Every finding on record at Evergreen Health Services

Based on observation, interview, and record review, the facility did not ensure the necessary care and services were provided to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R5) of 3 sampled residents.R5 developed an unstageable pressure injury on the coccyx after admission to the facility. The facility did not ensure wound care and repositioning were completed or pressure relieving boots were applied as ordered. In addition, R5's air mattress was not set at the appropriate setting. Findings include:The facility's Pressure Injuries and Non-Pressure Injuries policy, revised 7/20/22, indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries .Residents admitted with, or who subsequently develop a pressure injury .will receive care, treatment, and services that seek to promote healing .and prevent further development of pressure injuries/impaired skin integrity .If a wound fails to show .progress toward healing within 2 to 4 weeks, the area and the resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions .The clinicians, if deciding to retain the current regimen, should document the rationale for continuing the present treatment to explain why some or all of the interventions remain relevant despite little or no apparent healing .Engage resident and responsible parties in risk reduction interventions when indicated.The facility's Use of Support Surfaces policy, dated 6/16/22, indicates: Support surfaces will be used .for residents with or at risk for pressure injuries .Support surfaces will be used in accordance with manufacturer recommendations.The Prius Rhythm Multi Mattress manufacturer information on www.priushcusa.com indicates: Air mattress setting of 3 is for suggested weight range of 190-275 pounds (lbs). Air mattress setting of 5 is for suggested weight range of 300-425 lbs. Air mattress setting of 9 is for recommended weight range of 701-851 lbs. R5 was admitted to the facility on [DATE] and had diagnoses including weakness, rotator cuff tear or rupture of right shoulder, presence of left artificial shoulder joint, and osteoarthritis. A Minimum Data Set (MDS) assessment, dated 6/17/26, stated R5 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS assessment indicated R5 was at risk for pressure injuries, did not have a pressure injury, and required the assistance of 2 staff for bed mobility. A skin assessment on 7/8/26 indicated R5 had an unstageable deep tissue injury on the coccyx that measured 10 centimeters (cm) (length) x 5.5 cm (width) with 100% epithelial tissue in the wound bed.A care plan, revised 7/8/26, indicated R5 had a pressure injury on the coccyx/intergluteal fold, and right heel and great toe wounds. The care plan contained interventions to administer treatment, diet, and supplements per orders; encourage and assist R5 to turn and reposition; reposition every 2 hours; use assistive devices as needed; encourage R5 to lay down and alternate side-to-side when not at meals or activities; heel boots on in bed; special air mattress on bed-pressure at 5; use pillows and/or positioning device as needed; wound treatment as ordered.A care plan, revised 6/23/26, indicated R5 had an activity of daily living (ADL) self-care deficit due to impaired mobility related to a right shoulder rotator cuff tear and stenosis to the lumbar region at multiple levels. The care plan contained interventions to encourage R5 to be in their wheelchair for meals and to lay down in bed after meals; offload; assist of 2 for bed mobility; and therapy evaluation and treatment. A Kardex (an abbreviated care plan used by nursing staff), dated 7/29/26, indicated R5 required the assistance of 2 staff for bed mobility, should be repositioned every 2 hours, had an air mattress set at 5, and should wear heel boots in bed. (R5's last recorded weight was 226.6 lbs on 7/14/26. Per manufacturer's recommendations, the mattress should be set at 3.) R5's Medication Administration Record (MAR) contained the following orders: ~ Wear blue pressure relieving boots all the time only off for showers transfers, and bathing every shift (dated 7/2/26).~ Betadine swab top right great toe two times daily until healed (dated 7/2/26; discontinued 7/21/26).~ Dressing change to right medial great toe. Remove dressing, clean, apply Betadine, and cover with standard gauze island dressing for protection once daily (dated 7/2/26; discontinued 7/28/26) (R5's MAR indicated the treatment was not completed on 7/14/26, 7/15/26, and 7/25/26.)~ Reposition approximately every 2 hours. Assist, monitor, and remind PM Certified Nursing Assistants (CNAs). Monitor air mattress function and keep R5 off of back every 2 hours for pressure relief of coccyx (dated 7/9/26).~ Sacral wound: Cleanse with Vashe. Apply zinc oxide to peri-wound. Cover wound base with Hydrofera Blue foam after moistening with saline and wringing out. Cover with gauze and silicone foam sacral dressing. If silicone is holding too much moisture, may change order to secure with ABD pad and Medipore tape once daily until reassessed by wound Registered Nurse (RN) in one week. If small amount of drainage, may change every other day (dated 7/10/26; discontinued 7/16/26). (R5's MAR indicated the treatment was not completed on 7/14/26 and 7/15/26.)~ Coccyx/sacral wound: Cleanse area with Vashe. Apply zinc oxide to peri-wound. Cover central wound base with Hydrofera Blue foam after moistening with saline and wringing out. Cover with gauze and silicone foam sacral dressing. If silicone is holding too much moisture, may change order to secure with ABD pad and Medipore tape once daily until reassessed by wound RN in one week. If small amount of drainage, may change every other day (dated 7/17/26). (R5's MAR indicated the treatment was not completed on 7/25/26.)~ Apply zinc oxide 20% to pressure injury on urethral opening from catheter two times daily (dated 7/10/26; discontinued 7/28/26). (R5's MAR indicated the treatment was not completed on the 7/14/26, 7/15/26, and 7/25/26 AM shifts.)~ Skin prep twice daily to bilateral heels (dated 7/10/26). (R5's MAR indicated the treatment was not completed on 7/14/26, 7/15/26, and 7/25/26.)~ Monitor air mattress each shift. Air mattress setting should be at 5 (dated 7/28/26).~ Wound care referral: Evaluate, treat, and debride as indicated for coccyx ulcer with eschar (dated 7/29/26).A progress note on 7/8/26 indicated R5 had a deep tissue injury on the coccyx and right intergluteal cleft that was dark purple/maroon. There was a small open area with light serous drainage and bright red blanchable and non-blanchable areas with excoriation. R5 complained of pain while sitting and when the wound was touched. The wound measured 10 cm x 5.5 cm x <0 cm. Staff applied zinc oxide and covered the wound with a foam sacral dressing. R5's care plan was updated.A progress note on 7/10/26 indicated R5 was moved to different room to accommodate an air mattress. A progress note on 7/17/26 indicated R5 required extensive assistance of 2 staff to roll in bed.A progress note on 7/25/26 indicated staff did not complete a dressing change on the AM shift because R5 had visitors and did not lay down. Staff let the PM shift know.On 7/28/26 at 2:30 PM, Surveyor interviewed R5 who verified they had a wound on their coccyx and staff wanted them to lay on their right or left side. R5 was not sure why they needed to lay on their side. R5 stated they had pain in their right and left shoulders and preferred to lay on their back. On 7/29/26 at 11:37 AM, Surveyor interviewed Nurse Practitioner (NP)-M who had been seeing R5 since admission and stated the wound nurse saw them weekly. NP-M stated R5's coccyx pressure injury had worsened and now had an odor and eschar and may require debridement. NP-M and Director of Nursing (DON)-B discussed sending R5 to the wound clinic on 7/29/26. NP-M stated they wrote an order for an air mattress (on 7/28/26). NP-M verified R5 had an air mattress prior to that but did not have an order for one. NP-M stated the facility uses standardized orders for pressure injury interventions and verifed R5 was typically supine in bed with the head of the bed (HOB) upright.On 7/29/26 at 12:35 PM, Surveyor interviewed RN-F who was the facility's wound nurse and completed weekly assessments and care. RN-F was last at the facility on 7/16/26. Staff notified RN-F of R5's coccyx wound. When RN-F assessed the wound, an air mattress was in place. R5's right toe ulcer had resolved. RN-F stated R5 should be in bed other than for meals and therapy to allow their coccyx to heal. RN-F verified the importance of offloading, repositioning every 2 hours, dressing changes, and nutrition for optimal healing and stated an hour of pressure could cause a wound to worsen. On 7/29/26 at 2:05 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C and DON-B who stated wound education was started on 7/23/26 when they determined dressing changes were not being completed and orders were not being followed. ADON-C stated wounds care orders and care plans were reviewed/updated on 7/24/26 and past non-compliance audits were started on 7/28/26. ADON-C stated wound assessments should be completed Sunday through Thursday to ensure completion and tracking of wounds. R5's coccyx assessment and dressing change was completed on 7/23/26 and 7/28/26. ADON-C verified the wound had an odor and was more necrotic than the previous week. DON-B stated they discuss wounds weekly with RN-F, however, they had not discussed wounds in the last 3 weeks. DON-B verified there was a need for wound care improvement and stated the facility started a wound care past non-compliance plan. ADON-C confirmed R5's coccyx was reddened upon admission and verified staff should have measured and documented the redness and initiated wound interventions. DON-B stated staff encourage R5 to lay in bed instead of sleep in the recliner, apply barrier cream to their coccyx, and use pillows for positioning. DON-B verified pillows for positioning was the only intervention added to R5's care plan upon admission. On 7/28/26 from 12:00 PM to 2:30 PM, Surveyor observed R5 in a wheelchair in the dining and therapy rooms. R5 was not wearing pressure relieving boots.From 7/27/26 through 7/30/26, Surveyor observed R5 supine in bed on multiple occasions with the HOB at 30 degrees. On 7/28/26 at 4:08 PM, Surveyor interviewed DON-B who stated R5 refused repositioning daily and staff continued to educate them on the importance of repositioning. DON-B stated staff document the refusals, however, education provided to R5 and their spouse was not documented.On 7/28/26 at 4:15 PM, Surveyor observed R5 supine in bed. Surveyor interviewed Licensed Practical Nurse (LPN)-N and CNA-O who stated R5 had never refused repositioning for them. LPN-N stated R5 can adjust the height of their bed if the controller is within reach. LPN-N verified R5 required the assistance of 2 staff for bed mobility and had offloading orders. LPN-N confirmed R5 should not lay supine in bed due to the pressure on their coccyx.On 7/27/26 at 9:00 AM through 7/28/26 at 3:00 PM, Surveyor noted R5's Prius Rhythm multi air mattress was set at 9, alternating. The motor had a sticker that indicated the mattress should be set at 5. On 7/28/26 at 2:35 PM, Surveyor observed CNA-J and CNA-O transfer R5 to bed. CNA-J and CNA-O were not aware of R5's air mattress setting. CNA-J confirmed a sticker on the motor indicated the mattress should be set on 5, however, the setting was not on R5's care plan or Kardex (prior to 7/28/26). On 7/28/26 at 2:37 PM, Surveyor interviewed RN-D who was not aware of R5's air mattress setting. RN-D verified the setting was not in R5's care plan and confirmed they did not have an order for the mattress (prior to 7/28/26). On 7/28/26 at 3:11 PM, Surveyor interviewed DON-B who verified R5 did not have an order for an air mattress (prior to 7/28/26). DON-B verified R5 should have an order for the mattress and its setting which is derived from manufacturer's recommendations based on weight. DON-B stated staff refer to R5's care plan for the mattress setting and verified the air mattress should be set at 5 instead of 9. (As noted above, Surveyor reviewed the manufacturer's recommendations which indicated the mattress should be set at 3 based on R5's current weight.)

Based on observation, interview, and record review, the facility did not ensure food was labeled and stored appropriately. This practice had the potential to affect more than 4 of the 41 residents residing in the facility. Food stored in a resident refrigerator contained unlabeled and undated items.Findings include:The facility's Use and Storage of Food Brought in by Family or Visitors policy, dated 12/14/22, indicates: It is the right of the residents of this facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident .All food items that are already prepared by the family or a visitor brought in must be labeled with the contents and dated .The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator or other designated resident food storage refrigerator.During the initial kitchen tour that began on 7/27/26 at 9:00 AM, Surveyor and Dietary Manager (DM)-K observed the resident refrigerator on the Eagle View unit which contained the following 4 items that were not labeled with the contents, date opened or prepared, and/or were expired: ~ Two undated hot dogs in a plastic storage bag ~ An open and undated bag of frozen corn dogs in the freezer ~ An unlabeled and undated plastic container of an unknown food item in the freezer~ An unlabeled and undated plastic container of muffins and breads in the freezer During an interview on 7/27/26 at 9:45 AM, DM-K stated the dietary department is responsible for checking the resident refrigerator for any family prepared items that are not labeled with the contents and date received. DM-K stated the expiration date is 3 days for cooked food, 7 days for uncooked food, and 6 months for frozen items. DM-K stated the items should be dated as follows: date received; date opened; date expired.Surveyor observed a sign on the resident refrigerator that indicated all food items should be labeled with the date they were received, the date opened, and the expiration date. DM-K stated staff should date food items when they are received and put them in the resident refrigerator. Staff should update dietary staff of all new food items so dietary staff can monitor expiration dates daily. On 7/28/26 at 3:25 PM, Surveyor interviewed Director of Nursing (DON)-B who stated staff should update DM-K when new food items are added to the resident refrigerator. DON-B stated all staff who take in food for residents should label the food with the date received and the expiration date.

Based on observation, interview, and record review, the facility did not ensure food was prepared in a form to meet the needs of 1 resident (R) (R19) of 1 sampled resident.R19 had an order for a dysphagia level 2 (smaller than bite-sized pieces/chopped) diet. R19 was served broccoli florets, noodles, a roll, and cake that were not chopped or in bite-sized pieces.Findings include:The facility's Available Diets policy, dated 7/13/22, indicates: Nursing staff and/or the Registered Dietitian Nutritionist (RDN) or designee will notify physicians of the diets that are offered on the facility's menu. When necessary, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of a resident to achieve outcomes/goals of care. Available therapeutic diets should coincide with the therapeutic diets on the facility's menu extensions.R19 had diagnoses including failure to thrive, severe protein-calorie malnutrition, and absence of teeth. A Quarterly Minimum Data Set (MDS) assessment, dated 5/20/25, stated R19 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition.A care plan, dated 2/23/26, indicated R19 was at risk for nutritional status change related to malignant neoplasm of lower lobe, neoplasm of brain, failure to thrive, severe protein-calorie malnutrition, hypertension, edema, and anxiety. R19 had altered gastrointestinal (GI) function related to chewing difficulty as evidenced by a need for an L2 mechanically altered, soft diet texture to meet estimated nutrition needs. The care plan indicated R19 would not exhibit chewing or swallowing problems with the current diet texture as evidenced by no signs/symptoms of aspiration, choking, or complaints of difficulty eating. The care plan contained interventions to eat independently with set-up; honor food preferences; provide diet as ordered-regular diet, L2 mechanically altered texture, regular consistency; provide supplements as ordered; report signs/symptoms of diet and/or texture intolerance; and see tray card for specific food preferences.On 7/29/26 at 12:49 PM, R19 asked to speak to Surveyor and stated they could not eat their food because it was too hard. R19 showed Surveyor that they could not poke a fork through the broccoli. R19 stated the noodles were too hard and they could not eat them. Surveyor noted the broccoli and noodles were whole and mostly in large pieces. The dinner roll and cake were also whole. R19 stated everything was hard and they could only eat a small amount of cake. R19 stated they report food issues to dietary staff daily or as they arise.On 7/29/26 at 12:57 PM, Surveyor interviewed Dietary Manager (DM)-K who confirmed R19 frequently complains about food and gives the dietary staff notes. DM-K showed Surveyor a note from R19 that stated, I could not eat the meat tonight. It was too tough. DM-K gave Surveyor a diet guide sheet that confirmed R19 is on an L2 mechanical soft diet. DM-K stated R19 should have received ground chicken, buttered diced carrots (which DM-K confirmed was diced broccoli due to a vegetable substitution), pureed bowtie noodles, wheat dinner roll slurry (although DM-K stated R19 requested no bread and should not have it received it), and yellow cake slurry for dessert. Surveyor and DM-K observed R19's meal tray. DM-K confirmed the tray contained many larger pieces of broccoli, and a whole dinner roll and slice of cake. DM-K stated dietary staff needed additional training since R19 did not receive food in accordance with their diet order.

Based on interview and record review, the facility did not ensure weight monitoring was provided for 1 resident (R) (R5) of 2 sampled residents.R5's weights were not obtained using a consistent device, they were not re-weighed for weight loss/gain of greater than 5 pounds (lbs), and their physician was not notified of weight loss/gain greater than 5 lbs. In addition, R5's care plan did not include interventions for undesirable weight change based on their preferences, nutrition and hydration needs, and functional factors that inhibited independent eating/drinking. Findings include:The facility's Weight Monitoring policy, revised 12/21/22, indicates: Team members will follow a consistent approach to weighing and use an appropriately calibrated and functioning scale (e.g., wheelchair scale or bed scale). Since weight varies throughout the day, a consistent process and technique (e.g., weighing the resident wearing a similar type of clothing, at approximately the same time of the day, using the same scale, either consistently wearing or not wearing orthotics or prostheses, and verifying scale accuracy) can help make weight comparisons more reliable .Any weight change of five pounds or more since the last weight will be retaken or confirmed .a. 1 month-5% weight change is significant; greater than 5% is severe .Nursing staff will notify the individual or responsible party, physician, and Registered Dietitian Nutritionist (RDN) or designee of any individual with an unintended significant weight change .Care planning for weight change or impaired nutrition will be an interdisciplinary effort and may include the following members of the Interdisciplinary Team (IDT): The physician, nursing staff, the Dietitian, the Pharmacist, therapy staff, and the resident or their legal representative .Individualized care plans shall address, to the extent possible: a. The identified causes of weight change; .Interventions for undesirable weight change shall be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating with referral to therapy if applicable .The undesired weight change will be discussed with the resident and/or their responsible party.R5 was admitted to the facility on [DATE] and had diagnoses including weakness, anemia, rotator cuff tear or rupture of right shoulder, presence of left artificial shoulder joint, and osteoarthritis. A Minimum Data Set (MDS) assessment, dated 6/17/26, stated R5 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. R5 made their own healthcare decisions.A care plan, dated 6/10/25, indicated R5 was at risk for nutritional status change, inadequate oral intake, and increased nutrient needs related to poor appetite and wound healing as evidenced by meal refusals, significant weight loss, and pressure wounds. The care plan contained interventions (revised 7/8/26) for R5 to eat with supervision if needed, honor food preferences, administer vitamin/mineral supplements as ordered, provide a regular diet, record weight per facility protocol/Medical Doctor (MD) orders, review weights and notify Registered Dietitian (RD), MD, and responsible party of significant weight change, and see tray card for specific food preferences.R5 had the following orders:~ Weight on admit, daily x 2, weekly x 3, then monthly. Obtain re-weight if change of 5 lbs since last weight (started 6/10/26; discontinued 7/29/26).~ Regular diet, regular texture, regular/thin consistency (dated 6/10/26).~Med Plus 2.0 120 milliliters (ml) twice daily for weight maintenance between breakfast and lunch, lunch and dinner, and at bedtime (HS) snack (dated 6/16/26).~Med Plus 2.0 120 ml three times daily for weight maintenance between breakfast and lunch, lunch and dinner, and at HS snack (dated 6/30/26).~Liquid Protein 30 ml two times daily for wound healing (dated 7/8/26).~Weigh twice weekly, Mondays and Thursdays (dated 7/30/26).R5's medical record contained the following weights:~ 7/14/26 at 1:29 PM, 226.6 lbs (wheelchair scale)~ 7/3/26 at 9:52 AM, 224.6 lbs (mechanical lift scale)~ 7/2/26 at 12:19 PM, 225.2 lbs (wheelchair scale)~ 7/1/26 at 1:49 PM, 221.0 lbs (wheelchair scale) (R5's weight was up 7.5 lbs)~ 6/24/26 at 9:05 AM, 213.5 lbs (wheelchair scale) (R5's weight was down 8 lbs)~ 6/20/26 at 5:27 PM, 221.5 lbs (wheelchair scale) (R5's weight was up 6 lbs)~ 6/17/26 at 4:30 PM, 215.5 lbs (wheelchair scale) (R5's weight was down 22.4 lbs)~ 6/12/26 at 10:17 AM, 237.9 lbs (wheelchair scale)~ 6/10/26 at 6:39 PM, 236.5 lbs (mechanical lift scale)A weight progress note on 7/21/26 indicated R5's average intake was 51-100% of meals. R5 had a significant weight gain of 6.1%. The gain was likely due to improved meal and supplement intake. R5 had +2 edema.A weight progress note on 7/8/26 indicated R5's average intake was 51-100% of meals. R5 had a significant weight loss of 5.6%. The RD noted R5's weight loss was likely due to inadequate meal intake most days due to meal refusals. R5 was likely not meeting wound healing needs with their current intake. The RD recommended liquid protein twice daily for wound healing and weight maintenance and a multivitamin with minerals four times daily.A weight progress note on 6/30/26 indicated R5's intake average was 0-25% of meals. R5 had a significant weight loss of 9.7%. The RD noted R5's weight loss was likely due to inadequate meal intake with meal refusals. The RD recommended to increase Med Plus 2.0 120 ml to three times daily to meet estimated nutrition needs.Certified Nursing Assistant (CNA) task documentation for June and July 2026 indicated R5 refused 1-2 meals per day.R5's medical record did not indicate the provider was notified of R5's significant weight loss or gain. On 7/29/26 at 8:44 AM, Licensed Practical Nurse (LPN)-G stated R5 could not reach to the left and right to get food and drink due to decreased range of motion and pain in their bilateral shoulders. LPN-G stated R5's bedside table needed to be in front of them. R5 had an order to be up for meals 3 times daily and required the assistance of 2 staff for bed mobility. LPN-G stated R5 required encouragement to eat and often refused meals without encouragement. On 7/29/26 at 9:40 AM, Surveyor interviewed R5 regarding their significant weight changes. R5 did not know their height, stated they do not get out of bed for 3 meals per day, and said staff had not spoken to them about their weight. R5 verified they refuse 1-2 meals daily because they do not have an appetite. When asked if they could reach a cup of water on a bedside table to the right of the bed, R5 could not reach the cup. On 7/29/26 at 11:37 AM, Surveyor interviewed Nurse Practitioner (NP)-M who was not notified of R5's weight loss or gain since admission. NP-M stated they expect staff to notify the provider of a change in weight of 5 lbs or more and thought provider notification was on the facility's standing orders. NP-M confirmed staff should weigh R5 twice weekly. NP-M verified R5's current weight order is for monthly weights. NP-M stated they would change the order to twice weekly. NP-M stated R5 takes furosemide for bilateral lower extremity edema. On 7/29/26 at 3:10 PM, Surveyor interviewed Director of Nursing (DON)-B, Assistant Director of Nursing (ADON)-C and [NAME] President of Success (VPS)-L. DON-B and ADON-C were not aware of R5's weight loss. DON-B stated staff update the provider based on orders. DON-B confirmed R5's medical record did not contain weight parameters or indicate the provider should be notified. VPS-L stated the facility's policy says to do a re-weight if there is a change in weight of 5 lbs. VPS-L stated nursing staff should update the provider if a resident has an unintended weight change of 5 lbs. DON-B and ADON-C were not aware of the policy's details. VPS-L stated R5's orders and the facility's standing orders will be updated to reflect the facility's weight policy.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R5) of 8 sampled residents.Staff did not wear the appropriate personal protective equipment (PPE) when transferring R5 from wheelchair to bed.Findings include: The facility's Enhanced Barrier Precautions policy, revised 8/8/24, indicates: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident care activities.High-contact resident care activities include: .c. transferring .The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. R5 was admitted to the facility on [DATE] and had diagnoses including obstructive and reflux uropathy and weakness. A Minimum Data Set (MDS) assessment, dated 6/17/26, stated R5 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. A care plan, initiated 7/20/26, indicated R5 was at risk for infection related to a chronic wound and indwelling Foley catheter. The care plan contained an intervention for EBP during high-contact care activities (dated 7/20/26). R5's Kardex (an abbreviated care plan used by nursing staff) indicated staff should adhere to EBP during high-contact care activities. On 7/27/26 at 11:37 AM, Surveyor observed Certified Nursing Assistant (CNA)-H and CNA-I transfer R5 into bed without wearing gowns. An EBP sign on R5's doorway indicated providers and staff must: wear gloves and gown for the following high-contact resident care activities .transferring, changing lines . On 7/27/26 at 11:37 AM, Surveyor interviewed CNA-H who verified they transferred R5 into bed without wearing a gown. CNA-H stated staff are only required to wear a gown in a room of a resident on EBP while completing cares. CNA-H stated they did not complete cares. On 7/27/26 at 11:37 AM, Surveyor interviewed CNA-I who verified they transferred R5 into bed without wearing a gown. CNA-I verified R5 was on EBP and staff should wear a gown during high-contact resident cares. CNA-I stated they did not see the sign on R5's doorway prior to Surveyor asking about EBP. On 7/27/26 at 11:44 AM, Surveyor interviewed R5 who verified staff did not wear gowns while transferring them to bed and don't typically wear gowns while assisting them from wheelchair to bed. On 7/27/26 at 11:55 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated R5 is on EBP due to wounds and a Foley catheter. LPN-E was not sure if staff need to wear a gown and gloves while transferring R5. LPN-E confirmed staff should wear a gown and gloves during wound care and while washing R5. LPN-E stated R5 had wounds on the right foot, coccyx, and penis and transferred with a sit-to-stand lift. On 7/27/26 at 2:17 PM, Surveyor observed LPN-E complete wound care for R5. Prior to entering R5's room, LPN-E verified staff should wear a gown and gloves during transfers as indicated on an EBP sign outside the room. On 7/28/26 at 2:30 PM, Surveyor observed CNA-J and CNA-O transfer R5 into bed without wearing gowns. On 7/28/26 at 2:30 PM, Surveyor interviewed CNA-J and CNA-O who thought staff only needed to wear a gown during cares. When Surveyor pointed out the EBP sign on R5's door, CNA-J and CNA-O indicated they were not aware of the need to wear a gown while transferring a resident. On 7/28/26 at 2:53 PM, Surveyor interviewed Director of Nursing (DON)-B who was also the facility's Infection Preventionist. DON-B stated staff should wear a gown and gloves and complete hand hygiene when transferring a resident on EBP. DON-B stated they occasionally observe staff not wearing the appropriate PPE and provide real time education as needed. 2. On 7/28/26, Surveyor reviewed the facility's Infection Prevention and Control Program (IPCP) policies and procedures and noted the following: ~ The IPCP was last revised on 7/23/24. ~ The Infection Surveillance policy was last revised on 3/8/23. ~ The Infection Preventionist policy was last revised on 9/22/22. ~ The Standard Precautions Infection Control policy was last revised on 3/23/23. ~ The Enhanced Barrier Precautions (EBP) policy was last revised on 8/8/24. ~ The Hand Hygiene policy was last revised on 11/2/22. ~ The COVID-19, Return to Work for Healthcare Providers (HCP) with COVID-19 policy was last revised on 10/4/22. ~ The Influenza Exposure Control policy was last revised on 9/23/24. ~ The Pneumococcal Vaccine (Series) policy was last revised on 3/25/25. On 7/28/26 at 4:06 PM, Surveyor interviewed DON-B who stated the revision dates on the infection prevention and control policies were the most current version. DON-B acknowledged the policies had not been reviewed within the past year.

Based on observation, staff interview, and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 5 residents reviewed for elopement.R1 was at risk for wandering and elopement. On 8/15/25, R1 exited the facility unsupervised and was found lying on the side of the road 0.3 miles from the facility. The facility failed to ensure all exit doors alarmed and did not have a system in place to ensure doors were secure and an audible alarm functioned.The facility's failure to provide adequate supervision for a resident assessed to be at risk for elopement and who exited the facility and was discovered laying on the side of a road and to ensure a properly functioning alarm system led to a finding of immediate jeopardy that began on 8/8/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 9/10/25 at 4:30 PM. The immediate jeopardy was removed on 9/10/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan.Findings include: The facility's Elopement and Unsafe Wandering policy, revised 8/9/22, indicates the facility will ensure residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. On 9/8/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including toxic encephalopathy, chronic kidney disease, dysphagia, type 2 diabetes, anxiety, and mood disorder. R1's most recent Minimum Data Set (MDS) assessment, dated 8/8/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R1 had severely impaired cognition. The MDS assessment also indicated R1 required the assistance of one staff for transfers and used a wheelchair. R1 had an activated Power of Attorney for Healthcare (POAHC) and discharged from the facility on 8/15/25.A care plan, initiated 8/8/25, indicated R1 was at risk for wandering related to cognitive impairment. The care plan contained interventions to encourage rest throughout the day, check alert bracelet functioning per facility guidelines, check alert bracelet placement per facility guidelines, provide assistance in locating room, and redirect if attempting to go outdoors. R1's plan of care also indicated R1 was at risk for falls.The facility placed a WanderGuard bracelet (a security device that triggers an alarm if the wearer exits the facility) on R1's left ankle upon admission on [DATE].Daily skilled nursing notes indicated R1 required increased supervision related to impaired cognitive status. A skilled nursing note, dated 8/8/25 at 10:00 PM, indicated R1 attempted to open the D wing door (exit 10) and the alarm sounded. Staff were able to redirect R1 toward the nurses' station.The facility's investigation, dated 8/15/25, included a timeline of events that indicated: ~ At 8:30 PM, R1 was toileted by Certified Nursing Assistant (CNA)-E. ~ At 9:15 PM, R1 was last seen by CNA-H. ~ At approximately 9:52 PM, LPN-D observed R1's empty wheelchair at the nurses' station and asked CNA-E if CNA-E recently saw R1. CNA-E replied no, began to search for R1, and notified other staff in the building. ~ At 10:00 PM, Director of Nursing (DON)-B was notified and instructed staff to follow the facility's elopement protocol. Staff conducted a head count and searched the perimeter of the building.~ At 10:13 PM, DON-B called the police and reported R1 missing. The police informed DON-B that R1 was located and taken to the ED. ~ At approximately 10:50 PM, Director of Maintenance (DOM)-C arrived at the facility and checked all door alarms. DOM-C indicated exit door 5 did not alarm when opened even though the keypad indicated the door was alarmed. DOM-C indicated DOM-C checked the door alarms daily by visually observing the keypad (rather than sounding the alarm). DOM-C added a temporary magnetic strip alarm on all exit doors as a back up in case of another malfunction. ~ On 8/16/25, DON-B spoke with Family Member (FM)-K who stated R1 told FM-K that R1 walked until R1's legs were sore and sat down. ~ On 8/19/25, Service Technician (ST)-J inspected the facility's alarm system and indicated the keypad on exit door 5 was deprogrammed which could be due to a power issue. ST-J reprogrammed the keypad and tested the other doors with no concerns. The facility's investigation did not include resident or staff interviews regarding alarms that sounded/were turned off and did not contain a determination of the root cause of exit door 5's malfunction. The facility provided immediate education to DOM-C to check door alarms by setting them off rather than observing keypad lights. All staff were educated on the elopement/wandering policy and instructed that if an alarm sounds, staff need to know why. If unable to determine why, staff should complete a head count and document on the resident roster. The facility did not provide proof of staff education on how to ensure alarms are properly functioning/armed, including temporary magnetic strip alarms. A police report, dated 8/15/25, indicated the police department received a call at 9:09 PM for a welfare check due to a person laying on the side of the road. The officer arrived on the scene at approximately 9:13 PM and discovered R1 laying on the side of the road near County Highway B (CTH B) and Evergreen Street. The officer indicated R1 was confused and could not adequately answer the officer's questions. The officer thought R1 was having a medical emergency and called Emergency Medical Services (EMS). It was later determined that R1 eloped from the facility and had ambulated approximately 0.3 miles without a wheelchair or walker. The facility was informed that R1 was at the local ED.According to weatherunderground.com, the weather in Shawano, WI between 8:30 PM and 9:15 PM on 8/15/25 was partly cloudy with a temperature of 80 degrees. Sunset occurred at approximately 8:00 PM.On 9/8/25 at 3:21 PM, Surveyor interviewed LPN-D who verified LPN-D observed R1's empty wheelchair at the nurses' station on 8/15/25, initiated the elopement protocol, and notified administration when staff could not locate R1. LPN-D stated LPN-D did not hear any alarms after LPN-D last saw R1 at approximately 7:45 PM.On 9/8/25 at 3:38 PM, Surveyor interviewed Registered Nurse (RN)-F who stated RN-F did not hear any alarms after RN-F last saw R1 at approximately 7:45 PM on 8/15/25. RN-F stated RN-F often sits with R1 at the nurses' station to chart, however, that evening RN-F was on RN-F's assigned unit most of the evening. On 9/8/25 at 3:47 PM, Surveyor interviewed CNA-I who did not hear any alarms on the evening of 8/15/25 and did not see R1 that night.On 9/8/25 at 3:52 PM, Surveyor interviewed CNA-H who thought CNA-H heard an alarm that sounded like a siren around 9:00 PM. CNA-H indicated CNA-H was fairly confident about the time because CNA-H was providing care for a resident on a different wing and consistently provided care for that resident between 9:00 and 9:45 PM. CNA-H did not see R1 after the alarm sounded and was not sure who turned the alarm off. CNA-H did not report the alarm to any other staff.On 9/8/25 at 4:30 PM, Surveyor interviewed CNA-E who verified CNA-E was assigned to R1's wing on the evening of 8/15/25 and last saw R1 when CNA-E toileted R1 between 8:00 and 8:30 PM. CNA-E indicated CNA-E heard an alarm sometime after 8:00 PM while putting another resident to bed. CNA-E indicated the alarm was after CNA-E had toileted R1 and verified CNA-E did not see R1 after the alarm sounded. CNA-E was not sure who turned the alarm off and stated CNA-E did not know how to turn the alarm off. CNA-E did not report the alarm to any other staff. On 9/9/25 at 5:15 PM, Surveyor interviewed DON-B who verified DON-B last saw R1 as DON-B was leaving the facility at approximately 8:30 PM and CNA-E was taking R1 to R1's room to use the bathroom. DON-B was not aware of any concerns with the alarm system prior to the incident on 8/15/25. DON-B verified the facility did not investigate the discrepancy between CNA-H's statement that R1 was last seen at approximately 9:15 PM and the police report that indicated R1 was found by police at 9:09 PM. DON-B verified a cause was not identified for exit door 5's keypad malfunction. On 9/8/25, Surveyor toured the facility and observed all exit doors and temporary alarms. Surveyor noted exit doors 2, 3, 4, 5, and 6 had temporary magnetic strip alarms in place and were turned on. Exit doors 9, 10, and 13 had temporary magnetic strip alarms in place but was turned off. Exit door 12 did not have a temporary magnetic strip alarm in place. On 9/8/25 at 11:30 AM, Surveyor interviewed DOM-C who indicated there were concerns with the facility's alarm system prior to 6/6/25 when DOM-C started. DOM-C was not familiar with the concerns and stated DOM-C just knew that the alarm system had been worked on before. DOM-C indicated that prior to 8/15/25, DOM-C tested two exit doors per week and exit door 5 was last tested on [DATE]. DOM-C verified DOM-C checked the door alarm system visually prior to 8/15/25 but received education and currently activated each alarm daily. DOM-C demonstrated the door alarm which sounded like a loud siren throughout the building. DOM-C stated magnetic strip alarms were put in place until the facility could fix the issue with the alarm system. DOM-C and NHA-A verified the magnetic strip alarms for exit doors 9.10, and 13 were turned off. DOM-C and NHA-A were unsure why the alarms were turned off and indicated staff may have turned them off when going in/out and did not turn them back on. When DOM-C turned on the magnetic strip alarm for exit door 10 and it didn't sound, DOM-C indicated a new magnetic strip or battery was needed. When DOM-C turned on the magnetic strip alarm for exit door 13 and it didn't sound, DOM-C verified the magnetic strip was missing from the alarm. DOM-C stated ST-J inspected the system on 8/19/25 and indicated all door alarms appeared to be functioning when ST-J left. DOM-C verified the root cause of the original malfunction was not determined but thought it was power-related.On 9/8/25 at 11:54 AM, Surveyor interviewed NHA-A who was not aware of any issues with the alarm system until the elopement incident on 8/15/25. NHA-A toured the facility with DOM-C and Surveyor and acknowledged some of the magnetic strip alarms had been turned off because all doors were functioning when ST-J left the faciity on 8/19/25. On 9/9/25 at 8:30 AM, Surveyor interviewed DOM-C who verified all doors currently have a working magnetic strip alarm. DOM-C confirmed the magnetic strip alarms were installed as back-up/security because the cause of the malfunction was not determined. DOM-C stated the facility set up an appointment with a new company to inspect the alarm system on 9/10/25.On 9/9/25 at 10:45 AM, Surveyor interviewed ST-J who stated the company that installed the alarm system no longer provided support for the facility so ST-J was doing what ST-J could with another company's system. ST-J verified exit door 5's alarm keypad appeared to be armed since the door had a red light (which indicated it was armed) versus a green light (which indicated it was disarmed) but did not alarm when opened. ST-J re-programmed the keypad and verified all doors were functioning before ST-J left the faciity on 8/19/25. ST-J suspected a power issue caused the malfunction but could not be sure. ST-J indicated the facility installed temporary magnetic strip alarms as a backup in case there was another power issue. ST-J stated the door alarms were functioning on 8/19/25 but whatever caused the issue could happen again if the facility didn't identify a cause or replace the alarm system. ST-J's professional opinion was that the alarm system was not reliable or trustworthy at that time. A review of other residents determined the facility identified two other residents in the building on 8/8/25 who were at risk for elopement and wore WanderGuards.The facility's failure to provide adequate supervision for residents at risk for elopement/wandering and consistently implement a temporary solution for a malfunctioning door alarm created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 9/10/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan:1.Ensured temporary alarms were in place and functioning and implemented a new process that includes increased frequency of door alarm monitoring.2. Reviewed residents at risk for wandering.3. Educated all staff on the facility's elopement/wandering procedure and alarms, including monitoring and managing residents at risk for elopement or unsafe wandering and completing a wander risk assessment when a resident attempts to elope.4. Educated management staff on completing a thorough investigation. 4. Implemented audits to ensure wander risk assessments are completed, alarmed doors are functioning properly, and incidents are thoroughly investigated. Audits will be reviewed with Quality Assurance and Performance Improvement (QAPI) members.

Based on observation, staff and resident interview, and record review, the facility did not ensure 8 residents (R) (R3, R10, R8, R9, R11, R14, R15, and R13) of 16 sampled residents received timely assistance for activities of daily living (ADLs)R3 and R10 experienced long call light response times and had to wait to be assisted to bed.R8 experienced long call light response times which caused increased incontinence and embarrassment.R9 experienced long call light response times which caused stress and difficulty completing ADLs so R9 could go to bed.R11, R14 and R15 experienced long call light response times which resulted in increased stress and incontinence.R13 experienced long call light response times which resulted in increased incontinence. In addition, R13 had to wait to be assisted to bed.Findings include: The facility's Call lights: Accessibility and Timely Response policy, revised 7/6/22, indicates: .2. All residents will be educated on how to call for help by using the resident call system .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 11. Process for Responding to Call Lights: a. Turn off the signal light in the resident's room. b. Identify yourself and call the resident by name. c. Listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. d. Inform the appropriate personnel of the resident's need. e. Do not promise something you cannot deliver. f. If assistance is needed with a procedure, summon help by using the call light. Stay with the resident until help arrives.The facility's Activities of Daily Living (ADLs) policy, revised 7/26/22, indicates: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting .2. The facility will provide a maintenance and restorative program as applicable to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .1. On 9/8/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, chronic respiratory failure with hypoxia, low back pain, and obesity. R3's Minimum Data Set (MDS) assessment, dated 6/18/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. The MDS assessment also indicated R3 was totally dependent on staff for bathing/showering, standing, toileting, and transfers. On 9/8/25 at 3:18 PM, Surveyor noted R3's call light was turned on. R3's call light was turned off at 3:53 PM after 35 minutes. On 9/8/25 at 4:27 PM, Surveyor interviewed R3 who indicated R3 often has to wait for staff to answer R3's call light. R3 indicated it is not always acceptable to wait that long because sometimes R3 has to go to the bathroom and doesn't feel that R3 can hold it. R3 also indicated R3 and R3's roommate had to wait until the night shift arrived last week to go to bed which was after 10:00 PM. During the interview, R3's roommate confirmed R3's statement. R3 indicated R3 wanted to go to bed around 8:00 PM and turned on the call light, however, R3 was told a staff had gone home and staff were not able to put R3 to bed until the next shift arrived. R3 indicated the facility is understaffed.2. On 9/8/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF), chronic kidney disease, and polyosteoarthritis. R10's MDS assessment, dated 6/18/25, had a BIMS score of 10 out of 15 which indicated R10 had moderately impaired cognition. The MDS assessment also indicated R10 was totally dependent on staff for bathing/showering, standing, toileting, and transfers. On 9/8/25 at 3:20 PM, Surveyor noted R10's call was turned on. R10's call light was turned off at 3:59 PM after 39 minutes. Surveyor noted R10's call light was turned on again at 6:25 PM. R10's call light was turned off at 6:40 PM after 15 minutes. On 9/8/25 at 6:52 PM, Surveyor interviewed R10 who indicated R10's needs are not being met and stated R10's call light was on and R10 had to wait a long time. When staff responded, R10 was told R10 couldn't go to bed at that time and had to wait until later. R10 indicated staff said they had other things to do and R10 had to wait R10's turn to be put to bed. R10 stated R10 gets upset and wishes R10 didn't have to wait so often but there is nothing R10 can do. On 9/8/25 at 7:08 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who verified CNA-I turned off call lights in a few rooms on the A wing. CNA-I indicated R10 wanted to go to bed, but it was too early. CNA-I indicated if R10 went to bed now, R10 would turn the call light on too much. CNA-I indicated if R10 goes to bed early, R10 wants attention and turns the call light on to have staff fix R10's blankets, untuck the corner of the blanket, or move items in R10's room. CNA-I indicated R10 is lonely and CNA-I will keep R10 comfortable in R10's chair and put R10 to bed later. CNA-I indicated CNA-I has a routine of who to put to bed when and R10 is put to bed after two other residents. CNA-I indicated CNA-I does the same thing when CNA-I works another hallway and has a pre-determined pattern of who is put to bed in what order. CNA-I indicated residents in the other hallway also activate their call lights constantly if they are put to bed right after dinner (which is when CNA-I indicated they request to be put to bed) so CNA-I has them wait until a later time.3. On 9/8/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including macular degeneration, morbid obesity, chronic respiratory failure with hypoxia, and difficulty walking. R8's MDS assessment, dated 6/11/25, had a BIMS score of 15 out of 15 which indicated R8 had intact cognition. The MDS assessment also indicated R8 required substantial/maximal assistance of staff for bathing/showering and standing and was totally dependent on staff for toileting and transfers. On 9/8/25 at 6:07 PM, Surveyor noted R8's call light was turned on. The call light was turned off at 6:23 PM after 16 minutes. On 9/8/25 at 6:48 PM, Surveyor interviewed R8 who indicated R8 has to wait a long time for staff to answer the call light. R8 indicated R8 is continent, however, R8 has been incontinent due to waiting too long. R8 indicated it is messy when R8 has a loose bowel movement and has to wait for staff to respond. R8 stated R8 is embarrassed when R8 has to wait a long time in a soiled brief.4. On 9/8/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including COPD, CHF, vaginal prolapse, urinary incontinence, leukoplakia of vulva, and anxiety. R9's MDS assessment, dated 6/11/25, had a BIMS score of 14 out of 15 which indicated R9 had intact cognition.On 9/8/25 at 4:10 PM, Surveyor interviewed R9 who indicated R9 is not happy with call light response times. R9 indicated it takes staff too long to answer call lights and it's difficult to hold it when R9 needs to use the bathroom. R9 indicated R9 needs staff assistance to ambulate but it's hard to hold R9's bladder when staff take 30 minutes to answer the call light. R9 wants staff to answer call lights sooner. On 9/8/25 at 6:23 PM, Surveyor noted R9's call light was turned on. R9's call light was turned off at 6:41 PM after 18 minutes.On 9/8/25 at 6:58 PM, Surveyor interviewed R9 who indicated R9's call light was turned off by staff who didn't provide assistance. R9 asked if staff could put R9 to bed but was told R9 couldn't go to bed yet and had to wait. R9 was trying to undress R9's self and had part of R9's shirt off. R9 asked Surveyor to help R9 get ready for bed and said there aren't enough staff. When asked if R9 had to wait to go to bed prior to that evening, R9 stated staff often turn off R9's call light and say R9 has to wait until they come back. On 9/8/25 at 7:08 PM, Surveyor interviewed CNA-I who indicated all residents want to go to bed after dinner, including R9, but it is too early. CNA-I confirmed CNA-I turned off R9's call light, stated R9 had to wait for assistance to get ready for bed, and then left R9's room to answer other call lights.5. On 9/8/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction, CHF, contracture, and chronic pain syndrome. R11's MDS assessment, dated 8/13/25, had a BIMS score of 14 out of 15 which indicated R11 had intact cognition. The MDS assessment also indicated R11 was dependent on staff and required full assistance for bathing/showering and toileting and substantial/maximal assistance for standing and transfers.On 9/8/25, Surveyor noted R11's call light was turned on at 3:23 PM. R11's call light was turned off at 3:46 PM after 23 minutes.On 9/8/25 at 4:50 PM, Surveyor interviewed R11 who indicated call light response times are unreasonable. R11 indicated R11 has to wait a long time and urinates a lot. R11 indicated the worst part of call light response times and ADLs is that staff put R11 on the toilet and forget to come back. R11 indicated R11 has been incontinent due to long wait times. R11 told staff that R11 needs them to answer the call light faster but staff stated they are too busy. 6. On 9/8/25, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including osteoarthritis, morbid obesity, CHF, and slow transit constipation. R14's MDS assessment, dated 9/3/25, had a BIMS score of 15 out of 15 which indicated R14 intact cognition.On 9/8/25, Surveyor noted R14's call light was turned on at 1:07 PM. R14's call light was turned off at 1:48 PM after 41 minutes.On 9/9/25 at 1:36 PM, Surveyor interviewed R14 who indicated call light response times are not always acceptable. R14 indicated there are not enough staff and the facility is very corporate. R14 said R14 has a weak bladder and waits 20 to 25 minutes on average for staff to answer the call light. R14 indicated R14 would prefer staff answer the call light faster.7. On 9/8/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including COPD, chronic kidney disease, left leg above knee amputation, right leg chronic ulcer, difficulty walking, and weakness. R15's MDS assessment, dated 7/16/25 had a BIMS score of 15 out of 15 which indicated R15 had intact cognition.On 9/8/25, Surveyor noted R15's call light was turned on at 10:47 AM. R15's call light was turned off at 11:04 AM after 17 minutes. On 9/9/25 at 1:22 PM, Surveyor interviewed R15 who indicated call light response times are usually between 15 and 30 minutes. R15 wished staff would respond sooner so R15 was not incontinent due to not making it to the bathroom on time. R15 indicated staff turned off the call light without meeting R15's needs because staff didn't think it was necessary to help R15.8. On 9/8/25, Surveyor reviewed R13's medical record. R13 requested to remain anonymous. R13's most recent MDS assessment indicated R13 had intact cognition. On 9/8/25, Surveyor noted R13's call light was turned on at 1:16 PM. R13's call light was turned off at 1:41 PM after 25 minutes. On 9/9/25 at 1:01 PM, Surveyor interviewed R13 who indicated it takes staff a long time to respond to call lights and the average response time is 30 minutes. R13 indicated R13 has waited almost 2 hours for staff to answer the call light and stated staff often turn off the call light without meeting R13's needs, including 2 CNAs last night. R13 indicated one CNA stated Surveyors were watching call lights so they needed to turn the call lights off. R13 indicated the CNA turned off R9 and R10's call lights without meeting their needs. R13 indicated when staff turn off the call light without meeting R13's needs, R13 turns the call light back on if staff don't come back after 10 minutes. R13 feels bad for residents whose needs aren't being met and who can't advocate for themselves. R13 stated R13 gets annoyed when staff turn off the call light without providing assistance and has been incontinent due to waiting too long for help. R13 indicated R13 has to wait even longer after the call light is turned off and staff leave because staff don't come back for a longer time. Surveyor reviewed the facility's grievance log from the last survey (8/20/25) to the present and noted a grievance related to long call light response times that was dated 8/25/25. On 9/8/25 Surveyor requested call light audits for seven rooms on seven dates on a specified shift picked at random and noted the following call light times (rounded to the nearest minute) that were 15 minutes or longer: ~ On 8/3/25: 18 minutes and 19 minutes ~ On 8/9/25: 29 minutes, 32 minutes, and 44 minutes ~ On 8/14/25: 17 minutes and 26 minutes ~ On 8/15/25: 25 minutes and 57 minutes ~ On 8/26/25: 21 minutes and 25 minutes ~ On 8/30/25: 19 minutes and 26 minutes ~ On 9/1/25: 15 minutes, 20 minutes, 26 minutes, and 26 minutes On 9/8/25 at 1:54 PM, Surveyor observed the call light screen with Registered Nurse (RN)-P and noted call lights at 19 minutes, 25 minutes, and 41 minutes. RN-P indicated that was not unusual.On 9/8/25 at 5:10 PM, Surveyor interviewed CNA-I who indicated the facility is short staffed. CNA-I stated call light response times should be 1 to 2 minutes. CNA-I indicated CNA-I tries to respond to call lights within 2 to 3 minutes unless CNA-I is giving a shower or doing something that takes longer.On 9/8/25 at 5:48 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-N who indicated call lights should be answered as soon as they are turned on. LPN-N stated the average call light response time is approximately 7 minutes. LPN-N indicated the longest call lights LPN-N has seen have been 15 to 20 minutes.On 9/8/25 at 5:51 PM, Surveyor interviewed CNA-O who indicated staffing is not consistent and call light response times would be better if there were more staff. CNA-O indicated the worst times for call lights are in the morning, between 3:00 and 4:00 PM, and between 7:00 and 8:00 PM. CNA-O indicated residents' needs are likely not met at times.On 9/8/25 at 5:54 PM, Surveyor interviewed LPN-D who indicated there is room for improvement with call lights. LPN-D indicated the average call light response time is approximately 20 minutes but should be less than 5 minutes. LPN-D indicated if there were more staff, call light response times would be less. LPN-D verified residents complain about long call response times.On 9/9/25 at 1:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated call lights should be answered in the order they are turned on. NHA-A indicated if several lights are on at the same time, staff should check with residents, see what they need, and let them know they'll be back to assist them shortly. NHA-A indicated staff should not turn the call light off if the resident's needs have not been addressed since the call light serves as a reminder that the resident still needs services. NHA-A indicated it's not okay for staff to tell residents they can't go to bed. NHA-A indicated if staff assigned to a hall are busy elsewhere, they should use their walkie talkie to communicate with other staff and ask for help. NHA-A indicated staff can help residents on any hall as needed. NHA-A indicated the facility is staffed appropriately for the census and management should be on the floor helping as needed. NHA-A indicated NHA-A doesn't like to specify call light response times and indicated a 15 minute call light response time is acceptable at a busy time like shift change. NHA-A indicated on average call lights should be answered within 7 to 10 minutes.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 36 residents residing in the facility.The facility was following COVID-19 precautions due to staff exposure. During lunch and supper on 9/8/25, hand hygiene was not offered to residents prior to or after dining.Finding includes: The facility's Hand Hygiene policy, dated 11/2/22, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand Hygiene Table indicates hand hygiene is to be performed before and after eating .References: Centers for Disease Control and Prevention (CDC).About Handwashing information from CDC.gov, dated 2/16/24, indicates: Many diseases and conditions are spread by not washing hands with soap and clean, running water. Hand washing with soap is one of the best ways to stay healthy. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surface to person when you: Touch your eyes, nose, and mouth with unwashed hands; Prepare or eat food and drinks with unwashed hands; Touch surfaces or objects that have germs on them; Blow your nose, cough, or sneeze into hands and then touch other people's hands or common objects. You can keep yourself and your loved ones healthy by washing your hands often, especially during these key times when you are likely to get and spread germs: Before, during, after preparing food; Before and after eating food .On 9/8/25 at 10:00 AM, Surveyor entered the facility and was informed the facility was following COVID-19 precautions due to COVID-19 exposure to staff. On 9/8/25 at 12:00 PM, Surveyor began observing lunch in the main dining room. There were 11 residents in the dining room. Survey observed 8 additional residents arrive for a total of 19 residents. Surveyor noted the dining tables did not contain hand sanitizing wipes or bottles of hand sanitizer. Surveyor did not observe staff offer or complete hand hygiene for residents prior to eating their meal. At 12:08 PM, Surveyor observed Dietary Manager (DM)-Q and Dietary Aide (DA)-R begin plating and serving meals to residents in the dining room. No other staff initially assisted the residents or during the majority of the time the food was served. On 9/8/25 at 12:03 PM, Surveyor interviewed DM-Q who indicated Certified Nursing Assistants (CNAs) are supposed to help in the dining room, however, kitchen staff will assist residents with dining until CNAs arrive. On 9/8/25 at 12:27 PM, Surveyor interviewed DA-R who indicated staff should offer residents hand hygiene before meals but forgot to do so that day. When Surveyor asked how staff offer hand hygiene, DA-R retrieved a container of individually packaged hand sanitizing wipes that were near the sink in the dining room and stated staff can give residents a wipe. DA-R then put the container of wipes back and walked away. When Surveyor asked if staff should still offer residents a wipe even though they had started eating since the facility was in a COVID-19 outbreak, DA-R retrieved the wipes and said DA-R forgot. DA-R offered approximately 8 residents a wipe and then put the wipes away. Surveyor noted residents were not offered hand sanitizing wipes after they finished their meal and before they exited the dining room.On 9/8/25 at 4:44 PM, Surveyor observed [NAME] (CK)-L and CK-M plate and serve supper in the main dining room. CNA-I was also serving meals and assisting residents. Surveyor noted staff did not offer hand hygiene prior to dining to the 16 residents in the dining room. On 9/8/25 at 5:12 PM, Surveyor interviewed CK-L who was unsure if residents should be offered hand hygiene before meals.On 9/8/25 at 5:13 PM, Surveyor interviewed CK-M who indicated residents should be offered hand hygiene before meals and was unsure why hand hygiene was not offered. When Surveyor asked how staff offer hand hygiene, CK-M showed Surveyor a container of individually packaged hand sanitizing wipes that were near the sink. On 9/8/25 at 5:18 PM, Surveyor interviewed CNA-I who indicated residents should be offered hand hygiene before and after meals and was unsure why that didn't occur. CNA-I then offered a wipe to 3 residents in the dining room. On 9/9/25 at 1:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff were trained and should follow the facility's infection control and hand hygiene policies and procedures. NHA-A indicated residents should be offered hand hygiene in the dining room and should be provided hand sanitizing wipes on room trays for every meal.

Based on observation, staff interview, and record review, the facility did not provide the necessary enteral feeding services for 2 residents (R) (R2 and R1) of 2 sampled residents.R2 had an order to infuse 920 milliliters (mls) of enteral feeding between 8:00 PM and 4:00 AM. On 8/20/25 at 7:26 AM, R2's pump was running and had infused 990 mls. In addition, the head of R2's bed was not elevated to the proper height during multiple observations.R1 had an order to flush R1's feeding tube with 2000 ml of water per day after tube feeding at a rate of 390 until gone and an order for tube feeding with carbohydrate stability 1.2 (calories) 1422 ml at a rate of 90 for 15 continuous hours during the hours of 8:00 PM and 11:00 AM. On 8/14/25, Licensed Practical Nurse (LPN)-C did not flush R1's tube feeding line at the correct time and Registered Nurse (RN)-D did not start the tube feeding at the correct time. Findings include: The facility's Enteral Nutritional Therapy policy, dated 6/2017, indicates: Resident should be sitting upright at 30-45 degrees during the feeding and for 1-2 hours after the feeding to minimize risk for aspiration pneumonia. Administer the amount of feeding to be given .Adjust rate of flow as prescribed. Flush tubing with water as prescribed following feeding. 1. On 8/20/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, morbid obesity, diabetes, and obstructive sleep apnea. R2's Minimum Data Set (MDS) assessment, dated 8/4/25, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R2 had severe cognitive impairment. The MDS assessment also indicated R2 received enteral feeding. R2 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. R2's plan of care indicated R2 was at risk for nutritional change with no concerns. On 8/20/25 at 7:26 AM, Surveyor observed LPN-C administer medication to R2 via percutaneous endoscopic gastrostomy (Peg)tube. Surveyor noted the tube feeding pump was running at 45 ml/hour and the pump total volume to infuse read 990 mls. LPN-C verified R2 should have only received 920 mls of tube feeding solution. Surveyor noted the head of R2's bed was at 10 degrees. LPN-C verified the head of R2's bed should be elevated to 30 degrees and proceeded to elevate the head of the bed to 30 degrees. Surveyor observed LPN-C stop the tube feeding, administer a new feeding tube bag and tubing, and add 950 mls of Jevity 1.2 tube feeding solution to ensure the bag would not run out. The pump was cleared, the running time was set at 45 ml/hour, and the feeding was started. On 8/20/25 at 10:35 AM, Surveyor interviewed LPN-C who verified R2's tube feeding was running at 7:26 AM on 8/20/25. LPN-C verified the tube feeding should have been stopped at 4:00 AM. LPN-C also verified R2 received 990 mls of tube feeding solution but should have received 920 mls per R2's order. LPN-C verified the order indicated to stop the tube feeding at 4:00 AM and restart it at 8:00 AM after infusing 920 mls. When Surveyor asked how Certified Nursing Assistants (CNAs) know the head of R2's bed should be elevated, LPN-C indicated the information is contained in the CNA task documentation form. LPN-C verified there was not a sign in R2's room to alert staff that the head of the bed needed to be elevated and later verified the information was not contained in the CNA task documentation form. LPN-C then added an intervention on the CNA task documemtation form to elevate the head of R2's bed. LPN-C verified R2's Medication Administration Record (MAR) indicated to elevate the head of R2's bed. On 8/20/25 during the 11:00 AM hour, Surveyor and LPN-C observed R2 in bed with the head of the bed elevated to 10 degrees. LPN-C verified the head of the bed was at 10 degrees but should be elevated to 30 degrees. LPN-c then elevated the head of the bed to 45 degrees. 2. On 8/20/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] for respite care and had diagnoses including Alzheimer's disease, dementia, acute respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, anxiety, depression, and a gastrostomy. An MDS assessment was completed on 8/7/25; however, a BIMS was not completed because R1 was rarely or never understood. R1 was alert to self per staff assessment and had an activated POAHC who made medical decisions for R1. R1's MAR indicated to flush R1's feeding tube with 2000 ml of water per day starting after tube feeding at a rate of 390 until gone. (R1's tube feeding was supposed to be completed at 11:00 AM.) The MAR indicated LPN-C started the flush at 12:47 PM on 8/14/25. On 8/20/25 at 1:46 PM, Surveyor interviewed LPN-C who was not sure if LPN-C started the flush late or charted the flush late. LPN-C indicated the expectation was to chart right after starting the flush. R1's MAR also indicated tube feed enteral nutrition via pump - tube feeding with carbohydrate stability 1.2 (calories) 1422 ml rate of 90 for 15 continuous hours during hours of 8:00 PM and 11:00 AM daily. The MAR indicated RN-D started the tube feeding at 9:29 PM on 8/14/25. On 8/20/25 at 2:23 PM, Surveyor interviewed RN-D who indicated RN-D started R1's tube feeding at approximately 8:10 PM. RN-D indicated RN-D charted late because it was the first chance RN-D had to chart. RN-D indicated the expectation was to chart right away. On 8/20/25 at 3:10 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated nursing staff should administer tube feeding orders within 30 minutes to 1 hour of what the medical order specifies.

Based on observation, staff interview, and record review, the facility did not ensure meals were served at regular times and per resident preferences for 7 residents (R) (R27, R19, R14, R18, R237, R13, and R23) of 7 sampled residents. On 5/28/25 and 5/29/25, the facility served room trays 30 or more minutes after the posted meal service time for breakfast. On 5/27/25 and 5/28/25, the facility served room trays 30 or more minutes after the posted meal service time for lunch. In addition, R237 did not receive a lunch tray on 5/28/25 until one hour after the posted meal service time. Findings include: On 5/27/25 at 9:39 AM, Surveyor interviewed R27 who indicated room trays are always late. R27 indicated R27 has had to wait 30 minutes to an hour after the posted meal time to receive a tray. R27 indicated sometimes breakfast does not arrive until almost 10:00 AM and lunch until 1:00 PM. R27 indicated kitchen staff could help more and stated meals are delivered closer to the mealtime when there is a hospitality aide scheduled. R27 was frustrated that R27 had wait later than the posted meal time. R27 also expressed frustration with seeing residents return from the dining room who had already eaten when R27 had not been served. R27 indicated R27 preferred room trays should not have to wait for meals or go to the dining room. On 5/27/25 at 10:00 AM, Surveyor noted posted meals times in the nurses' station were listed as: Breakfast 8:00 AM, Lunch 12:00 PM, Supper 5:00 PM. On 5/27/25 at 11:48 AM, Surveyor observed meal service at the tray line in the dining room and noted room trays were plated first and put in a tray cart. Surveyor observed staff serve 15 residents in the dining room and put 24 meal trays in the cart to deliver to rooms. On 5/27/25 at 12:08 PM, Surveyor observed lunch service and noted the following room tray service times: ~ At 12:08 PM, a room tray cart was delivered to the nurses' station. ~ At 12:11 PM, a room tray cart left the kitchen and was sent to the Deer Path Trail. ~ At 12:25 PM, a room tray cart left Deer Path Trail and was taken to Eagle View Terrace to serve residents. ~ At 12:31 PM, a room tray cart left Eagle View Terrace and was taken to Appletree Court to serve residents. Surveyor noted R27 and R27's roommate were served lunch at 12:35 PM which was 35 minutes past the posted meal time. Surveyor noted R19 was served lunch at 12:38 PM. Surveyor also noted R14 was served lunch at 12:40 PM and received the last room tray. On 5/27/25 at 12:41 PM, Surveyor interviewed R27 and R18. R18 indicated breakfast was usually the latest meal served. R18 indicated an aide helped during the day twice per week and those days were better than the usual late times. R18 indicated having to wait was frustrating and stated R18 should not have to wait for meals to be served past the posted time. R27 indicated meals were always late and stated dinner was served closest to the posted time. R27 also indicated there was a new kitchen supervisor and stated the wait time was improving. R27 indicated currently the longest wait time was an hour, however, R27 used to wait for breakfast until 10:00 AM or later. R27 indicated breakfast was not served until 8:40 AM that morning which was unacceptable. On 5/28/25 at 7:54 AM, Surveyor observed the breakfast meal. Surveyor noted breakfast service had not started in the dining room and room trays were not being served despite the fact breakfast was scheduled for 8:00 AM. Surveyor observed 16 residents in the dining room and the following meal delivery times: ~ At 8:00 AM, staff started room tray service and loaded a cart with breakfast trays. ~ At 8:12 AM, a room tray cart left the dining room and was delivered to the nurses' station. ~ At 8:19 AM, room tray service began on Deer Path Trail. ~ At 8:37 AM, room tray service began on Eagle View Terrace. ~ At 8:43 AM, room tray service began on Appletree Court. On 5/28/25 at 8:41 AM, Surveyor interviewed R18 who indicated last night's dinner was served close to the posted time because the aides who were working always delivered trays as soon as possible. R18 indicated R18 was still waiting for breakfast and stated, I always say here goes (neighbor) who is coming back from breakfast and we still haven't been served. I should be able to choose where I eat and still get served at the same time as others. It just isn't right we have to wait so long. On 5/28/25 at 8:45 AM, Surveyor continued with an observation of room tray service on Appletree Court and noted the following meal delivery times: ~ At 8:49 AM, R18 and R27 were served room trays. ~ At 8:54 AM, a room tray cart left Appletree Court to serve R237 who received a tray at 8:59 AM. On 5/28/25 at 9:01 AM, Surveyor interviewed R237 who indicated R237 had to wait over an hour at times for R237's breakfast and lunch room trays. R237 expressed frustration with having to wait so long and stated R237 wanted to receive meals at 8:00 AM and 12:00 PM when the facility indicated they would deliver meals. On 5/28/25 at 10:29 AM, Surveyor conducted a resident council meeting that included R13, R19, R23 and R14. During the group interview, the following concerns were reported regarding room tray delivery: ~ R19 indicated room trays take a while to be delivered at times. R19 indicated the cart was delivered to the nurses' station and could sit for a long time before staff began to deliver room trays. R19 indicated R19 had waited over and an hour for a room tray and indicated trays were usually delivered at least a half hour late or later which was unacceptable. ~ R13 indicated breakfast took the longest. R13 indicated the wait time was unacceptable because residents who ate in the dining room had usually already eaten before some residents received their breakfast or lunch tray. R13 indicated when a hospitality aide worked twice per week there was still a wait, however, it was an acceptable wait and not an hour past the meal time. R13 indicated the concerns were brought up at resident council the past several meetings. ~ R14 agreed with what the other residents stated. R14 indicated it could take an hour after the posted meal time to receive a room tray. R14 indicated staff from different areas could help because nursing staff could be busy. ~ R23 indicated R23 waited a long times for meals. R23 indicated the wait for breakfast was the longest. R23 indicated the wait time was unacceptable and stated R23 should not have to wait so long to eat meals. On 5/28/25 at 11:50 AM, Surveyor observed 10 residents in the dining room and noted lunch service had not yet begun. Surveyor noted the following meal delivery times: ~ At 12:00 PM, dietary staff began plating room trays. ~ At 12:05 PM, a room tray cart was brought to the nurses' station. ~ At 12:12 PM, staff began to deliver room trays on Deer Path Trail. ~ At 12:24 PM, staff began to deliver room trays on Eagle Terrace. ~ At 12:30 PM, staff began to deliver room trays on Appletree Court. ~ At 12:43 PM, the last room tray was delivered on Appletree Lane. On 5/28/25 at 12:50 PM, Surveyor observed R237 in R237's room without a lunch tray. Surveyor interviewed R237 who indicated R237 was upset because meals were late and R237 had to wait a long time for meals. R237 indicated R237 should receive meals according to the posted meal times. Surveyor conducted a continuous observation and noted R237 was not served lunch until 1:01 PM. On 5/28/25 at 1:03 PM, Surveyor interviewed Dietary Manager (DM)-K who indicated kitchen staff did not pass room trays and stated it was nursing staffs' responsibility. DM-K indicated kitchen staff assisted at times when the facility was short staffed and staffing allowed for only one nurse aide to pass room trays, however, that was not the normal practice. DM-K was not aware of resident concerns regarding meal service times and indicated DM-K had only been in DM-K's position for a few weeks. DM-K indicated concerns may have been expressed prior to DM-K's arrival On 5/29/25 at 7:55 AM, Surveyor observed room tray delivery and noted the following meal service times. Surveyor also noted two staff assisted with delivering meal trays: ~ At 8:03 AM, a room tray cart was brought to the nurses' station by dietary staff. ~ At 8:10 AM, room service began on Deer Path Trail. ~ At 8:21 AM, room service began on Eagle Terrace. ~ At 8:30 AM, room service began on Appletree Court. ~ At 8:40 AM, the last room tray was passed on Appletree Lane. On 5/29/25 at 8:59 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware of residents' concerns regarding room trays and was not aware the resident council brought up concerns in the past.

Based on staff interview and record review, the facility did not ensure appropriate care and treatment were provided for 1 resident (R) (R29) of 1 resident reviewed for cardiac monitoring. The facility did not assess R29's ability to follow cardiac monitoring instructions or provide monitoring assessments for R29's cardiac monitor. Findings include: On 5/27/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction (also known as stroke) affecting the left non-dominant side, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), emphysema, and atrial fibrillation. R29's Minimum Data Set (MDS) assessment, dated 4/9/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R29 had moderate cognitive impairment. R29 was responsible for R29's healthcare decisions. R29 was transferred to the hospital on 5/24/25 and remained hospitalized during the survey. R29's medical record contained a physician's order that indicated staff should not apply lotion to R29's skin on the morning of 3/24/25 in preparation for cardiac monitor placement scheduled that day. A note, dated 3/24/25 at 12:29 PM, indicated R29 had a cardiology appointment. No new orders were initiated. A note, dated 3/25/25 at 1:12 PM, indicated a [NAME] monitor (a type of cardiac monitor) was set up and working properly. On 5/27/25 at 9:57 AM, Surveyor interviewed Close Friend (CF)-F via phone who indicated CF-F had been helping R29 since R29's spouse passed away several years ago. CF-F verified CF-F was R29's emergency contact. CF-F indicated CF-F tried to attend appointments with R29 but had to miss occasionally due to work. CF-F indicated the cardiac monitor should be in place for fourteen days. CF-F could not attend the appointment when the monitor was placed and stated, I know (R29's) moods. (R29) will sometimes tell them (healthcare professionals) about things, sometimes not. On 5/28/25 at 10:10 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who verified LPN-G wrote the above notes in R29's medical record. LPN-G indicated a folder sent to R29's cardiac monitor appointment was empty when R29 returned. LPN-G indicated if a resident comes back without papers, a nurse typically calls the clinic to get papers faxed to the facility. LPN-G reviewed R29's medical record and indicated LPN-G could not find any paperwork from R29's cardiac monitor appointment, however, R29 returned to the facility on [DATE] with a cardiac monitor in place. LPN-G indicated the monitor would have come with a phone which blue-toothed with the monitoring device. LPN-G indicated staff were to report any signs or symptoms experienced by a resident wearing the device on the phone after the button was pushed on the device. LPN-G indicated the device's batteries also needed to be checked. LPN-G verified there was no documentation in R29's medical record regarding how long the cardiac monitor was on, how frequently R29 was assessed for symptoms during use, or how frequently the device was checked for correct placement and battery function. LPN-G indicated LPN-G should have called the clinic to get orders since there was no paperwork in R29's folder. LPN-G verified LPN-G did not call the clinic and probably passed the task onto the next shift. When asked about R29's mentation and attending the appointment alone, LPN-G indicated R29 was for the most part alert and oriented with occasional confusion regarding historical questions and timelines of events. LPN-G indicated R29 knew why R29 needed care at the facility. LPN-G indicated if R29 was at an appointment, R29 could tell transportation or clinic staff where R29 needed to be when R29 was at baseline. On 5/28/25 at 2:20 PM, Surveyor interviewed Respiratory Therapist (RT)-H via phone who verified RT-H applied R29's cardiac monitor on 3/24/25. After application of the device, RT-H indicated a box containing a phone and an instruction booklet was sent to the facility with R29. RT-H indicated R29 was able to answer questions but the answers were not always appropriate. RT-H indicated R29 was unable to clearly express understanding of how to use the device. On 5/28/25 at 3:02 PM, Surveyor interviewed Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A, and [NAME] President of Success (VPS)-I. DON-B verified there was no documentation in R29's medical record to indicate follow-up occurred at the facility for R29's cardiac monitor. DON-B indicated the booklet probably went back to the clinic with the monitor. VPS-I verified assessment and monitoring related to cardiac monitor use should have been part of R29's plan of care.

Based on observation, staff and resident interview, and record review, the facility did not provide appropriate respiratory care and services for 3 residents (R) (R237, R187 and R139) of 3 sampled residents. R237, R187, and R139 did not have physician's orders to use, clean, or maintain a continuous positive airway pressure (CPAP) machine. Findings include: The facility's CPAP Therapy policy, revised 6/24/22, indicates: Continuous positive airway pressure is used to treat obstructive sleep apnea .Indications: 1) Obstructive sleep apnea 2) Hypoxemia .1) Verify physician orders .Cleaning and Maintenance: .7) Clean and inspect all components regularly. The mask, tubing, and headgear should last approximately 6-12 months, but the actual life of the equipment can vary greatly. 8) Clean the CPAP unit as necessary .13) Filter Maintenance: 14) Will depend on the model of the unit you have. 15) There will be two filters on some models. The first filter is usually disposable, and the second filter is reusable. Disposable filters should be replaced per manufacturers' recommendations. Reusable filters should be rinsed of dust and allowed to air dry. Never put a damp filter in your CPAP unit. 1. From 5/27/25 to 5/29/25, Surveyor reviewed R237's medical record. R237 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and obstructive sleep apnea. A Minimum Data Set (MDS) assessment was not completed for R237 due to recent R237's recent admission. Per a nursing assessment completed on admission, R237 was alert and oriented to person, place, time, and event. R237's baseline care plan, dated 5/21/25, indicated staff should follow physician orders for CPAP use; however, R237's medical record did not contain orders for CPAP use or cleaning. On 5/27/25 at 9:26 AM, Surveyor interviewed R237 who indicated R237 used a CPAP machine at night. Surveyor observed a CPAP machine on R237's bedside table and a CPAP mask on R237's bed. On 5/28/25 at 9:01 AM, Surveyor interviewed R237 who indicated R237 used CPAP settings from home and cleaned the machine the other day. R237 indicated R237 did not need assistance with the CPAP machine. On 5/28/25 at 9:26 AM, Surveyor requested R237's CPAP order and the facility's CPAP use and cleaning policy from Director of Nursing (DON)-B. On 5/28/25 at 10:38 AM, DON-B provided a CPAP order for R237, dated 5/28/25, for use per home set up when napping or sleeping at night three times a day. DON-B also provided an order, dated 5/28/25, to clean R237's CPAP machine weekly every Thursday. The orders were signed by a Nurse Practitioner (NP) on 5/28/25. On 5/28/25 at 1:30 PM, Surveyor interviewed DON-B who indicated R237 should have had an order for CPAP use and cleaning prior to using the CPAP machine. 47248 2. On 5/27/25, Surveyor reviewed R187's medical record. R187 was admitted to the facility on [DATE] and had diagnoses including mesothelioma of pleura (cancer of the lining of the lungs) and obstructive sleep apnea. R187 was alert and oriented to person, place, time, and event and was R187's own decision maker. R187's care plan, dated 5/21/25, indicated R187 was at risk/had respiratory impairment related to cancer and sleep apnea. The care plan contained interventions to administer medications as ordered and to use a CPAP machine per Medical Doctor (MD) orders. Surveyor noted R187 did not have orders for CPAP use, cleaning, or maintenance. On 5/27/25 at 11:55 AM, Surveyor interviewed R187 who indicated staff had not cleaned R187's CPAP machine but assisted with filling it with water nightly. R187 stated, They should be cleaning the machine and mask, but no one has cleaned it. Surveyor noted R187's CPAP mask and tubing were visibly dirty and oily in appearance and contained skin particles, cream-colored particles, and hair. R187 indicated R187 required assistance from staff to put the mask on and clean the machine. On 5/28/25 at 1:15 PM, Surveyor observed R187's CPAP machine in the same condition as on 5/27/25. R187 indicated no one had cleaned the machine. On 5/29/25 at 9:05 AM, Surveyor observed R187's CPAP machine in the same condition as on 5/27/25. R187 indicated no one had cleaned the machine. On 5/28/25, Surveyor requested R187's CPAP orders from Nursing Home Administrator (NHA)-A. On 5/29/25, Surveyor reviewed R187's CPAP orders and noted the orders for use, cleaning, and maintenance were dated 5/28/25 and indicated: CPAP per home set up when napping or sleeping at night and clean CPAP weekly. On 5/29/25 at 2:00 PM, Surveyor interviewed DON-B who indicated CPAP orders for R187 should have been obtained and added to R187's medical record upon admission. 3. On 5/28/25, Surveyor reviewed R139's medical record. R139 was admitted to the facility on [DATE] and had diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and obstructive sleep apnea. R139 was admitted to the facility from the hospital following a colostomy with colon resection. R139 developed bilateral pulmonary embolisms and pneumonia at the hospital. R139 was alert and oriented to person, place, time, and event and was R139's own decision maker. R139's medical record did not contain orders for CPAP use, cleaning, or maintenance. On 5/28/25 at 2:30 PM, Surveyor interviewed R139 who indicated R139 required assistance with cleaning R139's CPAP machine but did not receive assistance. R139 indicated staff had not cleaned any part of the machine since R139 was admitted . Surveyor noted R139's CPAP mask was visibly dirty and contained skin particles, hair, dirt, and oil. Surveyor also noted R139's CPAP tubing was visibly dirty. On 5/29/25 at 3:15 PM, Surveyor noted R139's CPAP machine was in the same condition as on 5/27/25. R139 indicated no one had cleaned the machine. On 5/28/25, Surveyor requested R139's CPAP orders from NHA-A. On 5/29/25, Surveyor reviewed R139's CPAP orders and noted the orders for use, cleaning, and maintenance were dated 5/28/25 and indicated: CPAP per home set up when napping or sleeping at night and clean CPAP weekly. On 5/29/25 at 2:00 PM, Surveyor interviewed DON-B who indicated CPAP orders for R139 should have been obtained and added to R139's medical record upon admission.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R9) of 17 sampled residents was provided safe and accurate administration of drugs and biologicals. On 5/27/25, Surveyor observed a tube of 1% hydrocortisone cream on R9's bedside table. R9 did not have a physician's order for the cream or an order have medication at the bedside. Findings include: The facility's Medication Administration Self-Administration by Resident policy, dated 1/2023, indicates: .Residents who desire to self-administer medication are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined the practice would be safe .1. If the resident desires to self-administer medication, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out the responsibility during the care planning process .3. The results of the interdisciplinary team assessment are recorded on a Medication Self-Administration Assessment which is placed in the resident's medical record .4. If the resident demonstrates the ability to safely self-administer medication, a further assessment of the safety of bedside medication storage is conducted .6. At least once during each shift, nursing staff check for usage of the medication by the resident . From 5/27/25 to 5/29/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including pathological fracture with subsequent encounter, atrial fibrillation, idiopathic corneal edema, and nonrheumatic mitral insufficiency. R9 was R9's own medical decision maker. R9's most recent Minimum Data Set (MDS) assessment, dated 4/30/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R9 had intact cognition. On 5/27/25 at 10:06 AM, Surveyor observed a tube of 1% hydrocortisone cream at R9's bedside. R9 indicated staff put the cream on R9 when needed for an itchy back. On 5/28/25 at 6:27 AM, Surveyor noted R9's medical record did not contain an order for hydrocortisone cream. A Medication Self-Administration assessment, last completed on 11/16/24, indicated R9 could not self-administer medication and did not wish to self-administer medication. A care plan, dated 4/24/25, did not indicate R9 self-administered medication or keep medication at the bedside. On 5/28/25 at 9:00 AM, Surveyor observed a tube of 1% hydrocortisone cream with the cap off at R9's bedside. On 5/28/25 at 10:22 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-J who recapped the tube of hydrocortisone cream and stated R9 did not have an order to keep medication at the bedside. LPN-J also verified R9's Medication Administration Record (MAR) did not contain an order for hydrocortisone cream. LPN-J stated LPN-J did not apply hydrocortisone cream to R9. On 5/28/25 at 1:34 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R9 should have an order for hydrocortisone cream. DON-B also indicated R9 needed a self-administration of medication assessment that indicated R9 could have medication at the bedside or the medication should be stored in the treatment cart.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R33, R32, and R15) of 3 residents observed during the provision of cares. R33 was on enhanced barrier precautions (EBP). During an observation of care for R33, Certified Nursing Assistant (CNA)-D did not complete appropriate hand hygiene and did not don clean gloves while providing care. Licensed Practical Nurse (LPN)-E did not don a gown while providing care. In addition, R33's uncovered catheter drainage bag was observed on the floor. During wound care for R32, LPN-J did not complete hand hygiene between glove changes. During an observation of care for R15, CNA-C removed soiled gloves after providing perineal care and did not wash or sanitize hands before donning clean gloves. Findings include: The Facility's Hand Hygiene Policy, revised 11/2/22, indicates: All staff will perform proper hand hygiene to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .2. Hand hygiene is indicated and will be performed under the conditions listed in .the hand hygiene table .Before applying and after removing personal protective equipment (PPE), including gloves .Before and after handling clean or soiled dressings, linens, etc .After handling items potentially contaminated with blood, body fluids, secretions, or excretions .When, during resident care, moving from a contaminated body site to a clean body site .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. The facility's Enhanced Barrier Precautions Policy, revised 8/8/24, indicates: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs) .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident care .3. Implementation of Enhanced Barrier Precautions: .b. Personal Protective Equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care .4. High-contact resident care includes: a. dressing; b. bathing; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use .urinary catheters .h. wound care: any chronic skin opening requiring a dressing . The facility's Catheter Care Policy, revised 3/15/23, indicates: .2. Privacy/dignity bags will be available and catheter drainage bags should be covered or always shielded while in use. 1. On 5/28/25 at 1:31 PM, Surveyor observed CNA-D complete a bed bath for R33. R33 was on EBP due to a urinary catheter. Following the bed bath, CNA-D touched the bed remote and R33's bed rail without changing gloves. CNA-D then changed gloves without completing hand hygiene and turned R33 on the left side to wash R33's rectal area. CNA-D touched R33's incontinence brief (which contained a smear of stool), rectal area, and linens and changed gloves without completing hand hygiene. LPN-E then entered the room without a gown, completed a skin check, removed a dressing (that covered excoriated skin) from R33's left posterior thigh, and assisted CNA-D with rolling R33 on the right side. LPN-E touched R33's bedding, removed gloves, completed hand hygiene, and left the room. CNA-D washed R33's rectal area, applied silicone prevent cream to R33's buttocks and groin, and touched R33's bed rail while applying powder to R33's periarea and under R33's breasts. LPN-E returned to the room with gloves and assisted with positioning R33 without a gown. CNA-D put an incontinence brief on R33, put on R33's pants, and touched R33's catheter bag without completing hand hygiene between a glove change. On 5/28/25 at 1:55 PM, Surveyor interviewed CNA-D who verified CNA-D should have completed hand hygiene between glove changes. CNA-D indicated CNA-D completed hand hygiene before entering R33's room and usually had hand sanitizer in CNA-D's pocket but forgot it. On 5/28/25 at 2:13 PM, Surveyor interviewed LPN-E who confirmed LPN-E provided care for R33 and did not wear a gown. On 5/28/25 at 2:23 PM, Surveyor observed CNA-D and another CNA transfer R33 from R33's wheelchair via Hoyer lift. CNA-D did not wear a gown or gloves and entered R33's room with the Hoyer lift. CNA-D touched R33 and the Hoyer lift. When Surveyor asked if PPE was required during high-contact cares for R33, CNA-D completed hand hygiene and donned a gown and gloves before emptying R33's catheter bag. CNA-D then placed R33's catheter bag under the wheelchair and removed PPE. Surveyor noted R33's uncovered catheter bag was touching the floor. On 5/28/25 at 2:45 PM, Surveyor interviewed CNA-D who verified R33's uncovered catheter bag was touching the floor. CNA-D indicated CNA-D would ask the nurse for a cover (dignity bag) and attach the bag higher on the wheelchair. On 5/28/25 at 2:49 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed a gown and gloves should be worn during high-contact cares for a resident on EBP. DON-B also confirmed staff should complete hand hygiene when doing cares and transfers, between glove changes, and after perirectal or any direct care. DON-B indicated DON-B needed to reeducate and review the EBP policy with staff. DON-B also indicated a dignity bag should have been provided for R33's catheter. 2. From 5/27/25 to 5/29/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including traumatic subdural hemorrhage with loss of consciousness, type 2 diabetes, dysphagia, and weakness. R32's Minimum Data Set (MDS) assessment, dated 4/14/25, had a Brief Interview for Mental (BIMS) score of 1 out of 15 which indicated R32's cognition was severely impaired. R32 had a Guardian for medical decisions. R32's medical record indicated R32 had a wound on the right heel and contained an order to complete wound care every 3 days. R32's wound care orders stated to cleanse the heel with normal saline, pat dry, apply skin prep to the peri wound, allow to dry, apply medical grade honey gel to the wound base, and cover with an island dressing. On 5/28/25 at 10:00 AM, Surveyor observed LPN-J complete wound care for R32's right heel. LPN-J donned the appropriate PPE and positioned R32 for wound care. LPN-J removed R32's soiled dressing, changed gloves, opened wound dressing supplies, and sprayed normal saline on R32's right heel. LPN-J dried the wound, changed gloves, and applied skin prep to the peri wound. LPN-J then applied medical grade honey to the wound and an island dressing. LPN-J removed gloves and dated and initialed the dressing. At the end of the procedure, LPN-J removed PPE and washed hands with soap and water. Surveyor interviewed LPN-J regarding hand hygiene. LPN-J indicated hand hygiene should have been completed in between glove changes. On 5/28/25 at 1:32 PM, Surveyor interviewed DON-B who indicated hand hygiene should be completed in between glove changes. 3. From 5/27/25 to 5/29/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including pelvic fractures, osteoporosis, cognitive communication deficit, and an open wound on the right lower leg. R15's MDS assessment, dated 4/16/25, had a BIMS score of 7 out of 15 which indicated R15 had severe cognitive impairment. R15 did not have an activated Power of Attorney for Healthcare (POAHC). On 5/27/25 at 1:49 PM, Surveyor observed CNA-C provide pericare for R15. CNA-C removed R15's incontinence brief and the bed pan and changed gloves without washing or sanitizing hands. On 5/28/25 at 1:29 PM, Surveyor interviewed DON-B who verified staff should complete hand hygiene between glove changes especially after pericare.

Based on observation, staff and resident interview, and record review, the facility did not ensure the provision of adequate supervision and assistance devices to prevent accidents for 3 residents (R) (R1, R4, and R3) of 3 sampled residents. On 10/24/24, R1 had a fall with injury while smoking outside without supervision. R1 sustained a head laceration and was transferred to the emergency room (ER). A smoking assessment indicated R1 could smoke independently unsupervised, however, R1 needed assistance with locomotion and could not independently get to or return from the smoking area. In addition, R1 did not have a smoking care plan at the time of the fall. R4 fell from a lift chair on 12/27/24. The facility did not reassess R4 for lift chair safety following the fall. R3 fell on [DATE]. A fall intervention was not implemented or added to R3's care plan in a timely manner. Findings include: The facility's Smoking Policy, revised 7/14/22, indicates: .To identify factors that may put residents at risk for smoking or nicotine use independently and to provide appropriate supervision/approaches for safety .2. Risk factors identified through the assessment process shall be used in the development of the plan of care . The facility's Fall Prevention and Management Guidelines policy, revised 7/18/24, indicates: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury .6. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .The plan of care will be revised as needed and should be communicated to the staff, resident, and resident's family/responsible party .7. When any resident experiences a fall, the facility will .d. Review the resident's care plan and update with any new interventions to try to prevent additional falls. E. Document all assessments and actions . 1. On 3/19/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including acute pulmonary edema, chronic obstructive pulmonary disease (COPD), emphysema, and weakness. R1's Minimum Data Set (MDS) assessment, dated 10/30/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was responsible for R1's healthcare decisions. On 10/11/24, R1 was assessed by therapy for wheelchair mobility. The assessment indicated R1 was dependent on staff to wheel fifty feet with two turns. A care plan, initiated 10/12/24, indicated R1 required the assistance of one staff for ambulation/locomotion. A smoking assessment, dated 10/16/24, indicated R1 could smoke independently. A smoking care plan was not developed at that time. A facility investigation indicated on 10/24/24 at 9:11 AM, R1 was discovered outside the door of the smoking area lying on R1's right side wearing gripper socks, clothing, and a winter coat. R1 had been outside smoking alone. R1 indicated R1 attempted to move the wheelchair with R1's feet but the chair didn't move and R1 fell forward onto R1's face. C-spine stabilization was provided by staff. R1 had significant facial bleeding and a laceration on the bridge of the nose. R1 was transferred to the hospital and received seven sutures for the laceration. The investigation indicated the incident occurred because R1 attempted to mobilize the wheelchair with R1's feet and had difficulty with one of the wheels crossing a seam in the concrete. An intervention was added for R1 to be accompanied by staff while smoking. Staff education was not provided following the incident. A smoking care plan, initiated 10/24/24, indicated R1 should be accompanied by staff while smoking. A nursing note, dated 10/25/24 at 3:37 PM, indicated R1 looked pretty rough with facial injuries related to an unwitnessed fall. R1 was black and blue, however, more bruising and pain were expected as a result of the fall. The note indicated to continue to monitor and update the physician with concerns, worsening pain, or injuries. On 3/19/25 at 12:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated residents need to demonstrate they can get outside independently before they are left alone to smoke. LPN-D indicated staff would have had to bring R1 outside to smoke. LPN-D indicated a resident who smokes should have a smoking care plan and should demonstrate they are able to get outside by themselves before they are left alone. On 3/19/25 at 2:52 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R1 was independent with the ability to bring a cigarette to R1's mouth but needed to be transported to the smoking area. DON-B indicated R1 was able to wheel R1's self short distances and could wheel to the door and ring the doorbell to be let in. DON-B verified an assessment had not been completed to determine R1's ability for independent short distance mobilization. DON-B indicated staff education was not provided after the incident. 47248 2. On 3/19/25, Surveyor reviewed R4's medical record. R4 had diagnoses including Parkinson's disease with dyskinesia, chronic respiratory failure, and asthma. R4's MDS assessment, dated 1/29/25, had a BIMS score of 14 out of 15 which indicated R4 was not cognitively impaired. R4 was responsible for R4's healthcare decisions. R4's medical record contained a care plan and lift chair assessment dated [DATE]. The care plan indicated R4 required the assistance of one staff for transfers with a sit-to-stand lift. R4's medical record indicated R4 fell from a lift recliner on 12/27/24. An intervention was added to reassess R4 for lift recliner safety and refer R4 to physical therapy. R4 had a physician order for physical therapy dated 12/27/24. On 3/19/25, Surveyor requested a lift chair assessment following R4's fall on 12/27/24, R4's plan of care following the fall, and physical therapy notes. On 3/19/25 at 11:50 AM, Surveyor interviewed Physical Therapist (PT)-C who was not aware of the PT referral after R4's fall on 12/27/24. PT-C indicated PT-C would request and provide the information to Surveyor. On 3/19/25 at 12:45 PM, Surveyor interviewed R4 who indicated R4 continues to use the lift chair independently despite having slid out of the chair a few months ago. R4 indicated R4 did not have physical therapy following the incident and indicated R4 made a mistake and lifted the chair too high. Surveyor observed R4 use the lift chair control when R4 showed Surveyor how high R4 lifts the chair to get out of it. On 3/19/25 at 2:53 PM, Surveyor interviewed DON-B who was unsure why R4 was not reassessed for lift chair safety following the fall on 12/27/24 and confirmed R4 should have been reassessed. DON-B indicated DON-B could not find documentation that indicated R4 received PT following the fall as ordered. DON-B verified the interventions put in place following the fall on 12/27/24 were not implemented. 3. On 3/19/25, Surveyor reviewed R3's medical record. R3 had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction, dysphagia (difficulty swallowing), and aphasia (a neurological disorder that affects a person's ability to communicate). R3's MDS assessment, dated 2/5/25, had a BIMS score of 12 out of 15 which indicated R3 had moderate cognitive impairment. R3 was responsible for R3's healthcare decisions. R3's medical record indicated R3 fell on [DATE]. The investigation indicated an intervention was added to R3's care plan for a bright-colored Call don't fall sign. R3's care plan indicated R3 was at risk for falls and contained an intervention for a Call don't fall sign with an implementation date of 1/2/25. On 3/19/25 at 2:30 PM, Surveyor interviewed R3 who indicated R3 fell in the last couple of months. R3 indicated the sign under R3's television was posted there to remind R3 to use the call light and not get up without help. On 3/19/25 at 2:53 PM, Surveyor interviewed DON-B who indicated the Call don't fall sign should have been implemented immediately after R3's fall. DON-B verified the intervention was not added to R3's care plan until 1/2/25 and confirmed the care plan was not updated in a timely manner.

Based on observation, staff interview, and record review, the facility did not ensure medications were appropriately stored for 2 Residents (R) (R1 and R4) of 8 sampled residents. R1 was prescribed an eye drop to be given daily as of 6/21/23. Registered Nurse (RN)-C administered the eye drops on 6/23/24 but did not return the eye drops to the locked medication cart. The eye drops were misplaced and R1 did not receive the eye drops as ordered for 9 days. On 8/7/24, Licensed Practical Nurse (LPN)-D left medication for R4 unattended on top of the medication cart. Findings include: The facility's Storage of Medication policy, revised 1/2024, states the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. The facility's Medication Administration policy, dated 1/2024, states: Medication Administration: .17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications . 1. On 8/7/24, Surveyor reviewed R1's medical record. R1 admitted to the facility on [DATE] with diagnoses including pneumonia, Sjogren's syndrome (inflammatory dry eye disease), and bacteremia. R1's most recent Minimum Data Set (MDS) assessment, dated 6/28/24, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated R1 had moderate cognitive impairment. R1 was R1's own decision maker and discharged from the facility on 7/10/24. R1's admission orders included an order for fluorometholone opthalmic suspension 0.1% one drop in both eyes daily for inflammation. R1's Medication Administration Records (MARs) for June and July 2024 indicated R1's eye drops were administered as ordered on 6/22/24 and 6/23/24. The MAR contained documentation of other/not given/blank from 6/24/24 through 7/2/24 (a total of 9 days). R1's eye drops were then documented as administered from 7/3/24 through 7/10/24 when R1 discharged from the facility. Surveyor reviewed a grievance, dated 7/1/24, related to R1's eye drops. The former Director of Nursing (DON) indicated the pharmacy had issues obtaining the medication due to insurance. The grievance was documented as resolved on 7/2/24 when R1's replacement eye drops were delivered to the facility. On 8/7/24 at 1:15 PM, Surveyor interviewed Registered Nurse (RN)-C who verified RN-C administered R1's eye drops on 6/23/24 and set them down somewhere in R1's room. When RN-C went back to retrieve the eye drops, they were missing. A thorough room search was completed but the eye drops were not located. On 8/7/24 at 4:08 PM, Surveyor interviewed DON-B who verified staff misplaced R1's eye drops and it took until 7/2/24 to receive a new prescription for R1 due to insurance difficulties. DON-B stated the facility paid for R1's eye drop prescription replacement. DON-B confirmed RN-C should have put R1's eye drops in a secure location so they weren't misplaced. 49563 2. On 8/7/24 at 9:35 AM, Surveyor observed LPN-D prepare medication for R4. LPN-D placed vitamin D 1000 units, an iron tablet, atorvastatin 10 mg (milligrams), Jardiance 10 mg, spironolactone 25 mg, furosemide 40 mg, furosemide 20 mg, Eliquis 5 mg, Entresto 24 mg, and carvedilol 3.125 mg in a medication cup. LPN-D then left the cup of medication unattended on top of the medication cart while LPN-D filled a pitcher of water. On 8/7/24 at 9:54 AM, Surveyor interviewed LPN-D who stated LPN-D did not usually leave medication unattended but felt it was okay since Surveyor was there. On 8/7/24 at 4:16 PM, Surveyor interviewed DON-B who verified medication should not be left on top of the medication cart unattended. DON-B stated DON-B expects staff to lock the medication in the cart or carry the medication with them.

Based on staff interview and record review, the facility did not revise a plan of care to reflect current care needs for 1 resident (R6) of 12 sampled residents. R6 had chronic gout and gout flare ups which were not included in R6's plan of care. Findings include: Between 5/20/24 and 5/22/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with a diagnosis of gout. R6's Minimum Data Set (MDS) assessment, dated 4/17/24, documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 had intact cognition. On 5/20/24 at 9:51 AM, Surveyor interviewed R6 who stated R6's finger hurt and was swollen. R6 stated R6 was waiting for R6's doctor to come to the facility. Surveyor noted R6's right pointer finger was red from the tip to the first knuckle. R6 stated R6 put alcohol wipes on R6's finger, but R6 was out of alcohol wipes. On 5/22/24 at 9:27 AM, Surveyor interviewed R6 who stated R6's finger felt better. R6 stated R6 did not have anymore pain and a nurse helped soak R6's finger. R6 stated R6 does not want to see a rheumatologist. R6 stated R6's gout flares up once in awhile and it's usually R6's right pinky and pointer fingers. R6's medical record indicated the following: ~ A progress note, dated 10/31/23 at 1:29 PM, indicated: R6 complained of right pinky finger pain. R1's finger was swollen, red, and slightly warm. Writer spoke with physician who stated R6 had arthritis and gout and was seen a couple days ago for a different finger. The physician stated if R6's finger worsens or the pain does not resolve, R6 should be seen. Writer talked with R6 who was in agreement. ~ A physician note, dated 11/1/23, indicated: The physician spoke with staff related to R6's right hand and foot gout flare up. The physician prescribed prednisone (a steroid medication) for 5 days and alloperinol (a medication to help prevent or lower high uric acid levels in the blood) prophylactically due to R6's second gout flare up in a month. ~ Physician notes, dated 12/1/23 and 12/8/23, indicated the physician saw R6 related to increased pain and swelling in the first and fifth fingers on the right hand. R6 was prescribed prednisone. A uric acid level was completed and R6 was referred to rheumatology. ~ A progress note, dated 3/13/24 at 12:47 PM, indicated: R6's right pinky finger was swollen, cherry red, and painful. R1 did not recall injuring the finger, had a history of gout, and wanted to be seen by a physician. R6 was afebrile and in pain. ~ A physician note, dated 3/14/24, indicated: R6 was seen for recurrent gout flare up. Staff made an appointment as recommended during R6's last flare up in December, but R6 refused the appointment. The physician again recommended R6 see rheumatology and R6 refused. R6 preferred to continue taking prednisone for flare ups. On 5/22/24 at 11:32 AM, Surveyor interviewed Nurse Practitioner (NP)-E via phone who confirmed R6 had frequent gout flare ups and refused to see rheumatology. NP-E stated NP-E saw R6 on 5/17/24 and R6 did not mention anything regarding R6's finger. NP-E stated NP-E frequently saw R6 who was good about communicating concerns. NP-E stated there were limited options for R6 due to R6's poor kidney function and R6's refusal to see rheumatology. R6's medical record did not contain a care plan regarding recurrent gout flare ups. On 5/22/24 at 12:28 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed gout flare ups were a frequent problem for R6. DON-B confirmed R6 should have a care plan to monitor R6's recurrent gout.

Based on staff interview and record review, the facility did not ensure monitoring for adverse reactions to high-risk medications for 2 residents (R) (R21 and R32) of 5 residents reviewed for unnecessary medications. R21 and R32 were prescribed gabapentin (an anticonvulsant medication) for pain management. The facility did not monitor R21 and R32 for adverse reactions to gabapentin. Findings include: The facility's Medication Monitoring Medication Management Policy, dated 1/24, indicates: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs, this includes any drug .without adequate monitoring .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff .perform ongoing monitoring for appropriate, effective, and safe medication use .The facility's medication management supports and promotes .The monitoring of medications for efficacy and adverse consequences. Procedures: The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis .Effects of the medications are documented as a part of the care planning process. Medline Plus.gov indicates gabapentin side effects include: drowsiness, tiredness, weakness, dizziness, headache, uncontrollable shaking, double or blurred vision, unsteadiness, anxiety, memory problems, unwanted eye movements, nausea, vomiting, heartburn, diarrhea, dry mouth, weight gain, swelling of hands, feet, ankles, or lower legs, fever, rash, itching, swelling of face, throat, tongue, lips or eyes, and difficulty breathing. 1. Between 5/20/24 and 5/22/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had a diagnosis of back pain. R21's Significant Change Minimum Data Set (MDS) assessment, dated 3/20/24, indicated R21 had frequent pain and received scheduled pain medication. R21's medical record indicated R21 had an order for gabapentin 300 mg (milligrams) for pain three times daily. R21's plan of care did not include adverse reaction/side effect monitoring for gabapentin. 2. Between 5/20/22 and 5/22/24, Surveyor reviewed R32's medical record. R32 had diagnoses including low back pain, osteoporosis, and opioid dependence. R32 had an order for gabapentin 100 mg two capsules by mouth three times daily for neuropathic pain (dated 2/1/24). R32's plan of care did not include adverse reaction/side effect monitoring for gabapentin. On 5/22/24 at 10:37 AM, Surveyor interviewed Director of Nursing (DON)-B who stated staff did not monitor R21 and R32 for side effects of gabapentin because gabapentin was used for pain and not seizures. Surveyor showed DON-B R6's medical record. R6 had an order for gabapentin for pain and had monitoring interventions for adverse reactions/side effects in R6's plan of care. DON-B stated DON-B was not aware the facility should monitor for adverse reactions and side effects if gabapentin was used for pain management.

Based on staff interview and record review, the facility did not ensure hospice services were coordinated for 2 residents (R) (R27 and R15) of 2 residents reviewed for Hospice services. Hospice visit notes were kept in R27's room instead of in R27's medical record or a Hospice binder at the nurses' station. Hospice visit notes were not kept in R15's medical record. The facility did not have a designated person assigned to coordinate care for Hospice services. Findings include: The facility's Inpatient Hospice Services Agreement between Hospice Company (HC)-F and the facility, dated 8/10/23, indicated: Coordination of care: Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure the needs of Hospice patients are met 24 hours a day. The facility's Hospice-Nursing Facility Services Agreement with HC-F, dated 8/10/23, indicated: Facility shall designate a member of the interdisciplinary team (IDT) who is responsible for working with Hospice representatives to coordinate care to each Hospice patient provided by Facility and Hospice. The facility's designated interdisciplinary team member shall be responsible for: iv. Obtaining patient specific information from Hospice as required by applicable laws and regulations .The facility and Hospice will prepare and maintain complete medical records for Hospice patients receiving facility services in accordance with this agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Copies of all documents of services provided by Hospice will be filed and maintained in the facility chart. The facility's Hospice-Nursing Facility Agreement between HC-G and the facility, dated 9/23/14, indicated: The facility will designate a member of the facility's interdisciplinary team (IDT) who is responsible to work with Hospice personnel to coordinate care provided to the Hospice patient .The IDT member is responsible for the following: 4.2.1 .This includes establishing the manner of documenting the communication process between Hospice and the facility to ensure the needs of the Hospice patient are addressed and met 24 hours per day. 1. Between 5/20/24 and 5/22/24, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] with diagnoses including endometrial and ovarian cancer, dementia, and encounter for palliative care. R27's Minimum Data Set (MDS) assessment, dated 4/12/24, documented a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R27 had severely impaired cognition. R27 was admitted to the facility on Hospice services but changed to HC-F on 4/25/24. ~ A progress note, dated 5/18/24 at 11:17 PM, indicated: Hospice saw R27 per daughter's request. R27 complained of abdominal pain, nausea, and constipation and had a 100.1 degree low-grade fever. A urinalysis (UA) was obtained and sent to the lab. ~ A progress note, dated 5/19/24 at 11:04 AM, indicated: Writer received a call from Hospice that they obtained a UA/UC (urine culture) via straight catheter on 5/18/24. Hospice called the lab and was informed the UA/UC was not run and a new one should be obtained. Writer spoke with Director of Nursing (DON)-B and the provider's office. Writer was instructed not to obtain a UA or administer antibiotics because R27 did not meet the criteria for a urinary tract infection (UTI). Writer spoke with Hospice and asked Hospice to speak with R27's Power of Attorney (POA) about the new orders and mediate the tension with R27's POA. ~ A progress note, dated 5/19/24 at 11:17 AM, indicated: Writer obtained R27's vital signs which were at baseline. R27 had bowel sounds in all 4 quadrants. R27's abdomen was distended. Miralax and senna were administered. R27 had medium-size stools that were hard with no complaints of nausea/vomiting, dizziness/lightheadedness, pain, or discomfort. Staff, R27, and R27's POA did not inform writer of any changes in urine or function. On 5/21/24, Surveyor reviewed R27's Hospice binder at the nurses' station and noted R27's Hospice visit notes were not in the binder. Surveyor requested R27's Hospice notes. On 5/21/24, Surveyor reviewed R27's handwritten Hospice visit notes which included a note written by a Hospice Registered Nurse (RN) on 5/18/24 that indicated: .Distended abdomen. Signs/symptoms of infection. Straight cathed and took urine to lab. On 5/21/24 at 2:59 PM, Surveyor interviewed DON-B who stated R27's Hospice communication notes were located in R27's room in a binder. DON-B stated staff were unaware Hospice staff were writing care notes in a binder in R27's room. DON-B stated the binder would be moved to the nurses' station with the other residents' Hospice binders since the binder contained information about care that was provided to R27. When Surveyor asked about the recent progress notes regarding the UA/UC, DON-B indicated staff were initially unaware Hospice staff obtained a straight cath for R27 and texted R27's POA that R27 should start Bactrim. DON-B stated R27's POA then came to the facility and requested the facility order Bactrim. Staff then contacted R27's physician who ordered a culture and sensitivity which showed bacteria and R27 was started on an antibiotic. DON-B indicated HC-F was contacted and informed all orders must go through physician services. 2. Between 5/20/24 and 5/22/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] with a diagnosis of encounter for palliative care. R15's MDS assessment, dated 4/3/24, documented a BIMS score of 2 out of 15 which indicated R15 had severely impaired cognition. R15 started services with HC-G on 12/29/23. On 5/21/24, Surveyor reviewed R15's Hospice binder at the nurses' station and noted R15's Hospice notes were not in the binder. Surveyor requested R15's Hospice notes. The notes from HC-G indicated they were faxed on 5/21/24 at 9:32 AM. On 5/21/24 at 2:59 PM, Surveyor interviewed DON-B who indicated HC-G staff provided services to R15 and completed visit documentation on their phones. DON-B contacted HC-G who faxed R15's visit notes to the facility. DON-B stated DON-B told HC-G that R15's Hospice notes should be provided to the facility. On 5/21/24 at 12:32 PM, Surveyor interviewed Social Worker (SW)-H who stated SW-H didn't do much with coordinating Hospice services. SW-H stated if the Hospice Social Worker visits SW-G communicates with them, but usually nursing staff ensure the day-to-day care. On 5/21/24 at 2:59 PM, Surveyor interviewed DON-B and asked who was designated to ensure coordination of Hospice care for Hospice residents, including ensuring residents received the correct number of visits per week. DON-B indicated the designated person was SW-H.

Based on observation, staff interview, and record review, medication was not administered in accordance with the facility's policy for 1 resident (R) (R31) of 4 sampled residents. Staff did not ensure R31's insulin was administered in accordance with the facility's policy for subcutaneous injections. Findings include: The facility's Medication Administration policy, dated 1/2023, indicates at section 7.22 Subcutaneous that the needle should be recapped using an appropriate safety device after withdrawing the medication dose. Between 5/20/24 and 5/22/24, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. R31 had the following medication orders: ~ Lantus Subcutaneous Solution 100 unit/ml (units/millimeter) (Insulin Glargine) Inject 40 international units (IU) subcutaneously one time a day. ~ Humalog Injection Solution 100 unit/ml (Insulin Lispro) Inject 10 units subcutaneously two times a day. On 5/21/24 at 9:11 AM, Surveyor observed Licensed Practical Nurse (LPN)-I draw up 40 IU of Lantus subcutaneous solution in an insulin syringe. LPN-I did not recap the needle after withdrawing the medication from the vial. Surveyor observed LPN-I walk from the medication cart to the dining room with an uncapped needle. On 5/21/24 at 9:12 AM, Surveyor observed LPN-I draw up 10 units of Humalog solution into an insulin syringe. LPN-I did not recap the needle after withdrawing the medication from the vial. Surveyor observed LPN-I walk from the medication cart to the dining room with an uncapped needle. On 5/21/24 at 9:17 AM, Surveyor interviewed LPN-I who stated the practice is to recap the needle after drawing up medication. On 5/21/24 at 11:37 AM, Surveyor interviewed Director of Nursing (DON)-D regarding the protocol for administering subcutaneous injections. DON-D stated staff should recap the needle after withdrawing the medication per the facility's policy.

Based on record review and staff interview, the facility did not ensure that each resident received necessary care and services to maintain the highest practicable physical well-being for 1 (resident #1) of 9 sampled residents. Resident #1 was admitted to the facility for rehab with a goal to return home. Resident #1's medications included [MEDICATION NAME] (a medication to assist with reducing fluid from the body). Resident #1 was admitted with history of multiple daily episodes of diarrhea/loose stools and consumed fluids independently. Although the facility completed an Hydration Risk Assessment which indicated resident #1 was at risk for dehydration, the assessment did not identify the loose stools/diarrhea as a risk factor. The facility did not develop or implement a plan of care to ensure resident #1 had adequate fluid balance to maintain hydration. Resident #1's physician was updated regarding the resident's loose stools/diarrhea and laboratory testing was ordered with negative findings. The facility did not monitor the resident's intake and output and did not complete hydration assessments to ensure hydration. The facility did not update the physician with the continued frequency of loose stools/diarrhea. CNA (Certified Nursing Assistant) interviews indicated resident #1 had multiple episodes of loose stools/diarrhea every shift and at times required complete bed changes. Nurse interviews indicated resident #1's loose stools/diarrhea were not significant, and CNA documentation of the resident's intake and output was not monitored. Staff indicated resident #1 did drink fluids well. The facility assessed resident #1 required 1745 cc (cubic centimeters) daily for fluid need, however, the facility did not assess the resident's full clinical condition to include loose stools/diarrhea. Resident #1 developed a reddened, swollen lump on the neck and was diagnosed with [REDACTED]. Fifteen days after admission, resident #1 fell twice in one day (no falls since admission until these falls occurred). The facility did not complete a comprehensive assessment for causal factors that would have included orthostatic blood pressures, which can be an indication of dehydration. Resident #1 was transferred to the hospital and was diagnosed with [REDACTED]. Facility failure to address resident #1's fluid loss and for keeping the resident from becoming dehydrated to the point of sustaining a kidney injury; failure of facility staff to assess the resident's fluid intake and take the resident's fluid loss into consideration when assessing resident fluid needs; failure to develop a care plan that addressed resident fluid loss; and staff failure to make the physician aware of the resident's fluid loss and to question whether the resident should continue to be on [MEDICATION NAME] created a finding of immediate jeopardy that began on 12/23/15. The facility was notified of the immediate jeopardy on 1/28/16. The immediate jeopardy was removed on 1/29/16, however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy and procedure dated 6/12/15 Hydration Risk Evaluation and Assessment Hydration Screener indicates the purpose is to identify residents at risk for dehydration, screen and comprehensively assess residents for signs and symptoms of dehydration. The procedure listed the following: ~ Nursing to complete Hydration Risk Evaluation and Assessment on Admission .and on change of condition. ~ If assessment identifies signs and symptoms of dehydration present, resident is placed on dehydration symptom pursuit and daily Hydration Screener. ~ If no risk factors or symptoms identified, Hydration screener is completed monthly or weekly based on evaluation and assessment. ~ Hydration Screener should be scheduled more frequently if any of the following is present: Suspicion of increased output or decreased input. Dietary Manager or dietitian to review Hydration Risk Evaluation and Assessment and Hydration Screener and make recommendations as needed. EXAMPLE: On 01/22/16, surveyor # reviewed resident #1's medical record. Resident #1's Admission Record dated 01/26/16, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission record indicated resident #1 was responsible for making his own decisions. The hospital H&P (history and physical) dated 12/23/15, documented resident #1 had dry mucous membranes and was a direct admit to the nursing facility from the ER (emergency room ). Resident #1's admission orders [REDACTED]. Resident #1's lab values on admission included BUN (blood urea nitrogen) 18 (normal 8-20 mg/dl (deciliter)), and Creatinine 0.89 (0.66-1.66 mg/dl). The facility completed a Hydration Risk Evaluation & Assessment) on resident #1, dated 12/26/15 and documentation included the resident had a history of [REDACTED]. No symptoms of dehydration at that time. A Nutritional Screen was completed on 12/28/15 and documented the following regarding resident #1: ~ able to feed self with set up and supervision ~ has poor appetite ~ usual body weight was 120 -130 pounds ~ current weight was 128 pounds ~ estimated fluid needs are 1745 ml (milliliters)/day ~ will monitor for further dietary interventions ~ care plan has been updated Resident #1's medical record did not include documentation regarding a plan of care addressing the resident's risk for dehydration. The facility's computer documentation of resident #1's fluid intake titled Water Pass and Nutrition Fluids was calculated as follows: ~ 12/24/15- 1100 ml ~ 12/25/15- 1280 ml ~ 12/26/15- 1540 ml ~ 12/27/15- 1450 ml ~ 12/28/15- 1200 ml ~ 12/29/15- 1340 ml ~ 12/30/15- 1340 ml ~ 12/31/15- 920 ml ~ 01/01/16- 1220 ml ~ 01/02/16- 1140 ml ~ 01/03/16- 1260 ml ~ 01/04/16- 655 ml ~ 01/05/16- 1510 ml ~ 01/06/16- 790 ml ~ 01/07/16- 790 ml ~ 01/08/16- 1040 ml ~ 01/09/16- 900 ml As documented, resident #1 never met his recommended daily amount of fluid intake. This was compounded by the fact that the Bowel and Bladder Elimination Record documentation indicated resident #1 had multiple daily entries of BMs (bowel movements) during the resident's stay at the facility from 12/23/15 to 01/10/16. The documented consistency of the BMs were soft/formed, loose and/or diarrhea/watery. A fax dated 12/29/15, was sent to the APNP (Advanced Practice Nurse Practitioner) stating the resident was having frequent loose stools since admission to the facility on [DATE] and questioned medication and/or labs? The APNP responded by fax on 12/30/15, and ordered to discontinue Senna (a laxative medication), obtain stool for [MEDICAL CONDITION] and ova and parasites. In addition, use prn (as needed) [MEDICATION NAME] more frequently. Note: the results of stool tests were returned and were negative. The MAR (Medication Administration Record) indicated resident #1 had not ever received Senna and instead of [MEDICATION NAME] received [MEDICATION NAME] A-D ([MEDICATION NAME] HcI) 2mg with effectiveness of the medication as follows: * 12/31/15 at 7:20 am-- Effective * 12/31/15 at 7:13 pm-- Unknown if effective * 01/01/16 at 9:16 am-- Effective * 01/04/16 at 9:04 am-- Effective * 01/06/16 at 9:08 am-- Effective * 01/07/16 at 9:24 am-- Effective * 01/07/16 at 9:20 pm-- Ineffective The Progress Notes indicated: * 01/06/16 documented at 2:26 pm-- noted to have redness and swelling on the left lower jawline below his ear. APNP notified and order for warm moist compressed received and noted. * 01/07/16 documented at 1:32 am-- Resident was found laying on the floor by bed at 1:00 am. No injuries. * 01/07/16 documented at 3:29 pm-- Resident had a fall with no injuries. * 01/08/16 documented at 11:16 am-- APNP assessed left jaw redness, swelling and pain. New orders received and noted. (Resident was placed on [MEDICATION NAME] 450 mg four times daily for [MEDICAL CONDITION]). * 01/10/16 documented at 6:10 am-- Resident found on knees on floor holding wheelchair at 6:00 am. No injuries. * 01/10/16 documented at 8:49 am-- Wife updated regarding orders for labs and urinalysis with culture and sensitivity order for resident confusion noted along with tremors of body. (No comprehensive assessment was documented in the medical record). * 01/10/16 documented at 10:39 am-- Physician reviewed labs and urinalysis. New orders received and noted to send resident to ER for eval and treat. The Hospital ED Provider Note dated 01/10/16 indicated the resident had complained of not feeling well for a few days. Apparently has been having some vomiting and chronic diarrhea .The ED report indicated elderly gentleman who does not appear in any acute distress but does appear chronically ill. Tongue appears dry and lips are slightly dry. BUN 60 mg/dl and Creatinine 1.84 mg/dl, Sodium 134. Urinalysis revealed trace amount of blood and white blood cell were elevated. CBC (Complete Blood Count) revealed and elevated white blood count of 20.1.It appears the patient has a Urinary Tract Infection and dehydration. He does have chronic diarrhea and has been worked up with the previous [MEDICAL CONDITION] and ova and parasite test which were all negative about three weeks ago. I planned on admitting the patient here but the family requested that he go to a hospital in Appleton. The Appleton hospital H&P, dated 01/10/16 indicated resident #1 has dry mucous membranes. The plan indicated admission to the hospital related to [MEDICAL CONDITION] and acute kidney injury .suspect prerenal azotemia as clinically he appear dehydrated on exam, and with his chronic diarrhea and recent nausea and vomiting, I suspect this is the etiology for his dehydration and acute kidney injury .Labs taken at the hospital on [DATE] were BUN 44, Creatinine 1.26 and Sodium 132. Day shift On 01/26/16 at 12:20 pm, surveyor # interviewed day shift CNA-A. CNA-A stated resident #1 consumed his meals in his room independently. CNA-A indicated resident #1 had a poor appetite but did consume fluids better than he ate. CNA-A stated she did not work with the resident very often, but did recall assisting the resident to the bathroom and the resident had multiple episodes of watery stool. CNA-A indicated the resident stayed in bed most of the day because he always said he didn't feel good. CNA-A indicated the resident needed encouragement to drink fluids towards the end of his stay at the facility. CNA-A stated everything that went in, came out. CNA-A indicated staff knew resident was going to have diarrhea after meals as he always did. CNA-A stated licensed staff were updated but the nurses always replied they were aware of the diarrhea and that was normal for the resident. CNA-A indicated she was concerned with the amount of episodes of diarrhea the resident was having and mentioned the concerns to CNA-B (the primary day CNA that cared for resident #1) and CNA-B stated it was a regular event that resident #1 had diarrhea. On 01/26/16 at 12:45 pm, surveyor # interviewed day shift CNA-C. CNA-C verified she worked with resident #1 often and initially was transferred with an EZ stand and then changed to a full mechanical lift due to weakness. CNA-C stated resident #1 was alert and oriented but did develop some confusion during his stay at the facility. CNA-C indicated resident #1 drank fluids independently but needed encouragement to consume fluids towards the end of his stay at the facility. CNA-C stated even with encouragement at times resident #1 refused fluid intake, but other times would accept. CNA-C stated every time staff checked the resident for incontinence (which was every 2 hours) the resident was incontinent of watery stool. CNA-C indicated she wasn't sure how much stool as the volume varied, but stool incontinence was always present. CNA-C stated she had updated the nurses about the watery stool, but the nurses would state they were aware and just to continue to notify them. CNA-C stated she was concerned regarding the amount and frequency of the diarrhea and assumed since the nurses were aware they were doing something about it. On 01/26/16 at 1:30 pm, surveyor # conducted a telephone interview with CNA-B (primary day shift CNA). CNA-B indicated resident #1 was alert and oriented and consumed meals in his room. CNA-B stated the resident's fluid consumption was ok, but needed encouragement to consume. CNA-B stated resident #1 had diarrhea and was always extremely loose in fecal consistency. CNA-B indicated that it was known resident #1 would have large amounts of loose stools after each meal. CNA-B stated nurses were aware of the resident's diarrhea and would say the resident has an order for [REDACTED].#1 was both continent and incontinent of bowel and bladder. CNA-B indicated the resident always knew who she was but just prior to transferring to the hospital resident #1 would ask who was I and was observed talking on the phone and was way out there. On 01/27/16 at 8:30 am, surveyor # interviewed Day LPN-I. LPN-I stated resident #1 had very loose stools at least multiple times on day shift each day. LPN-I indicated sometimes loose stools were more frequent. LPN-I stated at times resident #1's bowel movements resulted in a large amount of stool. LPN-I indicated she was concerned and spoke to resident #1 regarding his stools and the resident stated he had [MEDICAL CONDITION]. LPN-I stated resident #1 consumed fluids well and there wasn't any concerns regarding hydration because the resident consumed fluids well. LPN-I indicated nurses do not review CNA documentation regarding fluid intake and bowel and bladder output, and that information was used by the MDS nurse. LPN-I indicated the physician was aware of the loose stools and told staff to use the Immodium. LPN-I stated she was resident #1's nurse on 1/10 when transferred to the ER. LPN-I stated when she entered the resident's room resident #1 just didn't look right, but she couldn't pinpoint what was wrong. LPN-I indicated she went and updated DON (Director of Nursing, at the time)-J and he went and assessed the resident. DON-J told LPN-I after he had assessed resident #1 that he (DON-J) also thought the resident did not look right. LPN-I indicated she updated the physician and labs and a urinalysis were ordered. LPN-I stated when the results of the labs returned to the facility, she had updated the physician and initially the physician wanted to keep the resident at the facility but a short time later the physician called the facility and gave orders to send the resident to the hospital. LPN-I stated resident #1 was sent to the emergency room (ER) in Shawano and the family requested the resident be transferred to a hospital in Appleton. PM shift On 01/26/16 at 2:15 pm, surveyor # interviewed CNA-D (primary PM CNA). CNA-D stated resident #1 had very loose stools usually 2 - 3 times a shift for the entire time the resident resided at the facility. CNA-D indicated resident #1 spent most of his time in bed. CNA-D stated resident #1 consumed meals in his room and she wasn't sure of his fluid intake as CNA-D usually was in the dining room during the supper meal, but whatever the resident did consume for fluids it was independently. CNA-D stated she did know the resident did drink some fluids on the PM shift as she would fill the ice water pitcher and there was always some fluid gone. CNA-D stated she had told the nurses regarding the resident's loose stools and the nurses would say he has Immodium. CNA-D indicated she wasn't sure if she had told the nurses every time the resident expelled loose stools because the nurses said they were aware. CNA-D indicated no other residents had loose stools to the frequency resident #1 had. CNA-D stated she was a CNA and not sure if there were any concerns with hydration related to the resident's diarrhea. CNA-D indicated the nurses never told CNA staff to do anything differently for resident #1. On 01/26/16 at 2:30 pm, surveyor # interviewed PM CNA-E. CNA-E stated she was working on the day resident #1 was admitted . CNA-E indicated staff had to immediately assist the resident with personal cares as the resident had been incontinent of diarrhea. CNA-E stated resident #1 told the staff that they would be in the room all night because he had diarrhea. CNA-E indicated staff went into the resident's room at least every two hours and each time resident #1 was incontinent of watery stool. CNA-E stated every time she assisted on the unit, resident #1 had watery stool as often as every two hours. CNA-E indicated resident #1 did consume fluids well. CNA-E stated the nurses were aware of resident #1's diarrhea and believed it was common knowledge. CNA-E indicated the amounts of stool would vary and at times it would be a small amount to times when a complete bed change had to be done. CNA-E stated she only worked with the resident for the first few days of admission. On 01/26/16 at 2:40 pm, surveyor # interviewed PM RN (Registered Nurse) -F. RN-F stated resident #1 was admitted to the facility with nausea and loose stools. RN-F indicated at times the resident appeared confused. RN-F stated resident #1 always ate his meals in his room, had a poor appetite and fluid intake wasn't very good. RN-F indicated she had once made a referral to dietary and supplements initiated. RN-F stated resident #1 did have vomiting that was reported by the resident's wife, but the RN never observed as the wife would clean and flush down the toilet. RN-F stated the resident and wife would describe the vomit differently. RN-F indicated resident #1 had chronic loose stools once, maybe twice a shift, but the RN never observed the stools as the wife would flush down the toilet. RN-F indicated the resident was continent of bowels. RN-F stated the resident would drink 120 ml to 180 ml with the medication pass, but couldn't take too much fluids or the resident would vomit later. RN-F indicated the resident's loose stools were minor and the CNAs did say something to her about the stools once or twice and Immodium was given. RN-F indicated a care plan was not developed related to the loose stools as the stools were not a significant problem and I think it was his normal. RN-F stated the MDS (Minimum Data Set) nurse monitored the CNA documentation regarding fluid intake and bowel and bladder output for the MDS assessments. RN-F verified nurses would only monitor the CNA documentation if there was a concern and since there wasn't a concern regarding fluid status for resident #1, the documentation was not monitored. On 01/26/16 at 2:50 pm, surveyor # interviewed PM LPN (Licensed Practical Nurse) -G. LPN-G stated that she only worked with resident #1 a few times, but was aware the resident needed encouragement to consume fluids. LPN-G indicated even with encouragement the resident at times would accept fluid intake and at other times would refuse. LPN-G stated the resident was admitted to the facility with loose stools but she wasn't aware if the resident had any history of loose stools prior to admittance. LPN-G indicated she was aware of the loose stools because the CNAs had reported them. LPN-G stated the resident didn't have loose stools multiple times a shift that she was aware of. LPN-G stated the resident was alert and oriented. LPN-G indicated that she wasn't aware of any concerns regarding loose stools and hydration status. LPN-G stated the MDS nurse monitors the CNAs documentation regarding fluid intake and bowel and bladder output. LPN-G indicated she wasn't aware of any need to monitor hydration status closely for resident #1. On 01/27/16 at 8:15 am, surveyor # conducted a telephone interview with CNA-H. CNA-H stated she worked on another unit at the facility, but would assist with resident #1 when the unit CNA would request assistance. CNA-H indicated at the beginning of resident #1's stay at the facility the resident had loose, watery stools all the time. CNA-H stated the stool volume was copious and resulted in amounts where the bedding required changing. CNA-H stated she thought during resident #1's stay the diarrhea had lessened in amount and frequency but was still occuring multiple times per shift. CNA-H indicated she collected the resident's meal trays at times and the resident consumed most of his fluids on the tray. CNA-H stated she doesn't recall any conversations with updating the nurses regarding resident #1's diarrhea, because the unit CNA would have updated the nurses, but if a nurse was right outside the resident's door she would have said something. CNA-H stated she doesn't recall any conversations regarding any concerns regarding resident #1's hydration status. Night shift On 01/27/16 at 8:31 a.m., surveyor # conducted a telephone interview with Night CNA-L regarding resident #1's nightly routine. CNA-L reported that resident #1 would drink approximately 400 ml of fluid during the night. Resident #1 could drink independently as long as the mug with water was located on the bedside table and was within reach. Every night, resident #1 had a large loose/watery stool at least three times during the night shift that required a linen change after each episode. At least one time during the night shift, resident #1 would express thirst and staff would assist the resident with taking a drink of water. CNA-L stated she does not recall reporting resident #1's loose stools to the nurse on duty as it was a chronic issue for the resident and all nursing staff were aware of the resident's frequent, loose/watery stools. The nurse would assist with changing the soiled linens at times and would see the amount of stool present. CNA-L stated she would chart the resident's stools during the night and nursing staff would review the CNAs documentation. A fax dated 12/29/15, was sent to the APNP (Advanced Practice Nurse Practitioner) stating the resident was having frequent loose stools since admission to the facility on [DATE] and questioned medication and/or labs? The APNP responded by fax on 12/30/15, and ordered to discontinue Senna (a laxative medication), obtain stool for [MEDICAL CONDITION] and ova and parasites. In addition, use prn (as needed) [MEDICATION NAME] more frequently. Note: the results of stool tests were returned and were negative. The MAR (Medication Administration Record) indicated resident #1 had not ever received Senna and received [MEDICATION NAME] with effectiveness of the medication as follows: * 12/30/15 at 7:20 am-- Effective * 12/20/15 at 7:13 pm-- Unknown if effective * 01/01/16 at 9:16 am-- Effective * 01/04/16 at 9:04 am-- Effective * 01/06/16 at 9:08 am-- Effective * 01/07/16 at 9:24 am-- Effective * 01/07/16 at 9:20 pm-- Ineffective The Progress Notes indicated: * 01/06/16 documented at 2:26 pm-- noted to have redness and swelling on the left lower jawline below his ear. APNP notified and order for warm moist compressed received and noted. * 01/07/16 documented at 1:32 am-- Resident was found laying on the floor by bed at 1:00 am. No injuries. * 01/07/16 documented at 3:29 pm-- Resident had a fall with no injuries. * 01/08/16 documented at 11:16 am-- APNP assessed left jaw redness, swelling and pain. New orders received and noted. (Resident was placed on [MEDICATION NAME] 450 mg four times daily for [MEDICAL CONDITION]). * 01/10/16 documented at 6:10 am-- Resident found on knees on floor holding wheelchair at 6:00 am. No injuries. * 01/10/16 documented at 8:49 am-- Wife updated regarding orders for labs and urinalysis with culture and sensitivity order for resident confusion noted along with tremors of body. (No comprehensive assessment was documented in the medical record). * 01/10/16 documented at 10:39 am-- Physician reviewed labs and urinalysis. New orders received and noted to send resident to ER for eval and treat. The Hospital ED Provider Note dated 01/10/16 indicated the resident had complained of not feeling well for a few days. Apparently has been having some vomiting and chronic diarrhea .The ED report indicated elderly gentleman who does not appear in any acute distress but does appear chronically ill. Tongue appears dry and lips are slightly dry. BUN 60 mg/dl and Creatinine 1.84 mg/dl, Sodium 134. Urinalysis revealed trace amount of blood and white blood cell were elevated. CBC (Complete Blood Count) revealed and elevated white blood count of 20.1.It appears the patient has a Urinary Tract Infection and dehydration. He does have chronic diarrhea and has been worked up with the previous [MEDICAL CONDITION] and ova and parasite test which were all negative about three weeks ago. I planned on admitting the patient here but the family requested that he go to a hospital in Appleton. The Appleton hospital H&P, dated 01/10/16 indicated resident #1 has dry mucous membranes. The plan indicated admission to the hospital related to [MEDICAL CONDITION] and acute kidney injury .suspect prerenal azotemia as clinically he appear dehydrated on exam, and with his chronic diarrhea and recent nausea and vomiting, I suspect this is the etiology for his dehydration and acute kidney injury .Labs taken at the hospital on [DATE] were BUN 44, Creatinine 1.26 and Sodium 132. On 01/27/16 at 9:45 am, surveyor # interviewed DON-J. DON-J verified the admission hospital H&P indicated resident # 1 had dry mucous membranes. DON-J also verified the Hydration Risk Assessment, dated 12/26/15 indicated the resident was at risk for dehydration but had not included the resident's loose stools/diarrhea as a risk factor. DON-J verified a plan of care for potential for dehydration was not developed nor implemented. DON-J verified there wasn't any hydration assessments completed after the initial risk assessment. Surveyor # questioned if a comprehensive assessment to include orthostatic blood pressures was completed when resident #1 developed some confusion and had sustained two falls on 01/07/16 and hadn't fallen since admission to facility. DON-J verified a comprehensive assessment that would have included hydration status and orthostatic blood pressures were not completed in an attempt to determine why the resident started to sustain falls. Surveyor # questioned DON-J how staff ensured resident #1's hydration status and DON-J replied that nothing was ordered by the physician as far as to push fluids. DON-J stated resident #1 was ok with drinking fluids and he was his own person and staff can not force the resident to drink. On 01/27/16 at 10:25 am, surveyor # conducted a telephone interview with Nephrology APNP-K. Nephrology APNP-K stated resident #1 developed acute kidney injury and sustained tubular necrosis which was caused by dehydration and [MEDICAL CONDITION]. On 01/27/16 at 10:29 am, surveyor # conducted a telephone interview with APNP-M. APNP-M stated he had seen resident #1 on 01/08/16, but only looked at the inflammation on the side of the neck and nothing else. APNP-M indicated he doesn't recall staff telling him that the resident was having issues with diarrhea or loose stools. Facility failure to address resident #1's fluid loss and for keeping the resident from becoming dehydrated to the point of sustaining a kidney injury; failure of facility staff to assess the resident's fluid intake and take the resident's fluid loss into consideration when assessing resident fluid needs; failure to develop a care plan that addressed resident fluid loss; and staff failure to make the physician aware of the resident's fluid loss and to question whether the resident should continue to be on [MEDICATION NAME] created a finding of immediate jeopardy, given the resident's resulting kidney injury. This was removed when the facility completed the following: 1. A Hydration Risk Evaluation and Assessment started on January 27, 2016 to be completed on all residents by Licensed Nursing Staff by January 29, 2016. 2. Resident care plans will be updated as appropriate based on individual assessments. 3. Physicians will be notified immediately based on individual resident need and all licensed staff will receive re-education on physician notification protocol, policies, and procedures. 4. Policy and procedure on Hydration Risk Evaluation and Assessment has been updated to reflect current standards of practice. 5. Licensed staff will be educated starting January 27, 2016 and will continue until all staff are trained and demonstrate competency on the following: a. The updated policy on Hydration Risk Evaluation and Assessment-Hydration Screener. b. The eINTERACT built into the electronic medical record to enhance communication between line staff and licensed staff. c. Identifying risk factors for dehydration. 6. Certified Nursing Assistants will be educated, starting January 28, 2016 and will continue until all staff are trained and demonstrate competency on the following: a. Identifying risk factors of dehydration. b. eINTERACT built into the electronic medical record to enhance communication between line staff and licensed staff. 7. All other staff will be educated, starting January 28, 2016 and commence until completed, on identifying risk factors for hydration and communicating any changes of condition to licensed staff. 8. DON/Designee will audit residents for Hydration/INO assessments weekly for 3 months, and on an ongoing basis on admission and quarterly as required. 9. Any results from the audits will be forwarded to the QAPI for review and recommendation. 10. No rendering of care will take place by licensed staff and certified nursing assistants until they have been educated and signed off that they understand and received training for all of the above.