.05 %, apply to scalp topically one time a day every Wed, Fri, Sun for dry scalp, apply to scalp - Issue: was not reordered upon re-admission from hospital 8/4/25, please verify need and re-order9/22/25Cyanocobalamin 1000mg Oral Daily - CHANGE TO Cyanocobalamin 1000mcg Oral DailyDiclofenac Sodium External Gel 1% Topical, apply to right chest arms four times per day - CHANGE TO Diclofenac Sodium External Gel 1% Topical, apply 2g to right chest arms four times per dayClobetasol Propionate External Solution0.05 %, apply to scalp topically one time a day every Wed, Fri, Sun for dry scalp, apply to scalp - Issue: was not reordered upon re-admission from hospital 8/4/25, please verify need and re-order10/26/25Cyanocobalamin 1000mg Oral Daily - CHANGE TO Cyanocobalamin 1000mcg Oral DailyDiclofenac Sodium External Gel 1% Topical, apply to right chest arms four times per day - CHANGE TO Diclofenac Sodium External Gel 1% Topical, apply 2g to right chest arms four times per dayClobetasol Propionate External Solution0.05 %, apply to scalp topically one time a day every Wed, Fri, Sun for dry scalp, apply to scalp - Issue: was not reordered upon re-admission from hospital 8/4/25, please verify need and re-order R5's medication administration record showed:Cyanocobalamin 1000mg Oral Daily was administered daily 9/1/25 thru 11/19/25Diclofenac Sodium External Gel 1% Topical was administered 4 times per day 9/1/25 thru 11/20/25 Clobetasol Propionate External Solution0.05 %, remains unordered R5's medical record lacked evidence to support the pharmacy consultant (Pharm D) recommendations were addressed and corrected in a timely manner. A call to the pharmacy consultant on 11/20/2025 at 3:13 p.m., was not returned. During an interview on 11/20/2025 at 11:32 a.m., the director of nursing (DON) stated they do have a process to review pharmacy recommendations and confirmed sometimes takes a while for the providers to respond. DON stated she corrected R5's cyanocobalamin order this morning. DON stated ideally the recommendations should be addressed immediately but sometimes it takes a while for the providers to make the necessary changes. The DON stated the process breaks down getting the form back from the providers after she received the recommendations from the pharmacy. The DON reviewed R5's pharmacy reviews, noted the recommendations lacked documentation in the follow up section of the form. DON stated she knows the pharmacy recommendation process needs updating so recommendations aren't missed. Attempted to speak with medical director on 11/20/25 at 11:51 a.m., he was unavailable at this time. A policy titled Medication Regimen Review dated 7/24/24, providers will review the medication recommendations from the pharmacist, follow up as applicable, and return recommendation form to the DON or designee.

Based on observation, interview, and document review, the facility failed to ensure the nurse staffing data sheet was posted in a place readily accessible to residents, families, and visitors. This had the potential to affect all 29 residents in the facility. Findings include: During observation on 11/17/25 at 11:28 p.m., no staff posting was observed in the facility. During observation on 11/18/25 at 12:28 p.m., no staff posting was observed in the facility. During interview on 11/19/25 at 1:48 p.m., the administrator stated the staff posting was usually posted on the wall near the kitchen, however had been replaced by directional signage for visitors. The facility did not find a different location for the staff posting. A policy titled Staff Posting revised 10/19/23 indicated the facility shall post daily, for each shift, the actual hours and total number of hours worked by licensed and unlicensed nursing staff who are directly responsible for resident care on each shift in the facility. At the beginning of each shift, the facility will verify that the hours are posted in a clear and readable format: the name of the facility, current date, facility census for nursing home residents, facility specific shifts for the 24-hour period, total number of licensed nursing staff worked per shift, total number of unlicensed nursing staff worked per shift, actual time worked for the specific categories of nursing staff, including split shifts.

Based on interview and record review the facility failed to identify, assess, monitor, and follow physicians' orders for signs and symptoms of hypoglycemia (low blood sugar) for 1 of 3 residents (R1) who had diagnosis of diabetes. This resulted in an immediate jeopardy (IJ) situation for R1 who had continuous low blood sugars without treatment that resulted in hospitalization with hypoglycemia. The IJ began on 8/29/25 at 4:00 p.m., when interventions were not implemented to prevent hypoglycemia. The facility did not notify the provider and R1's blood sugars continued to drop until he was sent to the ED on 8/30/25 at 1:20 a.m. The administrator, director of nursing (DON), assistant director of nursing ADON), regional nurse consultant (RNC), activity director (D), health unit coordinator (HUC), and licensed social worker (LSW) were notified of the IJ on 9/4/25 at 5:14 p.m. The immediacy was removed on 9/5/25, but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:According to the American Diabetes Association (ADA) the recommendations for target blood sugar levels are: Before a meal (pre-prandial): Typically, between 80 and 130 mg (milligrams/deciliter); Two hours after starting a meal (postprandial): Less than 180 mg/dL According to the ADA, hypoglycemia is defined as a blood glucose level below 70 mg/dL (3.9 mmol/L). Hypoglycemia is further categorized into three levels: Level 1 is below 70 mg/dL but above or equal to 54 mg/dL (3.9-3.0 mmol/L), Level 2 is below 54 mg/dL (<3.0 mmol/L), and Level 3 is a severe event requiring assistance, regardless of the glucose level. R1's admission minimum data set (MDS) dated [DATE], identified R1 was admitted on [DATE] and discharged to a hospital on 8/30/25. Further identified R1's cognition was intact and had diagnoses of diabetes mellitus, rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood that can cause damage to the kidneys).R1's order summary dated 8/27/25, included the following orders for diabetic management:-Metformin (oral medication given to reduce blood sugar levels) 1000 milligrams (mg) twice daily for diabetes (start date 8/27/25).-Glimepiride (medication used to increase insulin secretion resulting in lowered blood sugar levels) 2 mg twice daily for diabetes (start date 8/27/25). -Accu-Chek (blood glucose monitoring system) every morning and evening and PRN (as needed) -(start date 8/27/25).-If Blood Sugar (BS) <70 and resident is symptomatic and not alert, give 1 mg Glucagon (an injectable medication used to counter the effects of insulin to raise blood glucose levels) intramuscular/subcutaneous (IM/SQ). Recheck blood glucose in 15 minutes. Repeat if resident is not alert and symptomatic. If resident is now alert, BS <70 and symptomatic, give orange juice or tube of Glucose gel (medication used hypoglycemia to raise blood glucose when it becomes dangerously low). Recheck blood sugar in 15 min. If BS >70 and not symptomatic, do not treat. If BS <70 and resident is alert, symptomatic or asymptomatic, give orange juice or tube of Glucose Gel followed by a complex carbohydrate. Recheck blood sugar in 15 minutes as needed for monitoring (Start date 8/28/25)-8/28/25 Glucagon Emergency Kit 1mg, inject 1 dose IM as needed for blood sugar <60, use if resident is unresponsive. Notify MD (Start date 8/28/25) . -8/28/25 Glucose Gel 40 %, give 1 dose by mouth as needed for hypoglycemia- blood glucose of <70, symptomatic and alert, notify MD recheck blood sugar in 15 minutes (Start date 8/28/25).R1's care plan identified a focus, the resident has Diabetes Mellitus, dated 8/28/25, with interventions dated 8/28/25 to Monitor/document/report as needed any sign/symptoms of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait and Fasting Serum Blood Sugar as ordered by doctor. R1's Blood glucose vital summary document identified blood sugar at 7:59 a.m. on 8/29/25 was 81. R1's plan of care response form identified on 8/29/25, R1 ate 75%-100% for breakfast. R1's medication administration record (MAR) for 8/29/25, identified Metformin1000 mg and Glimepiride 2 mg was signed as given on 8/29/25 at 8:00 a.m. when R1's blood sugar was 81.According to FDA Glimepiride starts working within about an hour, peak concentration is 2 to 3 hours after dose taken and the glucose-lowering effect is maintained for 24 hours after a single dose.R1's plan of care response form identified on 8/29/25, R1 ate 75%-100% for lunch. R1's record did not identify a blood sugar recording between 7:59 a.m. and 4:49 p.m. R1's blood glucose vital summary document identified blood sugar documented at 4:50 p.m. R1's blood sugar was 54 and R1's plan of care response form identified on 8/29/25, R1 ate 50% of his meal. In review of R1's record on 8/29/25 identified there was no indication R1 was assessed for signs/symptoms of hypoglycemia nor physician orders followed that directed intervention if the blood sugars were less than 70 that included administration of medications and/or give carbohydrates to raise the blood sugar and notify the physician. Further no indication R1's blood sugar was rechecked after R1 completed his meal.R1's MAR on 8/29/25, at 8:00 p.m. identified R1 was administered both Metformin1000 mg and Glimepiride 2 mg even though there was no indication R1's blood sugar was checked prior to the administration of the medications that would lower blood sugar. On 8/29/25 R1's Blood glucose vital summary document identified blood sugar at 9:05 p.m. R1's blood sugar was 39. In review of R1's record there was no indication the physician was notified after R1's blood sugar was 39 nor was there evidence R1 was continuously monitored and assessed for signs and symptoms of hypoglycemia. R1's Situation, Background, Assessment, and Recommendation (SBAR) note dated 8/29/25 at 9:45 p.m., identified R1 had Diabetes type 2, blood sugar during daytime was 81, blood glucose at 4:00 p.m. (which was inconsistent with the documentation in the vital summary), was 54, had eaten a half sandwich for dinner, now is 39. R1 was alert and oriented and not exhibiting signs and symptoms of hypoglycemia, R1 got IM glucagon 1 mg injection from emergency kit and blood sugar will be checked again in 15 minutes. Review of R1's record MAR indicated the glucagon was not documented as given. R1's blood glucose vital summary document identified blood sugar on 8/29/25 at 10:05 p.m. was 86. According to the Food Drug Administration (FDA) the Glucagon Injection the blood glucose concentration rises within 10 minutes of injection and maximal concentrations are attained at approximately 30 minutes after injection. The duration of hyperglycemic action after intravenous or intramuscular injection is 60 - 90 minutes.R1's blood glucose vital summary document identified blood sugar on 8/30/25 at 12:20 a.m. was 51. R1's late entry progress note for 8/30/25 identified R1 was transferred to the emergency department at 1:30 a.m. R1's ED to hospital admission notes dated 8/30/25 to 9/5/25, identified R1was admitted to the ED at 1:31 a.m. for hypoglycemia with a history of diabetes where he was receiving oral medications. R1 was recently hospitalized for rhabdomyolysis and discharged to Edenbrook Rochester [NAME] on 8/30/25. R1 presented to the ED from skilled nursing facility (SNF) for hypoglycemia and lethargy, endorsing symptoms of weakness, lightheadedness and dizziness. R1's glucose was 29 upon arrival prompting administration of intravenous (IV) dextrose (a sterile solution of glucose and water, administered directly into a patient's vein to restore blood glucose levels) 25 grams. R1 was admitted for continued evaluation and management. Upon admission to the hospital R1 continued to be persistently hypoglycemic requiring frequent dextrose injections and continuous D10 infusion (an IV solution containing 10% dextrose (D-glucose) in water, used to increase blood glucose levels). Per R1 history it was believed to be driven by Glimepiride. R1 returned to normal glycemic state on D10 infusion around 24 hours following his last Glimepiride dose. During a phone interview on 9/4/25 at 2:12 p.m., hospital registered nurse (HRN)-A stated R1 was admitted early morning of 8/30/25, and his primary diagnosis was hypoglycemia. When R1 arrived at the ED his blood glucose was 29. HRN-A stated regulating R1's blood glucose levels to normal ranges took about 16 hours and R1 was still in the hospital.During a phone interview on 9/8/25 at 11:22 a.m., R1 stated he has no recollection of the day at the facility when he was sent to the hospital for hypoglycemia. During an interview on 9/4/25 at 4:30 p.m., registered nurse (RN)-B stated she was the nurse that was responsible for R1 on 8/29/25 from 2:00 p.m. until 10:30 p.m. R1 was a new resident, and it was the first time she worked with him. RN-B checked R1's blood sugar at 4:00 p.m. At 4:50 and it was 54, she gave him orange juice. R1 questioned why he had to drink the juice, RN-B stated she explained to R1 it was very risky to have a blood sugar that low and if we don't do something he could die from it. RN-B stated she never called the provider for further direction for the blood sugar of 54. Then R1 had supper between 5:00-6:00 p.m.; he ate about a half white bread sandwich, ham, mayonnaise, and cheese. RN-B explained R1 told her he only ate half the sandwich because he did not like it, and she did not offer him any other food. RN-B stated at 8:00 p.m., she did give R1 1000 mg of Metformin and 2 mg of Glimepiride and stated she did not think to call the provider to see if it would be safe to give the medications. When she checked his blood sugar at 9:30 p.m., (which was inconsistent vital summary indicating 9:05) he was down to 39, that's when she gave him the glucagon injection. RN-B could not recall if she documented giving the glucagon and stated she did not call the on-call provider to get further instruction rather faxed an SBAR to the provider. RN-B stated she did work two days later after the event and typically worked at this facility three times a week. RN-B stated she had not received any education regarding diabetic monitoring or when to notify the provider with a change in condition.During a phone interview on 9/9/25 at 9:31 a.m., RN-C stated she worked the night shift on 8/29/25, she got to the facility at about 9:50 p.m. RN-C explained she received report from RN-B that R1 had low blood sugars, had some orange juice, a half a sandwich and required glucagon. RN-B was not told the times R1 was given orange juice/sandwich, what time the glucagon was administered, and R1 was still in the facility. RN-C indicated she had not immediately gone to evaluate R1, and some time had passed (could not recall how long) by the time she got to R1's room to check his blood sugar. When RN-C did check the sugar (documented at 12:20 a.m.) it was 51 and at that time R1 was kind of groggy. RN-C left R1's room, consulted with RN-A and it was decided to give orange juice and call the physician. RN-C brought R1 orange juice then left the room again to call the physician. RN-C explained she was on the on the phone for quite a while (did not know how long) trying to get through to an on-call provider and the person on the phone finally told her he would have a provider call her back. RN-C then went back to R1's room, she did not recheck the blood sugar because R1 was sleeping had 1/2 glass of orange juice in his hand that was tipped, and there was no point because the blood sugar would not have gone up in the time she was gone. RN-C then left the room again to talk to RN-A, decided to just call 911 and get R1 sent to the hospital. R1 was transferred out on 8/30/25 at 1:20 a.m. RN-A had only taken R1's blood sugar one time between 10:50 p.m. and 1:20 a.m. RN-C stated the nurse at the hospital called and reported R1's blood sugar was 29 when he got to the hospital. That was so dangerous to have a blood sugar that low. During an interview on 9/4/25 at 1:42 p.m., RN-A stated she was the charge nurse on 8/29/25. RN-A indicated at 9:30 p.m. RN-B came running down the hallway with glucagon injection in one hand and a glucometer in the other reporting R1's blood sugar was 39. RN-A stated she had not been aware of the blood sugar of 54 at supper time. RN-A directed RN-B to give Glucagon, check blood sugars every 15 minutes, and notify the provider. RN-A went to R1's room, his mentation was not great, woozy could not complete sentences and only could answer yes/no questions. She would not have considered R1 to have the ability to speak for himself because of the way he was speaking/acting because of his low blood sugars. R1 was sent to the hospital for further evaluation. However, RN-A reported her concerns to the director of nursing (DON). RN-A stated R1 had elevated risk of death from hypoglycemia with the predisposing diagnosis of rhabdomyolysis if he had not been sent the ED. During an interview on 9/4/25 at 1:28 p.m., DON stated she expected nurses to follow the hypoglycemic protocols with assessment and monitoring, providing emergency medications, and notify the provider. She expected for blood glucose under 50 the nurse would give emergency med, notify the provider and recheck every 15 minutes. DON verified the protocols were not followed and should have been. DON confirmed RN-B had not been provided any education nor had any other staff. The DON identified RN-B last worked on 8/31/25 and remained on the current schedule.During an interview on 9/4/25 at 1:22 p.m., medical doctor (MD)-A stated R1's low blood sugars may have been low related to the rhabdomyolysis and stated she would have expected to be notified if a resident's blood glucose was under 70 and after giving the glucagon, especially since R1 was a newer admit and the facility was unaware of his baseline. After glucagon was administered blood glucose needed to be checked every 15 minutes until they are within normal range. MD-A indicated failing to identify and treat hypoglycemia would result in further decreasing blood sugars and decline in mental status.Facility policy, Care of the Diabetic Resident, revised 6/30/25, identified a purpose to assist the resident to establish a balance between diet, exercise, and insulin; prevent recurrence of hyperglycemia/hypoglycemia; recognize, assist, and document the treatment of complications commonly associated with diabetes; and individualize teaching according to carefully assessed resident and family needs. Diabetes Mellitus is a chronic, hereditary, or developmental disorder in which there is relative or absolute lack of insulin characterized by glucose intolerance. It is defined as Type I (Insulin-Dependent Diabetes Mellitus) and Type II (Non-Insulin-Dependent Diabetes Mellitus) .2.Hypoglycemia a. Signs and symptoms of hypoglycemia (low blood sugar), usually have a sudden onset and may include the following: i. polyphagia (excessive eating/hunger); ii. weakness, dizziness, or faintness; iii. nervousness and/or muscle twitching; iv. tachycardia (increased heart rate); v. pale, cool, moist skin; vi. excessive perspiration; vii. dilated pupils; viii. irritability or bizarre changes in behavior; ix. blurred or impaired vision; x. headaches; xi. numbness in the tongue and lips/thick speech; xii. trembling and/or restlessness; xiii. paralysis with tonic or clonic spasms; xiv. incontinent of urine; xv. awkward body movement; xvi. stupor, unconsciousness and/or convulsions; and xvii. coma. b. Upon presentation of symptoms, the licensed nurse should check the blood glucose level via an Accu-Chek. I. If an Accu-Chek reveals a blood glucose level below 70 mg/dl or level identified per individual physician orders, hypoglycemia should be suspected. 1. Should evidence of severe, or life-threatening signs/symptoms exist, contact the physician immediately or call 911. ii. If any of the above signs or symptoms, or other abnormal condition, are identified, report the diabetic resident's condition to the physician immediately. c. Follow the resident's individual hypoglycemic protocol, if ordered by a physician. If no individual protocol is ordered, update the physician based on clinical assessment and current blood sugar. d. Hypoglycemic Treatment Protocol i. Treat hypoglycemia promptly with 15 to 20 g of fast-acting (simple) carbohydrates for blood sugar less than 70 mg/dl. ii. Half cup (4oz) juice OR 1 cup (8 oz) skim milk OR glucose gel/tablets OR four sugar packets. iii. Glucagon 1 mg (subcutaneously or I.M.) is given by a licensed staff if the patient cannot ingest a sugar treatment, per physician orders. iv. Repeat the Accu-Chek and report findings to the physician v. Repeat the protocol only once if the blood glucose level remains less than 70mg/dl and report findings to the physician. 3. If any of the above signs or symptoms, or other abnormal condition, are identified, report the diabetic resident's condition to the nurse and/or physician immediately.The immediate jeopardy that began on 8/29/25, was removed on 9/5/25, when it was verified, the facility implemented the following corrective actions:-Educated licensed nursing staff and agency staff about diabetic management of hypoglycemia and hyperglycemia monitoring, assessing, treatments, physician notification and standards of documentation with competency testing.-Reviewed all current residents with diagnosis of diabetes to ensure blood glucose levels were within range, had diabetic protocols in place, care plans were accurate and provider orders were followed.-Reviewed facility Diabetic Monitoring and Change of Condition policies for accuracy

Based on observation, interview and document review the facility failed to ensure food preferences were comprehensively assessed, a physician ordered nutritional supplement was available for administration and further failed to obtain physician ordered daily weights for 1 of 3 residents (R1) with impaired nutrition to help maintain adequate nutritional status that was consistent with the residents nutritional assessment, reviewed for weight loss. Findings include: Nutritional supplement: refers to products that are used to compliment a residents dietary needs (e.g., calorie or nutrient dense drinks .and meal replacement products). R1's order summary dated 2/20/24, identified an order to daily call MD if weight change of 3 pounds in 1 day or greater than 7 pounds in 1 week every day. An additional order dated 6/27/24, for Boost Breeze (a nutritional fruit flavored drink that provides extra calories and protein) every day at HS for additional nutritional support. On 8/27/24, identified to provide ProHeal (a liquid protein supplement for maximum protein content and absorption) give 1 ounce every day due to dialysis. R1's care plan revised 3/7/24, identified a problem, R1 was at risk for altered labs related to CKD (chronic kidney disease (when your kidneys are severely damaged and have stopped working properly, or are very close to failure) stage 5 with dialysis with potential for weight fluctuations. Goal revised 9/17/24, identified R1 will be free of signs and symptoms of dehydration, pertinent labs will remain within normal limits. Interventions revised 3/7/24, identified to record weight per facility protocol/MD orders. Monitor intake per facility protocol. R1's care plan did not identify and address goals for the physician ordered nutritional supplements and did not identify R1's food preferences. R1's annual Minimum Data Set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of CKD stage 5, dialysis dependent (treatment that helps people with kidney failure by removing waste and excess fluids from the blood), left and right Below Knee Amputation (BKA) and diabetes. R1's height was 63 inches, and his weight was 120 pounds, had a loss of 5% or more in the last month or loss of 10% or more in the last 6 months, was not on a prescribed weight loss plan by the MD and received a therapeutic diet. Further identified it was very important to have snacks available in between meals. R1's Nutritional assessment dated [DATE], identified R1 did not have a nutrition problem, was 63 inches and weighed 124.6 pounds and his usual body weight was 125 - 167 pounds in the last year which identified R1 had a significant weight change. R1 reported he liked most foods with the exception of pork .smaller carbohydrate portions given due to history of diabetes .received nutritional supplements and fortified foods. R1's current average meal intake was 2 meals per day on average, occasionally refused meals, and occasionally accepted snack between meals. R1 received regular renal diet, was independent with eating, no chewing or swallowing disorders and R1's current diet order/oral nutritional supplement(s) order provided adequate calories/protein to meet estimated nutritional needs. Continue current nutrition care plan, care plan was reviewed and updated. R1's Weight Vital Signs dated 12/10/24 identified R1 had weights taken on the following days: -10/16/24: 130.4 pounds -10/22/24 118.2 pounds -10/29/24: 114.6 pounds -11/5/24: 114.2 pounds -11/12/24: 114.2 pounds -11/28/24: 114 pounds R1's medical record reviewed and lacked documentation of daily weights as identified per MD orders and further lacked information that MD was notified of not following MD orders for further guidance with the monitoring of R1's weights. R1's Dialysis Fluid record reports identified the following weights: -10/23/24: 119.1 pounds -11/4/24: 119.7 pounds -11/13/24: 116.2 pounds -11/20/24: 116 pounds -11/26/24: 121 pounds -12/6/24: 116 pounds -12/9/24: 113.3 pounds R1's Medication Administration Record (MAR), dated November 2024, identified that R1 received 100% of nutritional supplements with the exception of the following dates: ProHeal: -11/20/24, 11/24/24 through 11/27/24, and 11/29/24 -11/21/24 received 50% -11/28/24 received 40% Boost Breeze: -11/4/24, 11/14/24, 11/15/24, 11/23/24, 11/27/24, 11/28/24 and 11/29/24 received 50% -11/5/24, 11/16/24, 11/17/24, 11/28/24, 11/20/24, 11/21/24, 11/21/24, 11/22/24, 11/25/24, and 11/26/24, was not received. R1's MAR dated December 2024, identified that R1 did not receive any of the ProHeal or Boost Breeze supplements, the spaces were either left blank, had a 2 which identified drug refused or a 9 indicating to see the progress note. R1's nutrition/dietary progress note dated 10/10/24, identified R1 was being monitored monthly due to high risk due to dialysis .supplement 8 ounces of Boost Breeze daily for additional nutritional support and ProHeal 1ounce daily for additional protein due to dialysis 100% .weights every day .eats 50 to 100% of meals, refuses occasionally, additional fluids offered between meals, accepts snacks 25%, renal Register dietician (RD) noted that resident may be ordering food from restaurants and bringing food in .RD will monitor monthly at high risk and follow up prn, will continue to communicate with renal RD, Executive Dietician (ED) to check in with resident related to food preferences. R1's progress note dated 11/17/24 identified Boost Breeze for additional nutrition was on order. R1's nutrition/dietary progress note dated 11/18/24, identified R1 was being monitored monthly due to high risk due to dialysis .supplement 8 ounces of Boost Breeze daily for additional nutritional support 50 to 100% refused x 1, and ProHeal 1ounce daily for additional protein due to dialysis 100% .weights every day .eats 0 to 100% of meals, refuses occasionally, additional fluids offered between meals, accepts snacks less than 50 %, renal Register dietician (RD) noted that resident may be ordering food from restaurants and bringing food in .weight on 10/22/24 was 1182 pounds and on 11/12/24 was 112.2 pounds, intake does not appear to be adequate to meet Emergency Nutrition Network (ENN) with snacks and supplements, will change diet to regular portion size carbohydrates due to weight loss. 1) RD will monitor monthly at high risk and f/u prn. 2) Will continue to communicate w/ Renal RD, updating on sig weight loss and change to regular portion carbohydrate 3) ED to check in w/ res re: food preferences. 4) Will change to regular portion size carbohydrate due to weight loss, Nursing to update NP. R1's progress note dated 11/18/24 identified Boost Breeze for additional nutrition was on order. R1's progress note dated 11/20/24, at 9:33 a.m., identified daily weight not obtained before resident left for appointment. R1's progress note dated 11/20/24 identified Boost Breeze for additional nutrition was on order. R1's progress note dated 11/21/24 identified Boost Breeze for additional nutrition was on order. R1's progress note dated 11/22/24 identified Boost Breeze for additional nutrition was on order. R1's progress note dated 12/2/24 identified daily weight was refused and ProHeal was refused made resident vomit. R1's progress note dated 12/2/24 identified no supply of Boost Breeze found. R1's progress note dated 12/3/24 identified daily weight and ProHeal was refused. R1's progress note dated 12/4/24 identified daily weight refused and ProHeal not given made him nauseated. R1's progress note dated 12/5/24 identified daily weight and ProHeal was refused. R1's progress note dated 12/7/24 identified daily weight refused and ProHeal not given made him sick. R1's progress note dated 12/8/24 identified daily weight and ProHeal was refused. R1's progress note dated 12/9/24 identified daily weight and ProHeal was refused. Review of Residents medical record there was no indication the physician was notified of R1's refusals to obtain the physician ordered daily weights nor evident the physician and/or RD was notified of R1's refusals to consume the nutritional supplement offered or the availability of the nutritional supplements so that alternative interventions if any could prescribed. R1's record did not include a comprehensive evaluation that addressed R1's behavior of refusing/rejecting the supplements for the development and implementation of alternative individualized interventions Furthermore, R1's record did not identify a physician evaluation that identified or determined R1's weight loss was expected and/or planned. During an interview on 12/10/24 at 2:21 p.m., R1 was lying in bed. Interview was performed via phone language interpreter. R1 stated, I do not like any of the food the facility has here, I do not like it, it is awful and has no taste. R1 stated he can't eat the breakfast here because the eggs are overcooked and taste bad. One year ago, my weight was 160 pounds and today I take a bath and weigh me, and I am 112 pounds. When asked if there was anything that could be done to help gain the lost weight back, R1 stated he needed the food he liked because the food here makes him nauseated, and he will only eat the food his son brings. When asked if nutritional supplements were offered, R1 stated sometimes they offer them but preferred the juice-based ones because the milk-based ones burn his stomach. During an interview on 12/10/24 at 10:06 a.m., nursing assistant (NA)-B stated R1 preferred Mexican food and very rarely ate the facility food. NA-B further stated she was usually unable to get him to eat breakfast unless he was really hungry. NA-B indicated R1 liked all authentic Mexican food, tamales, and all kinds of beans, scrambled and fried eggs. NA-B indicated R1 never refused to get weighed and his weight needed to be done without his clothes or prosthetics in the morning for an accurate reading using the full body mechanical lift weight. NA-B stated she did R1's weight today and was 114 pounds and indicated R1 was sleeping this morning so breakfast was not offered. During an interview on 12/9/24 at 2:13 p.m., NA-A stated R1 was very upset at another staff member yesterday because the staff member brought in a tray of the facility food. He yelled at her and called her horrible names, he told me he wanted his tamales from the refrigerator heated up. NA-A stated she heated up his tamales and R1 ate all of them, after he was done eating, he told me he was so upset because he was so hungry. NA-A stated R1 has asked to go to the store for him to get him a can of pinto beans and heat them up in the microwave for him, but NA-A was unable to because she does not drive. NA-A indicated R1 was not a daily weight and only got a weight on his bath day. During an interview on 12/9/24 at 1:54 p.m., licensed practical nurse (LPN)-A indicated R1 was a daily weight and verified his weights were not performed daily due to refusals. LPN-A indicated R1 always refused his ProHeal because it made him nauseated and was not aware that he was supposed to receive Boost Breeze nutritional supplement. LPN-A reviewed the medical record and stated R1's weights have not been performed per MD orders and was not receiving his nutritional supplements ProHeal and Boost Breeze daily as ordered. LPN-A stated the provider was not notified that R1 was not receiving his nutritional supplements and of the weight refusals and should have been. LPN-A further stated R1's meal intake is not that great, rarely eats breakfast, he has lost weight, will not eat the facility food, and only liked Mexican food that R1's son would bring in. During an interview on 12/9/24 at 2:33 p.m., registered nurse (RN)-A stated R1 had not been refusing his Boost Breeze nutritional supplements, we haven't had them available in the building to give him, it's been a couple weeks. RN-A indicated R1 would only eat Mexican food, when we try to give him facility food, he will not eat it. RN-A stated R1 was supposed to have daily weights every morning and was not sure if he had lost weight. RN-A stated she had documented in R1's medical record that the nutritional supplements were not given because they were not available to give. During a phone interview on 12/9/24 at 4:09 p.m., registered dietician (RD)-A stated she was a new employee with the facility on 12/2/24 but had reviewed R1's medical record and noted a concern with his weight loss. RD-A stated R1 was not getting daily weights as ordered along with not always receiving his nutritional supplements. RD-A further stated she would prefer to be notified right away when a resident is not receiving supplements along with several days of low food intakes. RD-A was notified the facility did not have any Boost Breeze available and indicated Boost Breeze was a juice flavored nutritional supplement versus a milk based one and was ordered due to his refusals of the milk-based supplements. RD-A stated the nutritional supplements were ordered to provide additional nutrition, protein, and calories to help maintain R1's nutrition and weight loss. RD-A further stated she would need to confer with R1's dialysis registered dietician (RD) to ensure identified interventions are put in place for R1 due to his high risk for malnutrition and weight loss and would need very close monitoring of his nutritional intake. During a phone interview on 12/10/24 at 11:04 a.m., dialysis nurse manager (DNM)-A stated R1 received dialysis once a week to clean his blood, we do not pull fluid from him. DNM-A indicated R1 did not bring any lunch to his appointments but would be offered a protein shake Novosource which is a milk-based supplement. DNM-A stated sometimes R1 would drink one towards the end of his appointment. DNM-A stated R1 last had dialysis on 12/9/24 and his pre-dialysis weight was 113.6 and post dialysis weight was 118.4 pounds. DNM-A further stated she gave R1 saline fluids to keep his blood pressure up so post weights are typically more than the pre-weights. DNM-A stated R1's food preferences were authentic Mexican food, yesterday R1's family brought Mexican food to him here to take back to the facility with him. During an interview on 12/9/24 at 2:38 p.m., director of nursing (DON) reviewed R1's medical record and indicated R1 had recent weight loss, acknowledged R1's MD orders for weight monitoring and notification, and stated R1's weights were not being provided daily and the provider had not notified. DON indicated an unawareness that R1 was only eating the food his son would bring in. DON stated they had been out of the Boost Breeze due to being bought out my another company and the ordering was not followed through. Facility policy and procedure, Diet and Diet Orders, revised 12/11/23, identified Policy: All diets will be prescribed by the Attending Physician. The Dietitian will review diets for accuracy and therapeutic goals and recommend changes to the Physician as deemed appropriate. Liberalized diets will be provided whenever applicable to improve quality of life and provide optimum nutrition without the use of restrictive diets. When necessary, the Attending Physician will order therapeutic or mechanically altered diets to address certain diseases and/ or facilitate oral intake . Responsibilities: Dietitian - Monitor compliance with policy by ensuring accuracy of diets and communicating changes or recommendations. Ensures that care plan is updated with diet changes. Food Service Director/Dietary Manager - Ensures that food provided is consistent with diet order and that tray card accurately reflects resident/patient diet order and food preferences.

Based on observation, interview, and document review the facility failed to ensure food temperatures were monitored consistently prior to serving to prevent risk of food born illness. The facility further failed to maintain a clean refrigerator and freezer for food storage. This had the potential to affect all 28 residents residing at the facility. Findings include: During dining/kitchen tour on 10/21/24 at 2:30 p.m., with dietary manager (DM) identified resident refrigerator in the dining room adjacent to the kitchen was to have loose debris laying on the bottom , unknown sticky substance spilled on bottom and on the shelves. In addition, items were not labeled to identify what items belonged to what residents. Observation of the freezer located in the basement of the facility had loose frozen carrots on the bottom, looked like ice buildup on top shelf, and frost around the door. DM reported cleaning the refrigerator and the freezer are shared by nursing and dietary staff. DM revealed there was no cleaning log or schedule to ensure completion. DM further identified they are to be getting a new freezer in the basement and is why it is has not been cleaned. During the evening meal on 10/21/24 at 5:07 p.m., cook (C-A) who checked the temperature of all food on the steam table. The temperature of the puree pasta was 98.9 and the puree ground beef was 142.7. C-A recorded the temperatures on the Service Line Checklist form and continued set up the area in preparation for serving. C-A then started to dish up the meal after looking at the meal slips. C-A proceeded to dish up puree pasts and was about to place it on the plate when surveyor asked C-A what the holding temperature for the food on the steam table should be and [NAME] A replied 140. Surveyor asked about the temperature of the pasta being 98.9 and C-A paused and said he needed to heat it up. During an observation on 10/22/24 at 11:50 a.m., DM-B was dishing up the noon meal. DM dished up a plate of puree food included chicken, mashed potatoes, gravy, and vegetables. DM took temperature of the food on the steam table; puree chicken at 111 degrees and the mashed potatoes at 123 degrees. DM indicated the holding temperature should be 145 degrees and he then proceeded to place the plate in the microwave to warm it up. Service Line forms which contained the food temperatures reviewed for October 1, 2024 through noon meal of October 22, 2024 indicated: 10/4/24 One temperature documented for hot cereal and not other temperatures monitored. 10/7/24 All meals had documentation of temperature monitoring completed. 10/8/24 Breakfast was monitored, lunch main entree was monitored, but no other food temperatures were recorded. 10/9/24 All meals temperatures were documented. 10/10/24 All meals temperatures were documented. 10/11/24 Breakfast and lunch had completed temperatures logged, however no other temperatures logged for dinner. 10/13/24 All meals had documented temperatures. 10/14/24 No temperatures for pureed foods at lunch and dinner. 10/15/24 All meals had documented temperatures. 10/16/24 All meals had documented temperatures. 10/17/24 Pureed food (broccoli) had temperature monitored for lunch and the alternate puree was monitored also for dinner. 10/18/24 Only pureed meat was monitored for temperature at lunch and no pureed food monitored at dinner. 10/19/24 All meals had temperatures monitored. 10/20/24 No temperatures were monitored for breakfast or lunch. No pureed food monitored for temperature for dinner 10/21/24 Lunch had no meat or starch pureed temperature monitored. 10/22/24 Breakfast temperature was monitored, and lunch was not. And six days no temperatures taken of food prior to serving. During an interview on 10/22/24 at 12:10 p.m., DM-B confirmed he had not checked the temperature of the food prior to dishing up for service. During an interview on 10/23/24 at 2:15 p.m., Regional Dietary Manager (RDM-C) indicated the expectation was for the cook to monitor food temperatures prior to serving the meal to ensure safe serving temperatures. During an interview on 10/23/24 at 3:21 p.m., dietician indicated their role was to oversee sanitation audits, review temperature logs, and assess residents for dietary needs. The dietician reported the cleanliness of the resident refrigerator has been a concern and she has been monitoring this. She confirmed food not held at appropriate holding temperature could be a risk to residents for food born illness. She identified her expectations would be food temperatures were monitored prior to being served to assure the proper temperature was maintained. Interview on 10/23/24 at 4:45 p.m., director of nursing indicated she would expect kitchen staff monitor the food temperatures to assure appropriate safe serving temperatures to prevent food born illnesses.

Based on observation, interview, and record review, the facility failed to appropriately assess for broken/missing teeth and difficulty chewing for 1 of 1 (R24) resident. Findings include: R24's 8/27/24, admission Minimum Data Set (MDS) assessment identified her cognition was moderately impaired. R24's diagnosis list identified diagnosis of moderate protein calorie malnutrition, paranoid schizophrenia, dementia, and weakness. R24's oral assessment dated [DATE], indicated R24 had her own teeth and does not wear dentures, has chewing problems and R24 would be a regular diet with thin liquids with a care plan intervention to provide diet as ordered. R24's Nutritional assessment dated [DATE], identified R24 ate independently, was on a regular diet, had no difficulty chewing or swallowing, and would be given a supplement three times daily. The assessment summary identified the current diet order remains appropriate, resident appears to be tolerating diet texture and consistency, and current diet order/oral nutritional supplement order provides adequate calories/protein to meet estimate nutritional needs. The summary further identified R24 should continue current nutrition plan of care and care plan had been reviewed and updated. R24's 8/21/24, care plan item identified she was at risk for inadequate intake related to recent hospitalization due to dizziness, with interventions of eating independently, provide diet as ordered, and record weight per facility protocol/MD [medical doctor] orders. During an observation and interview on 10/22/24 at 12:40 p.m., R24 was seated at the edge of her bed with an overbed table in front of her with a meal tray on the table. Her plate had a whole potato with unopened packet of sour cream and butter on the side, R24 attempted to open the sour cream but was unable to. Included on the plate was an open-faced chicken sandwich with large bite size pieces of chicken mixed with gravy on top of a bun, green beans, and a mixed fruit cup on the side. R24 placed a bite of the chicken in her mouth, chewed it up and spit it back out on her spoon. She placed the chewed food to the side of her plate then took another bite, chewed the food and then again spit it out on the spoon and laid it to the side of her plate. R24 said she cannot chew the meat stating, this would be good if it was done right, the sauce is good, but I can't chew the meat. During the observation a nursing assistant (NA)-A looked into the room and said she was just checking to see if R24 was done eating, she then closed the door. During and interview on 10/22/24 at 12:54 p.m., NA-A said she offered assistance to R24 when she dropped of her meal tray, she said R24 doesn't like people to help her, she identified she could have opened her sour cream prior to bringing the tray into her room but she did not think of that at the time. During an observation and interview on 10/23/24 at 8:53 a.m., R24 identified she has difficulty chewing, she opened her mouth to reveal no top teeth and several missing lower teeth. During an observation and interview on 10/23/24 at 12:33 p.m., R24, meal tray was on the overbed table in front of her, food items included whole boneless, chicken breast, mixed vegetables, and a dinner roll. R24 looks at her plate and stated same old same old, R24 points to the chicken breast and states I can't eat that, I don't have any top teeth. I need a blender so I can blend my food up so I can eat it. R24 said it was not anyone fault she can't eat the food, it's just her teeth. She asked surveyor if someone could give her a ride to the store to get a blender. During an interview on 10/23/24 at 3:24 p.m., registered dietitian (RD), identified she completes the nutritional assessment for residents at the facility. She determines the need for a mechanically altered diet by looking at the doctor orders and reviewing the nursing progress notes or from feedback at the interdisciplinary team meeting (IDT). RD identified she had completed a preference assessment with R24, and she had told her staff cut up her food. RD stated, I didn't really pursue it much more since that. RD identified they do not observe the resident eating as part of their assessment and agree R24 should have been evaluated by speech therapy if she had missing teeth and difficulty chewing. The RD identified she works for the facility 8 hours a week, of those hours she currently works 5 hours every other week on site and the rest of the hours are completed remotely. The facility provide Nutritional Assessment guidelines from the Food & Nutrition Services which identified the assessment process includes identifying and assessing the resident's nutritional status and risk factors, evaluating the assessment information, developing, and consistently implementing pertinent approaches, monitoring the effectiveness of interventions, and revising them as needed. The assessment should be completed with residents who are at risk for unplanned weight loss or compromised nutritional status. The guidelines identify the elements of the assessment which includes general appearance such as cognitive status, affect, oral health, and dentition.

Based on observation, interview and document review the facility failed to ensure an insulin FlexPen was appropriately primed prior to insulin administration for 1 of 2 residents (R14) who received sliding scale (SS) insulin. Findings include: During an observation and interview on 10/22/24 at 4:32 p.m., registered nurse (RN)-A prepared to administer R14's SS insulin dose. R14's blood glucose (BG) reading checked on 10/22/24 at 4:26 p.m. was 264. The physician orders for SS Novolog Aspart insulin (FlexPen) identified the dose to be administered as 8 units. RN-A checked the pen against the MAR, removed the pen cap, dialed the pen to 2 units and depressed the plunger. She then obtained a package containing the needle for the pen, and additional supplies and preceded to R14's room. RN-A performed hand hygiene, applied gloves, wiped the end of the pen with an alcohol pad and attached the needle. She then dialed the pen to 8 units, and prepared to administer the insulin dose. RN-A was interrupted and she and the surveyor exited the room, where RN-A was asked about priming the pen without the needle attached. She responded was the way she had always done it and reported she was not aware the needle should be attached prior to priming the pen. RN-A responded she was glad to learn this, and stated she had received training which included medication administration, but she was not aware of the FlexPen package insert detailing the correct method of applying the needle, then priming with 2 units to remove the air before dialing the ordered insulin dose. Review of the manufacture's steps for use of a FlexPen included: 1.) check the label to ensure the pen contains the ordered form of insulin 2.) Pull off the pen cap 3.) Pull off the outer needle cap. Keep it to remove the needle from the pen after injection, pull off the inner needle cap and dispose of it. 4.) Turn the dose selector to 2 units 5.) Hold the FlexPen with the needle pointing upwards. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. 6.) Keep the needle upwards and press the push-button all the way in. The dose selector should return to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If a drop still does not appear, you must use a new FlexPen. 7.) Turn the dose selector to select the number of units you need to inject. 8.) Push the needle into the skin, press the dose button until you reel or hear a click and the dose indication lines up with 0. Hold for 6 seconds and remove it. 9.) Guide the needle back into the outer needle cap and when completely on unscrew the needle and dispose of in a sharps container. Interview on 10/22/24 at 4:45 p.m., director of nursing (DON) and the corporate nursing consultant who was also in attendance identified the facility had a policy on administration of medication which included insulin's, and staff had all been trained on medication administration. She reported her expectation for nursing staff to read and follow the policy, and/or manufacture's instructions for use of an insulin pen, in addition to any other medication. Review of the January 2022 Medication Administration Subcutaneous Insulin from the Nursing Care Center Pharmacy & Procedure Manual Contained photo instructions on administration of insulin with a pen. The policy clearly explained how to attach and detach the needle safely, prime the pen, administer the ordered insulin dose, and safely remove the needle following the administration.

Based on observation, interview, and record review the facility failed to ensure utilization of proper personal protective equipment (PPE) with cares for 1 of 2 residents (R8) evaluated for enhanced barrier precautions (EBP). Findings include: R8's quarterly Minimum Data Set, dated dated dated [DATE] indicated R8 was cognitively intact with no behaviors, limited range of motion to both upper and lower extremities, frequent incontinence of bowel and bladder, G-tube (tube surgically placed in stomach), and tube feeding (liquid nutrition provided via g-tube) R8's face sheet indicated diagnoses of Parkinson's disease, severe protein-calorie malnutrition, nutritional anemia, and gastrostomy status. R8's orders indicated check tube placement before initiation of formula, medication administration, and flushing tube every 8 hours, flush tube with 20-30 ml of water before and after medications, check and record residuals, Compleat (brand of liquid nutrition) intermittent gravity 2.5 cans/day. 1/2 can at 9 am, 1 can at 2 pm, and 1 can at 9 pm. Water flushes of 90 ml before and after feeding. It also indicated enhanced barrier precautions d/t tube feeding. R8's careplan indicated risk for inadequate intake related to Parkinson's disease and need for supplemental enteral nutrition, incontinence of urine/bowel, assist with daily hygiene, grooming, dressing, oral cares and eating as needed. Bed mobility assist of 1-2, EZ stand lift (brand of lift used to assist residents to a standing position) for transfers and need for physical assist with transfers related to physical limitations. It also indicated feeding tube related to need for nutritional support. During observation and interview on 10/23/24 at 8:10 a.m., NA-A was wearing gloves and a hospital gown while providing cares for R8. NA-A assisted resident to a sitting position on the edge of bed. NA-A positioned the EZ stand in front of resident. NA-A assisted R8 to standing position and transferred the resident to the wheelchair. NA-A removed the resident's gown, provided underarm care, and assisted R8 with donning undergarments and shirt. NA-A then removed linens off bed and placed them on the floor and straightened remaining linens. NA-A picked up linens off the floor and placed them in an empty bag. NA-A removed hospital gown by pulling it over their head placing it in dirty laundry bag, removed gloves and washed hands. NA-A put on new gloves, gathered garbage and linens, and placed them in soiled utility room. During interview, NA-A stated residents are placed on EBP if they have devices such as catheters and g-tubes. NA-A stated staff would wear blue plastic gowns and gloves for incontinence cares and other close contact with residents. NA-A confirmed wearing a hospital gown and should have worn a disposable blue gown. During interview on 10/23/24 at 9:28 a.m., the infection preventionist (IP) stated EBP are implemented for residents with catheters, g-tubes, central lines, and some wounds to prevent the spread of multidrug resistance organisms (MDROs). PPE is required for resident cares and transfers. The IP stated signs are placed on the residents' doors identifying the level of precautions, the type of PPE to be warn, and the resident interactions require PPE. The IP stated the expectation is for staff to read the signs on a resident's door and apply the appropriate PPE prior to entering the residents' room. The IP confirmed NA-A should have worn a blue disposable gown to provide cares to R8. During interview on 10/23/24 at 11:40 a.m., the director of nursing (DON) stated staff are expected to wear the proper PPE for residents on transmission-based precautions to prevent the spread of MDRO's. The DON confirmed NA-A should have worn a disposable blue plastic gown when providing cares to R8. A policy titled Enhanced Barrier Precautions dated 8/8/24, indicated EBP is implemented for the prevention of transmission of MDRO's. EBP is initiated for residents with chronic wounds and/or indwelling medical devices such as central lines, urinary catheters, feeding tubes and tracheostomies/ventilator tubes. PPE (gowns and gloves) are to be donned for high-contact resident care activities such as dressing, bathing, transferring, hygiene, changing linens, and changing briefs/assisting with toileting. It is also required for indwelling device care and wound care. A policy titled Personal Protective Equipment dated 3/17/23 indicated the facility promotes appropriate use of PPE to prevent the transmission of pathogens to residents, visitors, and other staff. Gowns are worn to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material. Dispose of gowns into the appropriate waste receptacle.

Based on observation, interview and document review the facility failed to complete a comprehensive assessment for food preferences for 1 of 1 residents (R2) who preferred foods consistent with R2's culture. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2's cognition was intact with diagnoses of diabetes and chronic kidney disease. MDS identified R2 was independent withe eating and did not identify R2's preferences for food choices. R2's care plan dated 10/23/23, did not identify R2's food choices/preferences. R2's Nutritional assessment dated [DATE], indicated R2 had a history of liking most foods with the exception of pork and was satisfied that the food is hot. The assessment did identify R2's food choices pertaining to cultural or individualized preferences to ensure adequate nutritional needs were met. R2's internal medicine visit dated 10/30/23, indicated R2 had nausea which limited his intake, R2 stated it's because he does not like the facility food. R2's progress note dated 11/7/23 at 1:00 p.m., R2 was educated on the importance of eating and preventing low blood sugar. R2's progress note dated 11/26/23 at 1:08 p.m., R2 refused lunch but ate Cheetos, cookies, and Mountain Dew. R2 stated he did not like lunch, offered sandwich or an alternate food option, R2 declined. R2's Nutritional assessment, dated 11/27/23, indicated R2 had a history of liking most foods with the exception of pork and was satisfied that the food is hot. R2's progress note dated 11/27/23 at 12:29 p.m., indicated R2 had a care conference, only eats when R2 feels like it, and prefers to eat a lot of junk food and snacks. During an observation and interview on 11/29/23 at 11:49 a.m., R2 was dressed in facility gown lying in bed. Interpreter was present as R2 was Spanish speaking. When asked if food preferences were being met R2 indicated they were not and that he would like Mexican food and the hamburger was too tough here. During an interview on 11/30/23 at 2:25 p.m., registered dietician (RD)-A indicated with new admissions the dietary manager assesses residents for food preferences. RD-A indicated R2 did not have a food preference assessment completed and should have been completed within the first 48 hours and then should be completed quarterly. RD-A was not aware of R2's preference for Mexican food. During an interview on 11/30/23 at 3:16 p.m., dietary manager (DM)-A indicated he started one month ago and has bee mainly working as a cook. DM-A has not been trained in the role of dietary manager yet. DM-A has not assessed any residents for the food preferences since he started. DM-A stated he has not noticed anyone wanting to have specific preferences other than the regular meals served. During an interview on 11/30/23 at 3:33 p.m., nursing assistant (NA)-B indicated R2 does not like the facility food. NA-B stated, family will bring in traditional food but that isn't right. NA-B indicated an unawareness of how communication with kitchen staff to let them know when resident does not like food. During an interview on 11/30/23 at 3:27 p.m., registered nurse (RN)-B and licensed practical nurse (LPN)-A both indicated R2 did not like the food and his family would bring him traditional Mexican food. Both indicated they were not aware of any specific food preferences other than R2 liked his cultural Mexican foods. During an interview on 11/30/23 at 3:54 p.m., director of nursing (DON) indicated an unawareness that R2 preferred Mexican food, also indicated the care plan was not updated to reflect it. DON stated, we should be able to get him some Mexican food incorporated. Facility policy, Dining and Food Preferences, revised 9/2017, indicated individualized dining, food, and beverage preferences are identified for all residents. 2. The Dining Service Director, or designee, will interview the resident or resident representative to complete a food preference interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, meal times, including times outside the routine schedule, food, and beverage preferences. 3. The food preference interview will be entered in the medical director. 4. Food allergies, food intolerances, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. 6. The Dining Service Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal plan in the plan of care.

Based on observation, interview and document review the facility failed to ensure waking times were honored for 1 of 1 residents (R2) for choices. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2's did not have cognitive impairment. R2's quarterly psychosocial assessment, dated 11/27/23, identified R2 was Spanish speaking, under section 5. Culturally competent care included a focus of cultural/ethnic preferences: Spanish speaking services when needed. The assessment did not identify interventions to provide choice making activities. R2's care plan dated 10/23/23 did not identify R2's preferences for waking times and daily routines. R2 required assistance from two staff for bed mobility, toileting, and transfers and required assist of one staff for personal hygiene. During an observation and interview on 11/29/23 at 11:48 a.m., R2 was dressed in facility gown lying in bed. R2 explained he did not like to get up early and preferred to get up after lunch. He was not asked upon admission about times he would like to wake. R2 stated he could not get up out of bed on his own and [NAME] would offer to get him out of bed on the evening shift. During an interview on 11/30/23 at 3:27 p.m., register nurse (RN)-B and licensed practical nurse (LPN)-A indicated an unawareness of R2's preferences for waking times. During an interview on 11/30/23 at 3:56 p.m. assistant director nursing (ADON), indicated R2's preference of waking time was not assessed on admission and should have been. ADON was not aware of times R2's preferences to awaken for the day. During an interview on 11/30/23 at 3:54 p.m. director of nursing (DON) was not aware of R2's preferences for waking time. Resident preferences for wake/sleep schedule should be assessed on admission. DON reviewed R2's record and indicated R2's admission assessment for preferences was not filled out. Facility policy requested for resident choices was requested and not received. Facility policy comprehensive care plan dated 9/30/22 indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1.The care planning process will include an assessment of the resident's strengths and needs and will incorporate the residents personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally- competent and trauma-informed.

Based on observation, interview, and document review the facility failed to administer the right prescribed medications to right residents for 1 of 3 residents (R1). R1 had developed hypotension (low blood pressure) and bradycardia (low heart rate) that required emergency medical treatment and admitted to the hospital ICU (intensive care unit) to stabilize R1's condition which resulted in an immediate jeopardy (IJ). The immediate jeopardy (IJ) began on 10/9/23, when registered nurse (RN)-A failed to identity R1 prior to the administration of prescribed medications. The director of nursing (DON) and vice president of success (VPOS) were notified of the IJ on 10/24/23, at 6:30 p.m. The facility immediately implemented corrective action on 10/9/23, the deficient practice was corrected on 10/9/23, prior to the start of the survey and was therefore issued at Past Noncompliance. Findings include: Facility reported incident (FRI) dated 10/9/23, indicated registered nurse (RN)-A (who was in training as new employee) was orienting with RN-B working together on the cart to dish up medications. RN-A stated to R1 is your name (R2's name), R1 stated yes. RN-A went to the med cart and told RN-B that R1 did not want the nasal spray. RN-B went to check in the bathroom and realized RN-A had accidentally given R2's medications to R1. Vitals signs were checked, provider called, R1 was visually monitored throughout the shift, and R1 was sent to the ED. Education provided to RN-A and RN-B on medication competency checklist, review of cardiac medications, side effects and policies of medication administration and errors. All trained medication assistants (TMAs) and licensed staff will be educated prior to the start of their next shift. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's cognition to be moderately impaired and included diagnoses of multiple sclerosis (a neurological disease that results in nerve damage that disrupts communication between the brain and the body), hypertension (high blood pressure), and dementia. Further, the MDS identified R1 had adequate hearing without hearing aides. R1's medication administration record (MAR) dated 10/9/23, at 9:08 a.m. indicated R1 received the following scheduled medications per physician orders: amlodipine besylate 10 milligrams (mg) (a calcium channel blocker that helps to lower blood pressure), lisinopril 20 mg (relaxes blood vessels to help lower blood pressure), lactase 9,000 units (an enzyme that helps break down milk), acetaminophen 1,000 mg (pain reliever), and cholecalciferol (vitamin D),1000 units. R1's progress note dated 10/9/23, at 9:35 a.m. indicated R1 was given the wrong medications this morning, and received her own scheduled medications. R1 received in error, diltiazem (blood pressure medication)120 milligrams (mg), furosemide 20 mg (diuretic medication), metoprolol 20 mg (blood pressure medication), quetiapine fumarate 20 mg (antipsychotic medication), senna (stimulant laxative) and Tylenol 1000 mg (pain medication). Provider team notified, family notified. Blood pressure-151/51, pulse-66, O2 sats 94% on room air and temperature was 97.3, no pain noted. R1's med error report, dated 10/9/23, at 9:30 a.m. identified RN-B was mentoring RN-A had medications dished up and gave them to the wrong resident (R1). RN-B administered crushed medications to R1 instead of R2. R1 was aware she was given the wrong medications and vital signs are stable, no signs and symptoms of overdose at this time. Nursing at this time will continue to monitor. RN-B educated orientee RN-A about importance of following the medication administration rights. Also discussed not to go by what the resident says, some may not be able to answer accurately. There were no progress notes or vital signs records from 9:35 a.m. until 1:15 pm, to identify staff were monitoring R1's condition as a result of the medication error which she received medications diltiazem, furosemide, metoprolol, and quetiapine that could potential to lower blood pressure and/or heart rate. R1's progress note dated 10/9/23 at 1:15 p.m., indicated R1's vital signs were rechecked, blood pressure 55/32, pulse 32, respirations-12, and oxygen saturations were 96% on room air. R1 appeared pale cool, very lethargic, was able to respond to verbal commands. 911 was called, emergency medical services (EMS) arrived at 1:20 p.m. Intravenous (IV) started, fluids started IVP Atropine (used to treat slow heart rate) was given by EMS at 1:30 p.m. EMS obtained blood sugar 192 mg/dl (normal 80-120 mg/dl). Blood pressure 55/23 and pulse 26. Family member (FM)-A was called and wanted all action to be taken at this time. EMS took R1 via ambulance at 1:35 p.m. According to the American Heart Association a normal blood pressure for an adult is a systolic (top number) reading that is below 120 and a diastolic (bottom number) reading that is below 80. A blood pressure would be considered low if under 90/60. A normal pulse is 60 - 100. R1's nurse practitioner note, dated 10/9/23, at 1:25 p.m. identified Chief Complaint was medication overdose incident; R1 was administered another resident's medications. R1's heart rate recorded 36 bpm (beats per minute) and she was getting symptomatic. Nursing is sending R1 in for immediate evaluation and intervention. EMS has been called and is currently at the facility. R1's ambulance report dated 10/9/23, at 1:45 p.m. indicated upon arrival R1 was slumped over in her wheelchair and alert to painful stimuli. Staff reported shortly before arrival, R1 reported not feeling well with more sluggish behavior and weak pulses. Staff reported pulses between 30's -40's. R1 was not able to answer questions well, unknown if this was due to dementia or shock. R1's skin was pale and dry; speech was slurred and not able to follow commands appropriately and had noted hypotension and bradycardia. R1 transferred patient care to receiving team at Saint Mary's Hospital. R1's ED to hospital note, dated 10/9/23, indicated reason for visit was a drug overdose with a primary diagnosis as bradycardia. Hospital course: R1 presented with bradycardia and hypotension in the setting of iatrogenic (illness caused by medical treatment) medication administration, generally takes amlodipine 10 mg and lisinopril 20 mg daily while at Rochester West. R1 received diltiazem XL and metoprolol instead of her usual medications. R1 was then transferred to intensive care unit (ICU) where R1 weaned off of the vasopressor (a group of medicines that constrict (tighten) blood vessels and raise blood pressure) medications within hours. During an observation and interview on 10/24/23 at 8:40 a.m., R1 was seated in a wheelchair up to the table in the dining room. R1 stated I did have to go to the hospital recently, that's why I have bruises all over my arms from where they shot me up. R1 indicated not remembering why she was hospitalized . During a phone interview on 10/24/23 at 4:13 p.m., registered nurse (RN)-A indicated it was her first day of orientation at the facility on 10/10/23, and RN-B was training her in. RN-A indicated she mistakenly gave R1, R2's medications. RN-B told her R1 would be on the toilet. RN-A had asked R1 if she was R2 and R2 indicated she was R1, so she gave R1 the pills. R1's vital signs were checked right away and they were normal. We tried calling the provider three different times with no call back. We finally called 911 because R1's pulse was in the 30's and R1 was sent out to the hospital. RN-A indicated it was not known when R1's blood pressure and heart rate started to drop because no one was monitoring vital signs and did not identify why monitoring was not in place. RN-A stated R1's vital signs should have been frequently monitored after the error. During a phone interview on 10/24/23 at 10:33 a.m., RN-B stated on 10/9/23, she was mentoring RN-A who was a new nurse to the facility. Around 9:30 a.m. RN-B stated RN-A had dished up R2's medications and went to the bathroom and gave the medications to R1 in error. RN-B indicated R1 had received her morning meds around 7:30 a.m. and then received R2's morning meds around 9:30 am. RN-B stated she took R1's vital signs right away and they were within normal limits, attempted to call the on-call physician, but was unable to get a return call timely. RN-A indicated R1's vital signs had not been monitored after the medication error and before the physician returned the call at 1:15 p.m. RN-A was unable to articulate why there was no monitoring in place. When the provider called back at 1:15 p.m., R1 was lethargic, cool to the touch, and had a pulse of 32. The on-call provider gave the order to send to the hospital. She stayed with R1 trying to keep her awake until the ambulance arrived; they immediately started an IV and gave R1 some Atropine (a medication that increases heart rate) and sent to the hospital. During an interview on 10/24/23 at 3:02 p.m., director of nursing (DON), indicated that on 10/9/23, RN-A should not have been passing medications because it was her first day of orientation. RN-A should have just observed, that was the reason access to the electronic health record was not immediately given to new staff. RN-A gave R1, R2's medications in addition to her own mistakenly. DON indicated she informed RN-B to check vital signs and call the provider. DON was not aware there was difficulty with contacting the provider until after lunch time and not aware R1's vital signs were not being monitored or assessed. R1 was transferred from the ER to the ICU for cardiac treatment; her diagnoses were a drug overdose and bradycardia. DON immediately educated RN-A and RN-B on the five rights of medication administration, triple checking medications, cardiac med side effects, the monitoring and assessing of a change in condition, and education on how to contact the on-call medical provider. Additionally she educated all trained medication assistants (TMAs) and licensed staff prior to their next shift. During an interview on 10/25/23, at 11:00 a.m. medical director (MD) indicated he was aware of the medication error had occurred however was not aware of the details that led up to the error, did not realize R1's vital signs were not monitored from 9:09 a.m. until R1 was sent by ambulance at 1:15 p.m., and unsure why their was a delay with the on-call physician services. At a minimum MD expected frequent monitoring of R1's vital signs for changes and when R1's pulse dropped to 32 and blood pressure dropped to 55/32 with signs and symptoms of lethargy became an emergent situation requiring emergency services. MD further indicated medications R1 received in the hospital increased and stabilized her blood pressure and heart rate. Facility policy Medication Administration General Guidelines dated 01/21, identified .10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification include a. check identification band, b. check photograph attached to medical record, C. verifies resident identification with other nursing care center personnel. Note: the residents room number or physical location is not used as an identifier. Facility policy Medication Error Reporting and Adverse Reaction Prevention and Detection dated 9/2010, identified 3. Medication errors and adverse drug reactions are considered significant if they: a. require discontinuing a medication or modifying a dose, b. require hospitalization .require treatment with a prescription medication .F. are life threatening 6. In the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to protect the residents safety and welfare. A. The prescriber is notified promptly of any significant error or adverse medication reaction, b. Any new prescriber's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. Facility policy Change in Condition of the Resident, dated 9/20/22, identified A facility should immediately .consult with the resident's physician .when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly. Facility policy, Physician Visits, dated 6/17/19, identified a facility must provide or arrange for the provision of physician services 24 hours a day, in case of emergency. Lacked a procedure. The past noncompliance immediate jeopardy that began on 10/9/23, was removed on 10/9/23, after the facility implemented a systemic plan which included training of all staff responsible for medication administration to include: the right patient, right medication, right dose, right time, right route, and documentation. Assessing for a change in condition and monitoring the residents condition along with provider notification. A plan was made for medication competency checks and audits to ensure compliance, which was verified through interview and document review.

Based on interview and document review the facility failed to comprehensively assess and monitor a change in condition in respiratory and mental status and failed to notify the physician for 1 of 3 residents (R3). The facility's failures resulted in harm when R1 was emergently transferred to the hospital after an unwitnessed fall which resulted in shoulder and rib fractures. Findings include: R1's Face Sheet indicated she was admitted to the facility on [DATE], and discharged on [DATE]. R1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) dated [DATE], indicated R1 was unable to complete a Brief Interview for Mental Status evaluation, however a progress note dated 9/23/22, at 10:41 a.m. documented R1 was alert and oriented and able to communicate her needs. R1 also required extensive assistance from staff for bed mobility, transferring, walking, dressing and toileting. R1's undated comprehensive care plan was printed and provided on 11/2/22. Care plan identified R1 had a self-care deficit as evidenced by physical limitations requiring assistance of one and a four-wheel walker for ambulation. Further identified R1 was at risk for falls related to de-conditioning and weakness. R1 showed a potential for discharge. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further directed to check blood oxygen saturations every shift. Review of R1's treatment administration record (TAR) for September and October 2022, identified R1 received 1-2 L of oxygen; R1's oxygen saturations ranged from 92-97% (normal oxygen saturations are 97% to 99% on room air.) During an interview on 10/31/22, at 2:10 p.m. assistant director of nursing (ADON) stated she completed R1's admission assessment to the facility. R1's speech was clear, and she was able to communicate her care needs. During an interview on 11/02/22, at 2:00 p.m. nursing assistant (NA)-A stated throughout R1's stay at the facility, R1 was alert and able to voice her care needs. R1 was described as cooperative and did not have slurred speech. R1's progress note created by registered nurse (RN)-A dated 10/5/22, at 12:15 a.m. documented R1 was yelling, I can't breathe, I can't breathe. R1 was noted to have slurred speech and RN-A documented she was unable to understand what R1 was saying. R1's medical record lacked a comprehensive assessment(s), lacked documentation of vital signs were recorded, and lacked identification of what interventions were attempted or offered to stabilize R1. However, during an interview on 11/2/22, at 11:45 a.m. RN-A stated she placed the nasal cannula oxygen tubing back on R1 and calmed her down. RN-A stated she did not perform any other cares nor complete any other assessments. Further, R1's record did not identify if the physician was notified of a new onset of slurred speech or R1's difficulty breathing. R1's progress note created by RN-A dated 10/5/22, at 4:25 a.m. documented R1 yelled out and was found sitting on the floor. RN-A's assessment of R1 indicated R1 had a pulse oximetry reading of 76%. R1's progress note created by RN-A dated 10/5/22, at 5:30 a.m. indicated R1 was now sleeping but quiet. R1's medical record did not identify comprehensive assessment(s) were completed after identification of R1's low oxygen saturations, nor identify interventions implemented to stabilize R1's respiratory status, or evidence of ongoing monitoring. Further, it was not evident physician notification of the change in R1's respiratory status and R1 had sustained a fall. R1's progress noted created by RN-B dated 10/5/22, at 11:02 a.m. documented R1 had an unwitnessed fall that morning around 4:30 a.m. and now R1 was having neck and mid-shoulder pain. R1 was described as very pale and lethargic. Further, R1 was able to answer orientation questions appropriately, however, R1 was very slow to respond. RN-B additionally documented R1 was unable to keep her eyes open earlier in the morning. After an assessment and consulting with the assistant director of nursing (ADON), it was determined that R1 should be transported to the ED for further evaluation of the fall. During an interview on 11/2/22, at 11:45 a.m. RN-A stated R1 had been agitated, restless, uncooperative, and had strange and odd behaviors that started the evening of her shift on 10/4/22. At approximately midnight, R1 was yelling out and it was discovered R1 had taken her nasal cannula oxygen tubing off and the tubing was tangled in her night gown. R1 reported to RN-A that she could not breath and R1 had slurred speech. RN-A stated this was the first time she heard R1 slur her words. RN-A placed the nasal cannula oxygen tubing back on R1 and she seemed to calm down. RN-A stated she thought about contacting the doctor at the time, but she did not. RN-A stated at approximately 4:30 a.m. on 10/5/22, R1 was yelling out and upon entering her room, it was discovered R1 was sitting on the floor, next to her bed. RN-A asked R1 how she fell and R1 replied she sat down hard. RN-A obtained R1's vital signs and it was discovered R1's oxygen saturation was 76%. RN-A stated she again thought about contacting the physician on call, but she did not. RN-A indicated the reason she did not contact the physician was she was tired and had been assigned a double shift that included an overnight shift. RN-A further stated, it was a standard of practice to contact the physician for an unwitnessed fall, [CONDITION(S)], and change in condition. During an interview on 10/31/22, at 2:52 p.m. RN-B stated RN-A received an end of shift report the morning (at an unknown time) of 10/25/22, from RN-A. RN-A had reported to her R1 had had been awake all night, was having intermittent confusion, and had an unwitnessed fall while self-transferring. RN-B had questioned why R1 had not been sent into the hospital after the fall and change in condition, however she had not notified the physician of R1's change in condition after she had received report. RN-B described on 10/5/22, at approximately 11:00 a.m. R1 was complaining of shoulder and neck pain and seemed confused. RN-B stated when she attempted to obtain an oximetry reading that initially it did not read on the oximeter and when it did register, it was 71%. RN-B called ADON to assist in an assessment, and it was determined that R1 should be transported to the ED. During an interview on 11/2/22, at 10:37 a.m. DON stated R1 was a matter of a fact speaker and could verbalize her care needs. The DON stated when R1 had her first change in condition on 10/05/22, at 12:15 a.m., RN-A should have contacted the physician for instructions, but this did not happen. Further, when R1 had an unwitnessed fall on 10/5/22, at 4:30 a.m. and R1 had a low oximeter reading, RN-A should have immediately contacted the physician and R1 should have been transferred to the ED for evaluation. The DON stated that was facility policy and RN-A did not follow the policy. Review of the ED assessment, evaluation, and encounter summary dated 10/5/22 identified R1 was admitted to the ED for evaluation of falls and shortness of breath. MD-A documented the results of a computerized tomography scan and identified the following impressions: 1. new subacute (between acute and chronic) comminuted displaced intra-articular fracture of the left clavicular head (broken bone in the shoulder/neck area) and 2. new acute and subacute non-displaced fractures of the right anterolateral 5th and 6th ribs (broken ribs). The ED final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minnesota Document of Death dated 10/13/22, indicated a significant condition contributing to R1's death included, multiple [MEDICATION(S)] force injuries (left clavicle and right rib fracture), (fall). A review of the facility Change in Condition of the Resident policy dated 9/20/22, directed the facility should immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). Further, the provider should be immediately notified of acute or sudden onset of symptoms or a marked change in the residents condition. Resident assessment is to include vital signs, oxygen saturation, personality, behavioral and/or cognitive changes, speech disorder, and dyspnea (problems breathing). The policy also directs, but not limited to, staff documenting a description of change in condition and assessments or observations of findings.

Based on observation, interview and document review, the facility failed to thoroughly investigate allegations of abuse and neglect made by 4 residents (R9, R24, R5, and R17) about 1 nursing assistant (NA-A) and an unidentified NA. This resulted in an immediate jeopardy for R9, R24, R5 and R17 who expressed distress and psychosocial harm as they had not been protected from NA-A being verbally abusive towards them and rough with them. The IJ began on 4/20/22, when it was identified NA-A had multiple accusations of rough and verbally abusive behavior and neglectful behaviors made against her and the facility had not thoroughly investigated or protected residents during an investigation. The administrator and director of nursing (DON) of the facility were notified of the IJ on 4/20/22, at 2:13 p.m. The IJ was removed on 4/21/22 at 5:00 p.m., but noncompliance remained at the lower scope and severity level of D - no actual harm with potential for more than minimal harm. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], included cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No behaviors or rejection of cares were noted. R9's care plan revised 8/3/21, indicated R9 was a vulnerable adult and at risk for potential abuse related to being a long term resident that utilized adaptive equipment and required staff assistance for activities of daily living (ADL's). R9's care plan indicated facility staff would be educated on reporting abuse and would redirect from potentially dangerous situations. R19 should remain free of retaliation if alleged abuse was reported. Facility staff would observe for changes in mood, behavior, psychosocial needs and cognition. R9's care plan also included, Has verbalized specific staff that she prefers not to provide care to her. The only interventions for this included, it would be reviewed at care conferences how it was going and, Staff have been made aware of resident preferences. During an observation and interview on 4/18/22, at 3:41 p.m. R9 stated nursing assistant (NA)-A was, such a smartass and does not listen to her residents. R9 stated NA-A told her, don't tell me what to do! R9 stated NA-A is two faced; stating one minute she is really sweet and the next time she will turn a cheek on you. R9 disclosed NA-A and activities aide (ACT)-B were family members. R9 had asked ACT-B to assist her with elevating legs from floor to bed. NA-A entered R9's room on 4/11/22, and yelled at ACT-B for assisting resident's legs into bed, stating you can't do that, you don't know what you're doing, and you're not doing it right. R9 stated NA-A, threw, her legs into bed and it hurt her legs and hurt her pride. R9 stated she felt NA-A treated her legs roughly on purpose. R9 stated she did not report the incident to management, but thought ACT-B would have notified them. R9 stated NA-A would often make her feel, less than human and as someone without a brain, when providing cares to her. NA-A would often tell R9 she did not know what she was doing when it came to her own cares, well-being, and knowing her own body. R9 was observed teary eyed and saddened when speaking to surveyor about the incident. R9 stated she felt NA-A verbally abused her and physically hurt her legs. R9 stated she knew her own body, she has full cognition, and has to tell NA's how to do their jobs as most of them are improperly trained at facility. When interviewed on 4/19/22, at 8:24 a.m. R9 stated NA-A is, just a thorn in my side. R9 stated she wished NA-A wasn't even at the facility as she gets very nervous when NA-A is around her. R9 stated she has told facility staff about NA-A's, psychosocial mistreatment, verbal abuse, and being rough, with her. R9 stated she had informed other NA's, activity staff, and the director of nursing (DON) but nothing was ever done about it. R9 stated she felt the DON, didn't do anything at all, to be honest. R9 stated she cringed at the sight of seeing NA-A out in the north hallway, let alone, when she comes into my room. R9 was observed shaking and teary eyed again after repeating incident. When interviewed on 4/19/22, at 8:56 a.m. activities director (AD)-A stated she was unaware of the situation involving R9, NA-A, and ACT-B as ACT-B did not mention it to her. AD-A stated ACT-B should not have been completing activities of daily living (ADL's) such as assisting legs into bed for R9. ACT-B was not available for interview. When interviewed on 4/19/22, at 9:25 a.m. the director of nursing (DON) stated she was unaware of an incident involving R9, NA-A, and ACT-B where R9 made an accusation NA-A had verbally abused her and provided rough treatment by throwing her legs into bed roughly. DON stated numerous times the facility was immediately suspending NA-A pending an internal investigation. DON stated she was going to notify the facility management team and start an investigations right away. DON stated R9 and NA-A had a concern approximately one year ago, but there were no recent concerns noted. The DON was notified R9 was very tearful when talking about NA-A and R9 stated she cringes at the sight of NA-A. DON confirmed again NA-A would be suspended. A facility reported incident dated 8/19/21, identified R9 had reported NA-A and another NA had transferred her roughly, this was found to be unsubstantiated by the facility investigation. When interviewed on 4/20/22, at 7:56 a.m. licensed practical nurse (LPN)-A stated she had no knowledge of R9 making any allegations against NA-A. When interviewed on 4/20/22, at 8:19 a.m. environmental services manager (EVS)-A stated R9 shared with her an incident that occurred sometime in the past month but was uncertain of exact date. EVS-A brought laundry to R9'S room the following morning. R9 informed EVS-A an incident happened the evening prior when NA-A was working. NA-A yelled at R9 telling her, No we are going to do it my way, not your way. EVS-A stated R9 was visibly upset about this, raised her voice, and shook as she spoke about it. EVS-A immediately reported it to the DON, but did not know if anything had been done about it. EVS-A reported DON has bimonthly nursing staff meetings so EVS-A assumed it was addressed. EVS-A stated she has heard, through the grapevine, that NA-A can be rough with residents at the facility, but had not witnessed this herself. When interviewed on 4/20/22, at 9:30 a.m. SW stated she had witnessed NA-A, rushing, resident cares and has told NA-A to slow down. Once in December 2021, NA-A was putting on R9's shoes, so quick it hurt her. SW had told NA-A to slow down and NA-A got defensive. SW had stayed in R9's room afterwards and R9 told her, I was so thankful you stayed in the room and were here. SW stated R9 had confided in her that she was, terrified, of NA-A. SW stated she had reported the episode to registered nurse (RN)-D, however, RN-D told NA-A and then NA-A came back to her and NA-A became upset and told SW, this is none of your business. When interviewed on 4/20/22, at 10:20 a.m. the DON stated R9 and NA-A had, prior encounters and had gone back and forth many times. R9 did not like NA-A because she was, loud, brassy, and a know it all. NA-A had been moved to the other hallway (south) at one time as R9 did not want NA-A on her hallway (north) nor providing cares for her. The DON stated R9 was, strong-minded, needs to be in control, and tells staff how she likes things done and does not like to it if anyone gives their own opinion. The DON stated NA-A, clashes with any resident who required delicate care. The DON stated there were residents on the other hall that would be considered delicate too and NA-A was eventually moved back to the hall where R9 resides. When interviewed on 4/20/22, at 1:40 p.m. the administrator stated she was unaware of incident involving R9, ACT-B, and NA-A. The DON typically does the initial report to the state agency, but stated she kept a full paper copy of all incidences reported. The administrator had not allegations of abuse from R9. When interviewed on 4/21/22, at 8:51 a.m. R9 stated she cringed every single time NA-A was working and especially if she was assigned to the north hall. R9 stated NA-A caused her a great deal of pain when she, grabbed, her legs and no other staff has ever done this to her before. R9 stated she found out today that NA-A was not coming back and she was happy she would not be abused again. R9 stated she was about at the end of her rope with the cares she received from NA-A. R9 stated she was treated with much disrespect and this made her feel mad. When interviewed on 4/25/22, at 9:25 a.m. R9 stated knowing NA-A was gone that it took a big load off of her shoulders. R9 stated she cried many times behind closed doors from the treatment she received from NA-A. R9 stated facility staff were aware NA-A was not welcome inside her resident room, but for some reason NA-A consistently worked on north hall. R9 stated NA-A was rough and would, just yank my legs which caused severe pain in my back and legs. R9 stated she almost slipped off the edge of her bed once as NA-A, yanked on me so hard and fast. R9 stated she told multiple facility staff which included NA's, SW, and DON that she preferred NA-A to not be in her room, but this never happened as R9 felt she was never heard by facility staff. R9 stated she kept quiet for a long time until she could not take it anymore as the treatment only got worse. R9 stated she felt NA-A verbally and physically abused her at facility. R24's significant change MDS dated [DATE], included cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No behaviors or rejection of cares were noted. R24's care plan dated 4/16/21, indicated R24 was a vulnerable adult at risk for potential abuse due to requiring assistance for all activities of daily living (ADL's) and some assistance for decision making. R24's care plan indicated the facility staff were educated on reporting abuse and would redirect from potentially dangerous situations. R19 should remain free of retaliation if alleged abuse was reported. Facility staff would observe for changes in mood, behavior, psychosocial needs and cognition. When interviewed on 4/18/21, at 6:05 p.m. R24 stated some of the nursing assistants (NA) were, rough and tough. R24 stated she told them to be more gentle as it really hurt her. R24 stated an unnamed NA recently refused to get her a bedpan to have a bowel movement. NA instructed R24 to just go in her depends and they would change her afterwards. R24 stated the NA told her the bedpan was not big enough for her and the facility does not utilize bedpans. R24 stated she did not want to go in her pants and this was not okay with her. R24 would not provide specific information on who this NA was. R24 was observed to be teary eyed during interview and appeared to be hesitant in providing information specific to NA. When interviewed on 4/19/22, at 3:27 p.m. R24 stated she spoke to SW earlier today and informed her of the NA's name but was unwilling to share information as her roommate was in the room. R24 informed surveyor NA was a female. When interviewed on 4/19/22, at 4:43 p.m. SW stated R24 informed her the alleged perpetrator was NA-A and was very focused on this NA. When interviewed on 4/21/22, at 1:36 p.m. R24 stated the NA she had concerns with was NA-A. R24 stated NA-A on multiple occasions would grab her arm so hard it would hurt. Once she grabbed her arm so hard it lifted her right off the bed. R24 also stated NA-A would scrub so hard on her, private parts, that she felt like, a scrubbing board. R24 stated NA-A had left bruises on her arms and legs at times. R24 stated having to be cared for by NA-A had, taken a toll, on her mental health and she was depressed over it. Once R24 requested to be boosted up in bed by NA-A and NA-A told her to do it herself. When R24 told NA-A she was unable to do that, NA-A told her if she didn't stay in bed all the time, she would be able to do it. At that point R24 tried to explain her medical condition to NA-A and NA-A just walked out of the room while she was speaking. R24 stated she didn't know why NA-A was so rough and mean to her. I feel like a big fat nobody. R24 had tears in her eyes. R24 had not reported it, stating every time she would say something, NA-A would be take it out on her. R24 stated she felt she had been physically and verbally abused by NA-A on multiple occasions. When interviewed on 4/22/22, at 8:45 a.m. NA-B stated R24 had no behavioral concerns other than refusing cares at times. NA-A stated R24 could be, needy at times and demanding on staff. R5's annual MDS dated [DATE], identified R5 had had a slight decline in his cognitive score from being fully cognitively intact in January, to being moderately impaired, and also exhibited mild depression. The MDS indicated R5 did require assistance with his activities of daily living skills (ADLs). R5's care plan had a focus problem area dated 4/16/20: ADL self-care deficit related to: physical limitations. Associated interventions prompted NAs to provide assistance with his daily cares including bathing and hygiene, but did not indicate how many persons were required to assist with his care. Additionally, R5's care plan indicated: Resident was at risk for potential abuse due to requiring assistance with mobility and ADL's. The goal indicated he would be safe and free from abuse during his stay. Associated interventions indicated staff would be educated and R5 would be encouraged to verbalize concerns of problems. When interviewed on 4/19/22, 9:30 a.m. R5 stated there was a nursing assistant, that he was only able to describe as a black woman (her name possibly starting with a T) who would not respond to his request for assistance to clean up after a bowel movement. R5 stated, she will say, 'I need to find someone to help me', but then she will leave and it will be an hour or so. R5 stated the NA might come back and say she had not found anyone to help and would leave again. R5 felt he had waited up to four hours for help. R5 stated he was able to turn himself in bed so cares could be provided, and his ability to turn was observed during the interview. R5 stated he had asked for someone in leadership to come talk with him, but felt they did not respond to his requests. R5 also reported that he had complained to a NA about his care, feeling it was rough and caused him pain. R5 further reported, the NA responded to him in a mocking tone and said, why don't you call the ombudsman or your caseworker? R5 was unable to recall the name of the NA. R5 stated he had called his personal representative to report his concerns since he felt no-one was responding to his request to talk. R5 felt he had been treated roughly and rudely on multiple occasions by this NA. On 4/19/22, 4:31 p.m. the administrator brought in evidence of a past investigation related to R5, and also the nursing schedule for 4/7/22 through 4/10/22 that had been reviewed in response to R5's allegations. The administrator stated the only person with a name starting with T had worked on 4/7/22 prior to R5's stated concerns, and stated that individual did not fit the description, so they had no one they could suspend while they investigated. Administrator and DON were both present and stated they had not yet spoken with R5 since receiving the reported concern at 10:47 a.m. because the facility worked with R5's representative, a case worker-advocate (CW) instead, saying that was what he [R5] was comfortable with. The administrator was unaware R5 had requested management speak with him, but no one ever came. A review of a Grievance/Complaint form dated 4/13/22 indicated the facility had received a concern from R5's CW. It indicated the complaint was provided to the administrator and social worker (SW). The grievance outlined R5's concerns with the NA (a person of color, name starting with T) turning off the call-light after he had requested assistance, and included a statement that NA had indicated lack of knowledge of how to change a bed with a resident in it [standard of care for NA]. Grievance indicated NA did not return for four hours. Also, the form included a grievance that the same NA took two hours to bring a glass of ice, and also the same NA had told R5 to hurry up as NA was scheduled to leave soon as it was almost 10 p.m. A subsequent review of the nursing schedule for 4/8/22 and 4/9/22 did not show any nursing assistants with a name starting with the letter T. When interviewed on, 4/20/22, 8:54 a.m. CW, providing support to R5, stated R5 had had similar concerns in the past. In the last week or so, R5 had stated a similar complaint of a person not providing care when he had turned his light on for assistance after he had a BM. R5 had reported rude, mocking and disrespectful behavior by a nursing assistant to CW. CW stated, Last week we talked to SW and administrator to file a grievance. I didn't know another way to file a complaint. CW said R5 had requested to talk to anyone in leadership, the administrator, DON, but said no-one had responded to his request. CW stated she assisted R5 by calling the facility to file a grievance on 4/12/22. In response to that call, CW said the facility indicated they would investigate his concerns, pull a call-light report and try to talk with the staff person to address R5's concerns. CW also said R5 could not recall the name of the NA, but it might have started with a T, and the incident had occurred possibly Friday 4/8/22 or Saturday 4/9/22 during the evening shift. CW stated she attempted to advocate for R5, but felt it was difficult as the facility did not often reach out to her and she felt there was little change in response to any concerns brought forward. When interviewed on 4/20/22, at 9:30 a.m. SW stated she had spoken to R5's CW on 4/12/22, CW had been concerned because an aide had turned off his call light, was not attentive, would not give him ice and made him wait 4 hours in soiled undergarment before changing him. SW stated the CW was reporting neglect and this should have been reported to the state agency and investigated. When interviewed on, 4/25/22, 8:20 a.m. NA-F stated she usually took care of R5 in the morning and R5 would require a total change of bed linen almost every morning due to accidents with his urinal use. NA-F stated R5 did not get out of bed at that time because it was too painful for him to use the Hoyer lift, but his arms were strong. NA-F stated R5 only required a boost on his back or bottom to fully turn in bed. NA-F stated she could easily change the linens and provide personal cares to R5 independently without assistance. NA-F stated that R5 sometimes had refused to have cares completed, but one person could provide those cares when he was accepting of them. When interviewed on 4/25/22, 9:33 a.m. R5 again expressed distress about being left in BM unattended, and being talked to in a mocking tone of voice and stated it made him feel, so, so .I felt uncared for, like you're, like you're not good enough. R5 had difficulty speaking this, turned away and had tears in his eyes. R17's significant change MDS dated [DATE], identified cognitively intact and had no behavior problems. R17 required extensive staff assistance for most activities of daily living (ADL's) except could feed self with set up. R17 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's care plan dated 9/23/21, included paranoia/suspiciousness related to life experiences history of unhealthy relationships. R17's goal was to feel safe and secure in the environment. Staff were directed to, use consistent daily routine and caregivers, praise for acceptable behavior and explain procedures. Another care plan area was, ruminating and catastophizing behavior. Staff were directed to keep details to a minimum, remain positive, and ask if would like to be left alone for a while. In addition, the care plan identified R17 as a vulnerable adult and was at risk for abuse. Staff were to be educated on abuse reporting and R17 would be encouraged to verbalize concerns or problems. When interviewed on 4/18/22, at 2:31 p.m. R17 stated she was unsure of the date, but there was an incident which occurred possibly in August or September 2021 with NA-A. R17 stated she was unsure of the date, but she had been stronger and had been able to get up to the toilet. R17 said she had not been able to get fully seated on the toilet stool and had dribbled on it, so asked NA-A for paper towels to clean it. Then R17 said she realized she had not finished urinating and asked NA-A to wait. R17 reported that NA-A had said, Jesus Christ [R17's name]. R17 stated there had been another incident with NA-A where NA-A had come to collect her meal tray while R17 was on the toilet, and R17 had told her she was not yet done with the tray, and heard NA-A say, that figures. R17 stated she still had her beverages to drink, a dish of sweet potatoes and dessert left. R17 said, sweet potatoes are my favorite thing. When R17 returned to her room she found NA-A had removed the tray but left her beverages and dessert. R17 said she told NA-A that she was not done with the sweet potatoes and NA-A left the room, cursing under her breath, saying, [OBSCENITY] you, and slammed the door. R17 said she had tried to talk with NA-A about her treatment and told NA-A she could not talk to her like that. R17 said NA-A had replied, look at the way you talk to me! R17 said she did report NA-A's behavior to the DON. R17 said the DON sat on the foot of the bed with her head in her hands and said, I'm just so short [staffing]. R17 said she had replied, are you going to have someone so abusive work here? A facility reported incident dated 6/14/21, identified, Today the resident stated to facility interim Administrator that on Monday night around 6 pm, she was abused. The resident stated the evening aide came into the room, took her dinner tray, walked out of her room and slammed the door. The resident stated she repeatedly asked/told the aide she wasn't done eating yet. The alleged staff member, identified as NA-A, had been suspended pending investigation. The investigative report dated 6/23/21, identified NA-A had claimed she had been polite to R17. The facility assigned NA-A to a different group of residents and assigend R17 to, Cares in Pairs. When interviewed on 4/20/22, 2:53 PM R17 reported the DON and social worker (SW) had come to talk to her. R17 said the DON had asked if NA-A had left any bruises, R5 said, I said, 'no, it was verbal abuse,' I don't know why she can't remember it! When interviewed on 4/22/22, 11:07 a.m. R17 voiced frustrated on her interactions with NA-A in the past, stating how angry she felt about it, and that she felt it was abusive behavior and the facility did not protect her from being cared for by NA-A. On 4/25/22, 9:40 a.m. R17 stated she wanted to talk about her experience with NA-A again. R17 repeated that she had reported the incident, and described her feelings about how she had been treated. R17 said, I felt like I was going to throw up. I didn't feel safe. Each time she came in, I thought she would say nasty things to me. It pissed me off, and made me feel angry. When I tried to talk to her in the past, it was like a power play. She [NA-A] said, 'oh, [R17] get real! R17 shrugged her shoulders. An anonymous staff member had filed a complaint on 3/8/22, on behalf of all residents indicating NA-A was providing, rough treatment to residents and would often refuse to assist them. Another separate complaint from a staff member was also filed on 3/8/22, identified NA-A was, rough and rude to residents and would refuse to assist them with cares. It was unknown if either of these staff members had reported their concerns to the DON or administrator as required in the facility policy as they did not leave contact information. When interviewed on 4/20/22, at 8:00 a.m. RN-A stated she had witnessed NA-A treat residents poorly. RN-A stated NA-A was short with the residents and would not listen to their needs. A couple months ago two residents, R99 and R5 had complained about NA-A and had reported the concerns to the DON. NA-A was then not allowed in R5's, R17's, or R9's room, because they did not like how NA-A treated them. However, because of scheduling NA-A was actually still caring for those residents. RN-A had witnessed sometime in December of 2021, NA-A was talking in harsh tones to residents, she did not remember who, and RN-A had confronted NA-A, but NA-A told her the residents had behaviors. RN-A did not send NA-A home or provide continuous supervision. RN-A stated the executive director had a conversation with NA-A. NA-A then confronted RN-A. cornering her in a room and slamming the door and yelled at her, if you have a problem with me, we don't need to get leadership involved. In the past couple weeks RN-A had witnessed NA-A tell R18, You don't have to use the bathroom, you can wait until it is the right time. RN-A stated there had been multiple times NA-A had been reported to the DON. When interviewed on 4/20/22, at 8:53 a.m. NA-A stated the facility had called her yesterday and made her aware of allegations pertaining to R9, but they were not specific. NA-A stated back in December 2021, the executive director told her she had a poor bedside manner and talked to her about communication and not rushing residents. NA-A denied being rough with, abusing or neglecting any resident. NA-A stated, if we are honest, I feel it's a racist thing. NA-A stated she was not supposed to care for R9 or R17, but sometimes she was the only one available to care for them, so she did. NA-A stated she felt multiple residents were alleging neglect of care, being rough/physically abuse or verbally abusive towards them because she, speaks loud, is efficient with her work and dictative. NA-A stated she has never refused to take residents to the bathroom, but reminds them when they had just been there or it wasn't time to go yet. The administrator and director of nursing (DON) of the facility were notified of the IJ on 4/20/22, at 2:13 p.m. On 4/21/22, Between 8:30 a.m. and 10:00 a.m. LPN-A, NA-B, MAINT, HSK-A, EVS-A had been interviewed and had not recieved education on the abuse policy and abuse reporting prior to starting their shift. However, by noon all staff working had been educated. The immediate jeopardy that began on 4/20/22, was removed on 4/21/22, when the facility removed NA-A from working with residents and she subsequently resigned; psychosocial assessments were completed with affected residents, investigations into the allegations were started to include interviews with staff and other residents, staff were educated prior to working their next shift to include reporting of allegations of abuse, investigating and on their abuse policy and audits of grievances were reviewed to ensure none met the definition of abuse for reporting. However, the noncompliance remained at the lower scope and severity level of a G, actual harm that is not immediate jeopardy because R9 and R24 both had expressed they had lived in fear due to the abuse not being addressed by the facility and it had affected their psychosocial wellbeing. Actions taken by the facility were verified through interview of LPN-A, NA-B, MAINT, HSK-A, EVS-A, SW, RN-A and NA-C, and review of psychosocial assessments and documentation of staff being trained on abuse. A facility policy dated March 2018, titled Abuse Prevention Program included, residents have the right to remain free from abuse and neglect. Upon receiving an allegation of abuse, the staff member receiving the allegation must immediately notify the supervisor on duty. The supervisor will immediately notify the administrator or designee. The alleged perpetrator will be asked to leave the facility immediately and be escorted out of the facility. If necessary law enforcement would be notified. If an employee, they would be suspended immediately pending investigation. The resident would have a full physical assessment and psychosocial support as needed. The administrator or designee would report the allegation to the state agency within 2 hours. All facility staff would be inserviced on the abuse prevention policy.

Based on observation, interview and document review the facility failed to ensure infection control procedures were implemented to reduce the risk and spread of an unknown gastrointestinal (GI) illness in the facility resulting in 10 of 28 residents (R82, R27, R1, R20, R18, R19, R26, R15, R13, and R9) developing GI symptoms and the facility lacked any investigation of causal factors and or testing for pathogen. In addition, the facility failed to implement timely isolation of symptomatic residents, and failed to perform hand hygiene following care of symptomatic residents, placing this vulnerable population of residents and health care workers at risk of serious illness. Further, the facility failed to use sanitary practices when passing ice water to residents, using bare hands and a cup inside with the ice to scoop, this had the potential to affect all 28 residents currently residing in the facility. The immediate jeopardy (IJ) began on 4/12/22 when the facility failed to ensure infection control procedures were implemented related to signs and symptoms of GI illness to reduce the risk of spread of unknown GI illness and was identified on 4/22/22. The administrator and director of nursing (DON) were notified of the IJ on 4/22/22, at 1:31 p.m. The IJ was removed on 4/27/22 at 1:07 p.m. when the facility ensured all residents with symptoms of GI illness were placed on transmission-based precautions with signage in place. All residents were screened for signs of GI illness, the physician was notified, policies and procedures were reviewed, all staff were educated, high touch areas were disinfected, tracking was started for employee call in's, and audits of handwashing were started. However, the non-compliance remained at the lower scope and severity of an E - a pattern with no actual harm with potential for more than minimal harm. Findings include: When interviewed on 4/20/22, at 2;39 p.m. the director of nursing stated they had some GI illness in the facility but it was resolved at this point. The DON stated they treated it as an outbreak and notified [NAME] County Public Health and notified the nurse practitioner and the medical director. One test had been ordered for R9, but canceled because R9 went to the hospital and they determined her symptoms were from constipation. Another specimen was ordered, but pending. Some staff had been ill with GI symptoms, but did not come back to work until all symptoms were gone. The DON had not tracked which staff had been ill. They were questioning if they had a norovirus (gastro-intestinal illness that is highly contagious), but did not have confirmation of that. The DON stated they put anyone who had one to two loose stools on precautions and anyone who had an emesis immediately. Staff were to wear gowns and gloves in any symptomatic resident room. Also, they placed the residents on, enhanced barrier protection, which meant staff were also supposed to use soap and water for washing hands after any cares rather than hand sanitizer. R82's admission Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R82's care plan dated 4/15/22, identified a gastro-intestinal illness related to an outbreak of [CONDITION(S)] [CONDITION(S)], (an inflammation of the colon caused by the bacteria Cloststridium difficile, often resulting from disruption of normal healthy bacteria in the colon, often from antibiotics. C. Diff can also be transmitted from person to person by spores and spores are not killed by hand sanitizer, they can be washed off with judicious hand washing with soap and water). Staff were directed to, Maintain droplet precaution as indicated for cdiff, and monitor for signs of dehydration. The care plan did not direct staff on contact precautions or direct them to use soap and water for hand washing rather than hand sanitizer and did not give any direction on cleaning room or dedicating equipment to prevent the spread of infection. R82's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R82's bowel record showed she had frequent loose stools, up to several times per day since admission on 4/6/22. The facility GI illness tracking log identified R82, but did not identify the start date of loose stool, it indicated, Ongoing, only. The map of GI illness had R82 listed as being, C. Diff. During observation on 4/19/22, at 4:10 p.m. R82's door was closed and there was a sign on the door indicating, enhanced barrier precautions, and instructed to staff to clean hands and there was picture of a bottle of hand sanitizer on it, use of gloves and gown. A bottle of hand sanitizer was on top of the cart and some disinfectant wipes. During observation on 4/20/22, at 8:20 a.m. NA-B entered R82's room with a meal tray. NA-B did not put on gown or gloves. NA-B set the meal tray on R82's over-bed table and with bare hands moved the table towards R82 and arranged items on the tray table. NA-B then took the plate cover off and left the room without performing any hand hygiene. NA-B placed the plate cover on the tray cart, then proceeded to move the cart down the hall with her bare hands. When interviewed at this time, NA-B stated R82, might have C. Diff. NA-B stated she had been told to wear a gown and gloves if she was working with, body fluids, and did not wash her hands due to being in a hurry. NA-B stated she should have used hand sanitizer and was unaware C. Diff spores are not removed by using hand sanitizer and hand washing with soap and water should be used instead. When interviewed on 4/20/22, at 9:38 a.m. the environmental services supervisor (EVS)-A stated hand sanitizer should be used before going into a resident room and after leaving the room. In the case of C. dif, EVS-A stated she was not aware of any difference, stating, we typically use hand sanitizer, it is quicker. EVS-A stated infection control education had been provided at the facility, but did not recall receiving anything specific related to washing hands with soap and water in the case of C. dif. or Rotavirus. When interviewed on 4/20/22, a 9:46 a.m. licensed practical nurse (LPN)-A stated, for residents such as R82 who had C. Diff, the resident should have separate dedicated equipment, staff should use gown and gloves and hands should be washed with soap and water instead of hand sanitizer. LPN-A stated staff should be using hand washing with soap and water for any residents with vomiting or diarrhea symptoms. LPN-A was not sure why the TBP sign indicated hand sanitizer was to be used for R82. During observation on 4/21/22, at 10:50 a.m. occupational therapist (OT)-A was observed assisting R82 to the bathroom, R82 had an incontinent loose stool and OT-A wearing gown and gloves assisted R82 with cleaning up, when completed OT-A placed the soiled items in a bag. OT-A removed her gloves and gown and left the room with a tablet, OT-A set the tablet down and used hand sanitizer. When interviewed, OT-A stated R82 had an infection, but was unsure what type of infection. OT-A did not know R82 had C. Diff and hand washing should be used instead of hand sanitizer. OT-A had not sanitized her tablet after it had been in R82's room and touched by OT-A with contaminated hands. It was noted at this time, R82 shared a bathroom with R15 in an adjacent room. When interviewed on 4/21/22, 10:59 a.m. a registered nurse (RN)-C stated staff would know what type of transmission based precautions (TBP) a resident required if infectious by the sign posted on their door. RN-C also said that staff should use soap and water hand washing instead of alcohol based sanitizer when working with a person with C. dif, but was unsure it that information was posted on the door, or how staff knew that. After checking R82's door, and not finding such information, RN-C stated he was going to post a sign immediately. When interviewed on 4/21/22, 11:30 a.m. the director of nursing stated there had been some gastro-intestinal (GI) infections in the facility over the past week, but normally they did not consider it to be an outbreak until they had three or more cases of diarrhea in residents. DON said the physicians and nurse practitioners (NP) had been notified, but said they, didn't think anything of it, but DON stated in her past experience they would have been hyper-vigilant. Three residents had received orders for testing, but DON said they had been unable to gather a sample for one resident, and the orders for another had been canceled. The test for R82 had indicated R82 was positive for C. Dif. DON said in the case of a GI outbreak, residents with symptoms would be monitored, signs regarding TBP would be posted, and personal protective equipment (PPE) supplies would be placed outside the room. DON said she was unsure if there was a sign posted about using soap and water instead of hand sanitizer in the case of C. Dif. DON said she had not posted a sign, but had started educating staff between 9:30 a.m. and 10:00 a.m. and she would go post the sign right away. DON said she was going to start PPE and handwashing audits. DON said R15 and R26 had developed symptoms of GI illness, and she had placed them in enhanced barrier precautions and droplet precautions and was going to talk with the medial providers and strongly encourage testing to be done on them, and any residents who developed GI symptoms. DON said R15's FM should not use the bathroom shared with R82, but was unsure if there was a sign on the door or in the bathroom. R27's admission MDS dated [DATE], identified cognitively intact and had heart disease and diabetes. R27 required limited assistance with toileting and was continent of bowel. R27 was not shown on the facility GI illness tracking log. R27's medical record identified R27 had loose watery stools and emesis on 4/12/22, and had been placed on TBP, which were removed on 4/14/22. When interviewed on 4/22/22, at 9:00 a.m. R27 stated he had gotten ill about 10 days ago and has had loose stools off and on since then. When interviewed on 4/22/22, at 10:19 a.m. the DON stated a stool collection order was not obtained for R27 as they only had vomiting and no diarrhea. The DON was not aware R27 reported he had loose stools along with the vomiting on 4/12/22. During an observation and interview on 4/22/22, at 10:31 a.m. RN-C was observed leaving R27's room and proceeded going from room to room on south hall completing vital signs on each resident. RN-C observed using hand sanitizer outside each resident room instead of hand washing. RN-C was observed not sanitizing thermometer and pulse oximeter equipment between resident use. RN-C stated he should have disinfected the equipment between each resident and used soap and water for hand washing. R1's annual MDS dated [DATE], identified cognitively intact with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's bowel record identified loose stools as early as 4/9/22, with multiple daily loose stools starting on 4/12/22. R1's care plan dated 4/22/22, identified a gastro-intestinal illness related to C. diff and Rotavirus, staff were to educate on signs and symptoms of GI outbreak, frequent handwashing and encourage to stay in room along with contact precautions, and to monitor for signs of dehydration. The care plan also directed to use soap and water for hand washing. R1 was identified on the facility map of GI infections as being in one room but moved due to GI illness symptoms to another room where she did not have a room mate and a stool specimen was sent on 4/23/22. The line listing of GI illness identified R1 as starting symptoms on 4/20/222, with the word, again. A stool specimen had been sent and was back, with no information on pathogen. R1's Clinical Communication from Mayo Clinic lab identified they had received a stool specimen on 4/23/22, and the stool contained Rotavirus and C. Diff and directed facility to place R1 on isolation and provide proper infection control processes and a report was sent to community heath. [MEDICATION(S)] (antibiotic used to treat C. Diff) was ordered. R1's progress note dated 4/23/22, at 10:42 p.m. included, Call received from [physician] from clinic with lab results for resident. Stool was tested and resulted with positive results for Rotavirus and C-diff. Pharmacy notified, as [physician] gave telephone order for [MEDICATION(S)] 125 mg to start within 24 hrs. Pharmacy will be sending enough med through back up pharmacy to be started tomorrow morning. When interviewed on 4/24/22, 8:17 a.m. RN-C stated R1 had developed GI symptoms the previous evening, and had to be moved to a private room. Testing had been completed immediately and returned results indicated R1 had Rotavirus and C. Diff. RN-C stated staff were to isolate the resident, wear PPE of gown, gloves and mask and wash hands with soap and water. R20's quarterly MDS dated [DATE], identified cognitively intact and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20 required extensive assistance with toileting, but was always continent of bowel. R20's bowel and bladder elimination log for April 2022 identified loose stools starting on 4/14/22, had two loose incontinent stools on 4/15/22 and again on 4/21/22. R20's progress notes identified the DON had been notified of loose stools and R20 was placed on transmission-based precautions (TBP). R20 was identified on the facility GI illness tracking log as starting symptoms on 4/21/22. The map of GI illness's identified R20 as having Rotavirus and GI symptoms. R20's Clinical Communication from Mayo Clinic identified a stool sample had been obtained by the lab on 4/22/22, and on 4/25/22 the specimen identified Rotavirus (a very contagious virus that causes diarrhea, vomiting, fever and/or abdominal pain and can lead to dehydration or even death). The communication identified public health would need to be notified of this contagious virus. A nurse practitioner note dated 4/22/22, also identified R20's stool sample was positive for Rotavirus. During observation on 4/22/22, at 9:50 a.m. nursing assistant (NA)-B was in R20's room and arranged items on the bedside stand, removed gloves and left the room without washing hands. NA-A touched R20's door handle, then went to a mechanical lift in the hallway and brought it to the communal bath hallway. NA-A then went into R3's room and went into the bathroom where she washed her hands. NA-A did not disinfect the door handle or the lift after touching with contaminated hands. During observation on 4/22/22, at 9:58 a.m. medical doctor (MD)-C was observed to have assisted R20 with toenails, when MD-C exited the room he used hand sanitizer outside of the room. According to the Center for Disease Control (CDC) updated 2021, hand washing with soap and water is most effective for removing Rotavirus from hands versus hand sanitizer. MD-C used his personal laptop, touched a backpack then used personal cell phone from shirt pocket and proceeded to R30's room. MD-C donned gloves without washing hands with soap and water and assisted R30 with toenails. When interviewed on 4/22/22, at 12:11 p.m. MD-C stated staff had instructed him to don/doff gloves at door, but did not specify the type of illness the residents who were on TBP had. If he had known, he would have used soap and water versus hand sanitizer. During observation on 4/24/22, at 9:25 a.m. R18 attempted to bring a bottle of sparkling water to R20 whose room is directly across the hall. The regional nurse consultant (RNC)-B instructed R18 she could not take items from one room to another without using a bleach wipe on it. During observation on 4/25/22, at 8:27 a.m. the health unit coordinator (HUC) knocked on R20's door, donned personal protective equipment (PPE) and entered the room with a meal tray. The HUC set the tray on the bedside table, moved R20's urinal off the bedside table, removed gloves and stepped outside the room, where she punched a code into the utility room door and used the door handle to open the door. The HUC then washed her hands, but did not disinfect the code buttons or the door handle that she had touched with potentially contaminated hands. The facility provided room tracking log identified R20 as having GI symptoms, and the GI illness tracking log identified R20 as beginning symptoms on 4/21/22, even though loose stools were noted prior to that date. R18's significant change MDS dated [DATE], identified cognitively intact with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 required extensive assistance with toileting and was frequently incontinent of stool. R18's bowel record identified loose watery stools on 4/14/22. R18's medical record identified she had been placed on TBP on 4/16/22, but was removed on 4/18/22. A progress note identified a note was sent to R18's physician on 4/22/22 indicating she had loose stools again, so isolation precautions were started again. R18 was identified on the facility GI illness log as starting symptoms on 4/22/22. During an observation on 4/24/22, at 8:08 a.m. a new isolation cart was located outside R18's room. During an observation on 4/24/22, at 8:47 a.m. R18 was observed coming outside of her isolation room and into hallway. LPN-A glanced over and asked R18, What's up? and did not provide redirection to R18 to go back into her room. Family member (FM)-A was observed leaving another resident room on north hallway and redirected R18 to go back into her room. FM-A donned PPE and assisted R18 back to room. During an observation on 4/24/22, at 8:54 a.m. R18 was observed back in hallway requesting help to get to the bathroom. LPN-A observed at medication cart; while FM-A ran down the hallway to assist. FM-A requested help from DON; however, DON told FM-A to, hold on. R18 stated she couldn't wait. R19's quarterly MDS dated [DATE], identified cognitively intact with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R19 required extensive assistance for toileting and was always continent of bowel. When interviewed on 4/19/22, at 11:35 a.m. R19 stated he had become ill with severed diarrhea starting 4/16/22. R19 stated staff were aware of his diarrhea and had placed incontinent pads on his bedding as he was unable to control the loose stools. R19 stated he had started to feel better on 4/18/22 in the evening, but was still unable to eat much dinner. R19 stated he had never been placed on any time of precautions and he went out to eat Easter lunch on 4/19/22, but was unable to eat as he still felt ill. R19's bowel elimination record for April 2022, identified regularly formed stools until 4/16/22, then had incontinent watery/diarrhea bowel movements after 4/16/22. R19's progress notes did not show any identification of the diarrhea, nor did R19's medical record show any evidence the physician had been notified of the illness or any monitoring of R19's illness. When interviewed on 4/22/22, at 10:19 a.m. the DON stated . DON confirmed she was aware R19 had diarrhea on 4/16/22 as she worked an overnight shift. DON failed to inform medical provider of gastrointestinal symptoms. DON confirmed R19 was never placed on isolation precautions and his symptoms still existed on 4/18/22. No stool sample had been sent to the lab. A facility provided map of GI illness symptoms, undated, identified several residents who had GI illness, but R19 was not identified as having any GI illness. A line listing of residents who had been ill with a GI illness dated 4/24/22, also did not identify R19. R26's quarterly MDS dated [DATE], identified cognitively intact with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R26 was identified on the facility GI illness tracking log as beginning GI symptoms on 4/21/22. The map of illness showed she had GI symptoms. R26 has 2 loose stools on 4/19/22, 4/20 had one loose, one formed, 4/21 had 7 loose stools, was put on isolation the 21st. During an observation on 4/21/22, 10:29 a.m. R26 had a sign on her door indicating the need for droplet precautions, but the door was wide open and R26 was sleeping without cough or obvious symptoms of respiratory disease noted. R26's bowel record showed R26 had loose stools on a regular basis, but had an increase in frequency on 4/21/22. R26's clinical communication from Mayo clinic identified R15's stool sample had been obtained on 4/22/22, and was identified to be Rotavirus and community health was to be advised. R15's admission MDS dated [DATE], identified cognitively intact, required extensive assistance with toileting, and was frequently incontinent of bowel and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's bowel record showed she had started having loose stools on 4/16/22. R15's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility GI illness tracking log identified a start date of symptoms as 4/20/22. The map of infections identified her as having a GI illness. During an observation on 4/21/22, at 10:49 a.m. it was noted R15 shared a bathroom with R82 who had been placed on precautions for GI illness. Family member (FM)-C was visiting R15, but was not wearing a gown, gloves or mask. He was overheard on the phone to not visit as R15 had a case of, stomach flu. FM-C went into the shared to the bathroom. FM-C came out of the bathroom. At 10:57 a.m. FM-C said he was aware of R15's illness and also R82's illness. FM-C said persons should not enter without wearing a gown and gloves. FM-C stated it was too far to walk all the way down the hall to dump things such as unconsumed beverages, so he had gone in the bathroom to dispose of them. He said he had been told he should not use the bathroom. He stated there was no posted information in the bathroom regarding use of the toilet or handwashing. R15's progress note dated 4/22/22, at 8:45 a.m. identified R15 had developed, GI symptoms that have been going around the facility. R13's quarterly MDS dated [DATE], identified cognitively intact with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13 was identified on the GI illness tracking log that he had developed symptoms and was placed on isolation on 4/21/22. R9's quarterly MDS dated [DATE], included cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 required extensive assistance with toileting and was always continent of bowel. A progress note dated 4/12/22, at 1:29 p.m. indicated R9 had four episodes of emesis which started at 7:15 a.m. Registered nurse (RN)-A documented R9 suddenly awoke this morning and threw up without no warning. R9 had one small, hard bowel movement but has refused enema at this time. RN-A documented there were reports of other residents with symptoms on emesis at the skilled nursing facility. A progress note dated 4/13/22, at 10:08 a.m. indicated R9 requested to go to emergency room for evaluation as she was not feeling well. R9 stated she felt weak and had abdominal discomfort. R9 refused enema at this time. At 4:50 p.m., R9 returned to facility. An emergency department note dated 4/13/22, at 1:47 p.m. indicated R9 was likely to have constipation; however, abdominal pain and vomiting resolved without further intervention. A fleets enema offered to R9, but she declined since her abdominal pain resolved. A progress note dated 4/16/22, at 10:21 a.m. indicated R9 had two emesis and two loose stools which was reported to director of nursing (DON). At 10:09 p.m., R9 had three emesis and diarrhea. On 4/17/22, at 6:30 p.m. licensed practical nurse (LPN)-A indicated R9 had no emesis or loose stools on this shift and the issues were resolved. When interviewed on 4/18/22, at 4:02 p.m. R9 stated she became violently ill on 4/12/22 with gastrointestinal signs and symptoms of vomiting and diarrhea. R9 stated she was so ill that it was coming out both ends at the same time. R9 stated she requested to be transferred to the local emergency department on 4/13/22. R9 stated other resident's down the south hallway with similar gastrointestinal symptoms. R9 stated she was sick all week with nausea, vomiting, and diarrhea and could barely eat as her stomach did not feel well. R9 stated the facility placed her on isolation precautions; however, the isolation cart which was located outside R9's room was not utilized on 4/18/22 and no door signs were posted. When interviewed on 4/22/22, at 10:19 a.m. the DON stated the nurse practitioner (NP)-A had canceled a stool specimen for R9 as she had issues with constipation not diarrhea and was maybe not part of the GI illness outbreak. When interviewed on 4/21/22, at 12:27 p.m. the facility social worker (SW) stated she had not received any new infection control training today. When interviewed on 4/21/22, at 12:31 p.m. RN-E stated she had not received any recent infection control training. When interviewed on 4/22/22, at 11:18 a.m. the DON stated it was important for staff to be using a bleach based cleaning solution for surfaces, but had not switched out their standard disinfectant with bleach. The DON stated they would do that right away. When interviewed on 4/22/22, at 10:19 a.m. the DON stated no stool samples had been obtained yet, they had received orders, and sent specimens in the wrong type of specimen cup so they had been rejected by the lab on 4/21/22. When interviewed on 4/24/22, 8:39 a.m. DON stated one staff person had developed GI symptoms 4/22/22 and was sent home, and another had called in sick overnight; R1 was moved due to symptoms and confirmed GI infections The facilities GI illness outbreak log identified a dietary aide had come down with GI symptoms on 4/22/22 and a nurse had on 4/24/22. When interviewed on 4/24/22, 8:39 a.m. DON stated one staff person had developed GI symptoms 4/22/22 and was sent home, and another had called in sick overnight; R1 was moved due to symptoms and confirmed GI infections. DON also said R18 had started to develop some GI symptoms on 4/22/22 in the afternoon. DON said she had done some staff audits on PPE use and handwashing for the facility IJ removal plan that morning when arriving at the facility. DON stated a regional nurse consultant (RNC)-B had come in to help, and they had been going through their infection control policies in the last two days. When interviewed on 4/24/22, 8:59 a.m. RNC-B stated she was not sure if the correct cleaning products were out on the isolation carts for staff to use, but then brought in a container of Oxivir TB wipes containing peroxide, and said they did have the correct cleaning solution. Shortly after this, an observation revealed there were no bleach, peroxide or Oxivir TB wipes on any isolation carts or with the shared equipment in the facility such as mechanical lifts. During an observation on 4/25/22, at 8:14 a.m. NA-F walked across the north hallway carrying unbagged laundry against her clothing to the dirty clothes bin. NA-F then washed hands located near the laundry receptacle. NA-F did not change her potentially contaminated clothing. When interviewed at 8:17 a.m. NA-F stated she should have bagged the laundry and not carried it against her clothing. During an observation on 4/25/22, at 8:27 a.m. HUC knocked on R20's door, donned appropriate PPE, entered the room with R20's breakfast tray, set the breakfast tray down the bed side table, moved R20's urinal off the bedside table, removed gloves, stepped outside the threshold of R20's room, removed her gloves, walked to the utility room door, punched the code in, used the door handle to open the door, entered and washed her hands with soap and water, exited the room and walked away. HUC did not disinfect the door handle. During an interview on 4/25/22, at 8:39 a.m. RNC-C indicated she had seen the HUC contaminate the door code and handle, and indicated more infection control audits of the staff needed to be completed. When interviewed on 4/25/22, at 9:29 a.m. registered dietician (RD) indicated even though she had educated nursing staff to not return trash from isolated resident trays back to the kitchen, the practice continued. RD indicated in order to mitigate this she had made signs so that this practice was stopped. When interviewed on 4/24/22, at 10:01 a.m. RNC-B and the administrator stated they had updated all resident care plans and had ordered disinfectant that works on Rotavirus and C. Diff. They had placed spray bottles of bleach solution for staff to use on each wing. Lab results for R20 and R26 had come back and were positive for Rotavirus. When interviewed on 4/25/22, at 11:28 a.m. RD stated even with all the signs on the resident doors who are on isolation and again talking to nursing staff, nursing brought back 5 trays from isolation rooms with garbage back to the kitchen. One was tray was even set on a kitchen countertop. During an observation on 4/25/22, at 11:49 a.m. R21 wheeled down to use the communal bathroom in the hallway and then returned to her room. R21's roommate remained on TBP for GI illness. The toilet bowel in the bathroom was observed to have brown spots all over the toilet bowel. At 11:57 a.m. NA-B walked down the hallway with gloves on carrying a used mattress protector up against her chest. NA-B then walked to a mechanical lift located down the hallway and used the appropriate disinfectant to wipe it off, then washed her hands with soap and water. NA-B did not change her contaminated clothing. At 11:59 a.m. NA-B assisted R9 onto mechanical lift and put her on the toilet in the communal bathroom, even though the brown spots on the toilet seat had not been cleaned off. During an interview on 4/25/22, at 12:04 a.m. NA-B confirmed she put R9 onto the toilet in the communal bathroom and stated R10 who was on TBP and was R21's roommate. NA-B stated R21 had a formed bowel movement, stated she had wiped down the toilet seat however did not clean the toilet bowel prior. NA-B indicated the toilet bowls were not cleaned between residents, the toilet had overflowed over the weekend, the brown spots on the bowl had been there the whole weekend, and housekeeping had not cleaned it after it overflowed. NA-B stated she knew that brown stuff has been there since Saturday, that's when I noticed it During an interview on 4/25/22, at 12:13 p.m. HSK stated she had been the housekeeper on Saturday. HSK indicated she had been told to clean only the resident room bathrooms and did not clean the communal bathrooms and/or toilets on Saturday. During an observation and interview on 4/25/22, at 12:21 p.m. EVS-A completed cleaning the toilet in the communal bathroom, brown spots were not longer observed in the toilet bowl. EVS-A verified the condition of the toilet bowl prior to cleaning. EVS-A stated that was the first time she had cleaned the bathroom/toilet today. Indicated she had not cleaned it prior because the bathroom had been busy. EVS stated the toilet bowls were not disinfected after each resident and were cleaned after breakfast, after lunch, and before leaving at the end of the day. EVS-A stated she had worked on Sunday and did not notice the dirty toilet bowl. During an interview on 4/25/22 at 12:39 p.m. RNC-C was unaware why commodes were not being used until surveyor brought it to her attention. RNC-C indicated in outbreak status it would be expected to be cleaning the toilet in between each use. RNC-C indicated the facility would need more time to have an interdisciplinary team meeting to reevaluate the action plan to correct the ongoing lack of implementation of appropriate infection prevention interventions. When interviewed on

Based on observation, interview, and document review the facility failed to ensure safe diabetic management for 1 of 1 residents (R1) admitted to the facility with an insulin pump. This resulted in an immediate jeopardy (IJ) and had the potential to cause serious harm, or death to R1 and all future residents admitted to the facility with insulin pumps. The IJ began on 6/18/21, when R1 was admitted to the facility with an insulin pump in which the facility failed to identify, educate staff on the pump, transcribe physician orders for insulin and blood sugar monitoring, and develop an individualized diabetic care plan which resulted in R1 self-administering a bolus (a single dose of a drug or other medicinal preparation given all at once) of insulin that caused a hypoglycemic (a condition in which your blood sugar (glucose) level is lower than normal.) event on 6/29/21. The IJ was identified on 7/13/21, and the interim administrator, clinical nurse manager, and registered nurse (RN)-D were notified of the IJ on 7/13/21, at 5:00 p.m. The IJ was removed on 7/14/21, at 3:30 p.m. but non-compliance remained at the lower scope and severity of D, isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's facility Admission Record identified R1 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 cognitively intact and did not have rejection of care behaviors. The MDS indicated R1 required extensive assistance from two or more staff for bed mobility and transfers and required supervision with personal hygiene. The MDS identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital Discharge Summary dated 6/18/21, indicated R1 was discharged from the hospital on 6/18/21, to the facility for rehab. The Summary identified R1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is on insulin pump therapy (Medtronic 670G). The settings indicated R1 received hourly doses of insulin via the pump to equal 25.2 units over 24 hours and one unit of insulin would reduce R1's blood glucose by 62 mg/dl (milligrams/deciliter). R1's glucose goal range was 100-140 mg/dl. The Summary also included orders for Novolog U-100 insulin 35-70 units via pump daily and to check blood sugar 5 times daily. R1's baseline care plan dated 6/18/21, included a section for Diabetic-Interventions, the box was checked with a handwritten 0 (zero). The baseline care plan instructed refer to the medication/treatment administration record for medication and treatment orders. R1's admission record, did not identify history of [CONDITION(S)] with coma, chronic insulin pump use, or history of repeated falls as indicated on the hospital discharge summary. R1's comprehensive care plan current at the time of survey, lacked a plan of care for diabetes and insulin pump that included individualized goals and interventions for hypo/[CONDITION(S)] and safe management for R1's insulin pump. During an observation and interview on 7/13/21, at 12:41 p.m. R1 stated she had an insulin pump that she has had for years. R1 stated the pump infuses 1.0 to 1.1 unit of insulin per hour continuously via a small needle inserted in her abdomen held in place by a patch. R1 stated she also self-administered insulin before meals based on her blood sugar; she would dial the amount in on the pump. R1 stated since admission staff had not offered nor ever administered insulin. R1 stated she must refill the syringe that is inside the pump when it is low. R1 took out the pump that was hanging around her neck, removed the top, pulled out the small syringe with a black plunger on the bottom, then put it back in. R1 explained she had a hypoglycemic event a couple of weeks ago after accidentally injecting some insulin when trying to reload the syringe into the pump. R1 indicated she typically felt symptoms of low blood sugars around 60, however, did not feel symptomatic that morning even though her sugar dropped to 34, stated she did not call for staff for assistance or treat her symptoms. R1's record lacked a self-administration assessment for insulin/insulin pump. R1's Physician orders, did not include order for R1's need for insulin and need for blood glucose checks. R1's blood sugar readings located in R1's electronic medical record included: -6/18/21, no blood sugar (BS) recorded -6/19/21, at 8:02 a.m. BS was 296, and at 12:02 p.m. BS was 181 -6/20/21, at 7:15 a.m. BS was 292, and at 12:05 p.m. BS was 80. -6/21/21, no BS recorded -6/22/21, no BS recorded -6/23/21, no BS recorded -6/24/21, at 5:10 p.m. BS was 167, and at 8:37 p.m. BS was 281 -6/25/21, at 7:54 a.m. BS was 218, and at 10:54 a.m. BS was 198 -6/26/21, no BS recorded -6/27/21, no BS recorded -6/28/21, at 11:14 a.m. BS was 214, at 4:30 p.m. BS was 115, and at 7:56 p.m. BS was 240. -6/29/21, at 10:20 a.m. BS was 34, at 10:40 a.m. BS was 65, at 11:10 a.m. BS was 98. R1's progress note dated 6/29/21, at 10:25 a.m. included, Writer went to resident's room to have her sign some paperwork, when writer saw resident having an active full body [CONDITION(S)]. This was not a grand mal [CONDITION(S)]. Writer stayed by resident's side until the [CONDITION(S)] was finished. Writer witnessed resident's [CONDITION(S)] for 2-3 minutes. When resident's [CONDITION(S)] was finished, writer asked resident if she could hear and understand writer and she stated yes. Writer asked resident if she has ever had a [CONDITION(S)] before and she stated no. Writer told resident's nurse what had happened and her nurse checked her blood sugar as she is a diabetic. Resident's nurse told writer that her blood sugar was in the 30's. Resident's nurse brought her 2 glasses of orange juice. R1's change of condition progress note dated 6/29/21, at 11:25 a.m., included Another Nurse had been with the resident and observed the resident to have full body shaking that lasted about 2 min. The resident is groggy appearing but she is alert and responsive. Assessment: Upon questioning the resident stated she has no [CONDITION(S)] history and she was conscious during the entire shaking incident. Her blood sugar was promptly checked and found to be 35 at 10:20 a.m. and the resident was given two glasses of juice. The resident's blood sugar was rechecked at 10:40 a.m. and found to be 65. She was given one additional glass of juice and at 11:10 a.m. her blood sugar was 98. The resident was feeling well at this time. This morning she had refilled her insulin pump and may have likely pushed on the syringe when re-installing giving herself a bolus of insulin by mistake. This morning the resident's blood sugar was 230 at 7:00 a.m The note then indicated the provider had been notified. R1's physician visit note dated 6/29/21, included Since her admission to the facility her glucose monitoring has been ranging between 115 to 296. Today at 10:20 a.m. her glucose was 35 and the resident was given two glasses of juice. [R1] reported earlier today she had refilled her insulin pump and may have likely pushed on the syringe when re-installing giving herself a bolus of insulin by mistake. This does not happen often, but is not the first time that this happened to her. Before this incident, her glucose was 230 at 7:00 a.m. The note also included, She [R1] does have [CONDITION(S)] awareness, is usually around 60. The notes also indicated that had been R1's only hypoglycemic event at the facility, however, there was not access to the accumulative report of readings from the pump. The physician note also included, Given her current clinical status, non-ambulatory [sic] due to several fractures, erratic meals schedules with limited food options, recent UTI [urinary tract infection] and current setting (first time at SNF and keeps door closed), I will feel more comfortable with the patient having glucose tablets available at bedside in case she dose have another hypoglycemic event. I will set up a return visit at the facility on Friday to recheck her glucose monitoring results before the holiday weekend. The note indicated R1's prescriptions were reviewed which included insulin type and dose, blood sugar checks 5 times a day, and included direction to change the insulin infusion pump site every 3 days. New orders included the following orders: Glucose 4 grams chewable by mouth as needed for [CONDITION(S)]. Please keep at bedside for patient to self-administer R1's record did not included the physician's orders transcribed into the electronic health record (EHR) for insulin type and dose, blood sugar checks, insulin infusion site changes, and glucose tabs at bedside. In addition, R1's blood sugar was not consistently monitored. R1's blood sugar record from 6/30/21 to 7/2/21 included: -6/30/21- no blood sugars recorded -7/1/21- at 7:28 a.m. BS was 216, and at 11:28 a.m. BS was 219. 7/2/21- at 7:59 a.m. BS was 219, at 12:09 p.m. BS was 115, at 4:10 BS was 239, at 9:16 BS was 106. R1's follow-up physician visit dated 7/2/21, identified R1's hypoglycemic event on 6/29/21, with no re-occurrence since then. Facility has not been regularly checking blood sugars as patient's insulin pump does record readings but she has no way to upload her readings given her stay at short-term rehabilitation center. She reports that she does have an alarm on her monitor if she does have [CONDITION(S)]. The section Assessment/Plan, included Continue current regimen. Notify provider if patient has hypoglycemic events. R1's blood sugar record from 7/3/21 to 7/6/21, continued with inconsistent blood sugar monitoring. -7/3/21, no BS recorded -7/5/21, no BS recorded. -On 7/6/21, BS recorded at 4:43 a.m. and 8:50 p.m. During an interview on 7/13/21, at 12:19 p.m. licensed practical nurse (LPN)-A stated he had went into R1's room that morning, R1 appeared to be having a [CONDITION(S)], whole body was shaking, and he yelled for help. LPN-A stated R1 was alert, however, did not respond to questions. LPN-A stated he observed 2-3 minutes of R1's [CONDITION(S)] activity before registered nurse (RN)-A entered the room. LPN-A stated he stayed with R1 the entire time, did not leave the room, and did not check R1's blood sugar. LPN-A stated after RN-A had entered the room, R1's [CONDITION(S)] activity stopped, and RN-A took her blood sugar it was dangerously low for a type one diabetic. LPN-A stated RN-A then gave her some orange juice; R1 was able to swallow without difficulty. LPN-A stated R1 managed the insulin pump herself, stated he had no idea what type of insulin pump R1 had, where it was located, what type of insulin, nor how much insulin R1 required, or what the dose of insulin was. LPN-A stated, The most I know, she refills with a syringe from a vial, and she puts it in the insulin pump. LPN-A indicated staff were not monitoring R1's blood sugar until 7/6/21; stated physician order was to check it twice per day. LPN-A stated the facility had not provided education on the insulin pump before or after R1 was admitted to the facility and did not provide education on the pump after the event. LPN-A indicated the facility did not have diabetic standing orders, would have to check to see if there was a diabetic protocol for hypo/[CONDITION(S)], and was not aware if the facility had emergency hypoglycemic medications in the emergency kit. During an interview on 7/13/21, at 12:30 p.m. RN-A stated an awareness R1 had an insulin pump and type of insulin, however, stated and unawareness of dose(s) of insulin. RN-A reviewed R1's record and verified the physician orders lacked orders to check blood sugars, type of insulin and doses, and record lacked a self-administration assessment. RN-A verified the care plan did not include a diabetic care plan, did not identify R1 had an insulin pump, and stated it probably should be care planned. RN-A indicated he would check per standard of practice when he worked despite the lack of a physician order to check R1's blood sugar. RN-A said he would check before meals and recorded the values in the blood sugar record. RN-A stated R1 wore the insulin pump around her neck and there was a dressing on her belly that held the needle that delivered the insulin. RN-A stated an unawareness if the pump monitored her blood sugar or if the pump sounded an alarm when her blood sugar was low. RN-A stated R1 would administer herself insulin before meals based on what her blood sugar was. RN-A stated the day R1 had a hypoglycemic event, he had entered the room and she could respond to questions. RN-A stated he checked her blood sugar, which was 34, he gave her orange juice, rechecked blood sugar until safe level, and notified the physician. RN-A stated the facility did not have diabetic standing orders, stated emergency medications were in the emergency kit and voiced his understanding of hypoglycemic protocol. RN-A stated education was not provided to staff because R1 self-managed her own pump, and if there was a problem, then we would need education on the pump. During an interview on 7/13/21, at 2:45 p.m. administrator stated the facility did not accept residents with insulin pumps. During an interview on 7/14/21, at 9:34 a.m. LPN-B indicated she had not started taking R1's blood sugars until after the order was entered on 7/6/21. LPN-B stated she had some familiarity with insulin pumps because of another job, however, was not familiar with R1's; was not aware if the pump alarmed and was not aware of type or doses of insulin. LPN-B stated the facility had not provided education on the pump. LPN-B reviewed R1's record and verified R1's care plan did not address diabetic management or the insulin pump and verified R1's physician orders did not include insulin type or dose. During an interview on 7/14/21, at 9:56 a.m. nurse practitioner (NP)-A stated if the facility could not manage insulin pumps, then they should not have accepted a resident that had one and/or had the pump discontinued while the patient was a resident at the facility. During an interview on 7/14/21, at 1:51 p.m. medical doctor (MD)-A stated a familiarity with R1 and R1's hypoglycemic event the morning of 6/29/21. MD-A stated R1 accidentally gave herself a bolus dose, indicated that was the first time at the facility, however not the first time historically. MD-A stated an expectation the staff be familiar with functionality of insulin pumps, type/dose of insulin, and that there would be a diabetic care plan. MD-A stated staff should have been checking R1's blood sugars and signs/symptoms of [CONDITION(S)] and the orders written on 6/29/21 for glucose tablets at bedside should have been immediately transcribed into the record because of meal variations and she liked the door closed. During an interview on 7/14/21, at 3:10 p.m. RN-B and RN-C stated they didn't know R1 was diabetic or that she had an insulin pump until after hearing about R1's hypoglycemic event on 6/29/21. RN-B and RN-C both stated neither were aware what type of insulin R1 required, safety functions of the pump, or that R1 required pump infusion site changes until they were provided with education today (7/14/21). The immediate jeopardy that began on 6/18/21, was removed on 7/14/21, when the facility developed and implemented an acceptable plan of correction that included: 1) R1's was assessed for self-administration and facility diabetic resident's orders were reviewed for identification if the deficient practice had effected other residents; no other residents were impacted. 2) Physician orders and care plan was revised to reflect orders for blood sugar checks, insulin pump, insulin type, dose range, and infusion site dressing change. 3) Facility policies on diabetic management [CONDITION(S)] management protocol, and [CONDITION(S)] were reviewed and updated with changes. 4) Facility staff were educated on safe diabetic management for R1 in respect to R1's self-administering insulin via insulin pump. Staff were also educated on hypoglycemic symptoms and management and R1's insulin pump. Staff were also provided education on updates to diabetic policies. 5) An auditing system for compliance with diabetic care plans, self-administration of medication, and diabetic protocols was developed and implemented.