Every finding on record at Homestead Health Services

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 19 residents residing in the facility.The facility did not cool food with an approved cooling method.The facility did not use sanitizing solution per manufacturer's instructions to ensure proper sanitization of kitchen prep surfaces.Findings include:Cooling Method:The 2022 Food and Drug Administration (FDA) Food Code documents at section 3 501.14 Cooling Methods: .(A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 degrees C (41 degrees F) or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. (C) Except as specified under (D) of this section, a time/temperature control for safety food received in compliance with laws allowing a temperature above 5 degrees C (41 degrees F) during shipment from the supplier as specified in 3-202.11(B), shall be cooled within 4 hours to 5 degrees C (41 degrees F) or less .During a self-guided initial tour of the kitchen that began at 8:32 AM on 3/8/26, Surveyor observed the following pre-cooked items in the walk-in cooler:~ A container labeled fried ham dated 3/7/26~ A container labeled ham dated 3/7/26~ A container labeled chicken dated 3/6/26~ A container labeled baked beans dated 3/6/26~ A container labeled beef gravy dated 3/6/26~ A container labeled chili dated 2/26/26Surveyor observed the following pre-cooked food in the walk-in freezer:~ A container labeled maple mustard pork chops dated 3/5/26Surveyor observed a food cooling log near the walk-in cooler that did not contain any entries.During a continuous kitchen observation that began at 12:17 PM on 3/9/26, Surveyor interviewed Dietary Manager (DM)-H who verified the above items in the walk-in cooler and freezer were cooked, cooled, and saved for future resident consumption. DM-H confirmed the facility did not have a cooling log for foods cooked and cooled for future consumption. DM-D stated the facility previously had a cooling log; however, DM-D was informed by the facility's Registered Dietitian that the cooling log was not necessary since the facility did not save large amounts of food.Sanitizing Solution:During a continuous kitchen observation that began at 12:17 PM on 3/9/26, Surveyor noted the facility used Cleanslate Knoxville Disinfectant-Sanitizer. The sanitizing solution was connected to and used in the third compartment of the three-compartment sink. Surveyor interviewed DM-H who stated the facility used sanitizing solution in buckets to clean kitchen prep surfaces. DM-H stated staff prepare a bucket of sanitizing solution, wipe all countertops with a cloth, and leave the kitchen prep areas to dry. Surveyor noted the manufacturer's directions for Cleanslate Knoxville Disinfectant-Sanitizer indicate a pre-cleaning step is required for visibly soiled areas and a fresh solution should be prepared for each use. To disinfect inanimate, hard, non-porous surfaces, apply solution with a mop, cloth, sponge, low pressure coarse sprayer, or hand pump trigger sprayer and wet all surfaces thoroughly. Allow to remain visibly wet for 10 minutes and remove excess liquid. Surfaces which may contact food must be rinsed thoroughly with potable water after use. The General Disinfection section indicates: To disinfect food processing premises: floors, walls, and storage areas, add 3 ounces of product per 5 gallons of water. For visibly soiled areas, a pre-cleaning step is required. Apply solution with a mop, cloth, sponge, or hand pump trigger sprayer and wet all surfaces thoroughly. Allow to remain visibly wet for 10 minutes and remove excess liquid. Before using the product, food products and packaging materials must be removed from the area or carefully protected. After use, all surfaces in the area must be thoroughly rinsed with potable water. To disinfect food service establishment or restaurant contact surfaces: floors, walls, storage areas, countertops, outside of appliances, and tables, add 3 ounces of product per 5 gallons of water. For visibly soiled areas, a pre-cleaning step is required. Apply solution with a cloth, sponge, or hand pump trigger sprayer and wet all surfaces thoroughly. Allow the surface to remain visibly wet for 10 minutes, remove excess liquid, and rinse the surface with potable water .DM-H verified the sanitizing solution was not left on surfaces for 10 minutes and kitchen prep areas were not rinsed with water following the sanitization process.

Based on staff interview and record review, the facility did not implement their abuse policy for 3 (Certified Nursing Assistant (CNA)-J, Registered Nurse (RN)-I, and CNA-K) of 8 employees reviewed for caregiver background checks. This practice had the potential to affect more than 4 of the 19 residents residing in the facility.CNA-J was hired on 12/30/25. CNA-J's background check information did not contain Department of Justice (DOJ) or Government Findings (GF) (formerly known as Integrated Background Information System (IBIS)) reports completed prior to CNA-J working in the facility and caring for residents. RN-I was hired on 1/12/22. RN-I's background check information did not include an updated Background Information Disclosure (BID) form or DOJ and GF reports.CNA-K was scheduled to begin working on 3/9/26. CNA-K's BID form was dated 11/15/24. In addition, CNA-K's background check information did not include DOJ or GF reports.Findings include:The facility's Abuse, Neglect and Exploitation policy, dated 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistently with applicable state law and regulations. Responsibility for performance of compliance checks on contracted temporary staff will be established via contractual agreement. 2. Screenings may be conducted by the facility, a third-party agency, or academic institution. 3. The facility will maintain documentation of proof that the screening occurred .1. On 3/8/26, Surveyor requested background check information for CNA-J who started at the facility on 12/30/25. Surveyor received the background check information on 3/9/26 and noted CNA-J's BID form was completed on 12/21/25. CNA-J's DOJ and GF reports were requested on 2/11/26. Surveyor reviewed CNA-J's timecard which indicated CNA-J worked at the facility as a CNA starting on 12/30/25. 2. On 3/8/26, Surveyor received background check information for agency RN-I and noted RN-I's background check was completed on 1/22/22. RN-I's BID was due to be completed on or before 1/22/26. Surveyor requested the most up-to-date background check information for RN-I. On 3/9/26, Surveyor reviewed RN-I's background check information again and noted RN-I's BID form and DOJ and GF reports were dated 3/9/26.3. On 3/8/26, Surveyor requested background check information for CNA-K who was scheduled to work on 3/9/26. On 3/9/26, [NAME] President of Success (VPS)-C provided CNA-K's BID form and a copy of CNA-K's driver's license, Social Security card, and CNA registration. VPS-C indicated CNA-K's background check was in the process of being completed and CNA-K was no longer scheduled to work that day. Surveyor noted CNA-K's BID form was dated 11/15/24.On 3/9/26 at 2:03 PM, Surveyor interviewed Director of Nursing (DON)-B and VPS-C who stated the facility did not have a Business Office Manager who completed background checks and indicated other individuals in the organization oversaw the completion of background checks. DON-B and VPS-C verified CNA-J worked from 12/30/25 until 2/11/26 without completed DOJ and GF reports. DON-B and VPS-C confirmed RN-I's background check renewal was not completed until Surveyor requested the information. DON-B confirmed CNA-K worked in the facility in 2024, recently returned, and was scheduled to work on 3/9/26 without a completed background check. DON-B and VPS-C were not aware CNA-K's background check was not completed until Surveyor requested the information.

Based on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 1 resident (R) (R1) of 8 sampled residents.The facility did not contact the state mental health authority to pursue futher PASRR Level I screening after R1's PASRR Level I 30-day exemption expired.Findings include:On [DATE], Surveyor reviewed R1's medical record. R1 had a diagnosis of depression. R1's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.R1's medical record contained three PASRR Level I Screens but did not contain a PASRR Level II Screen. Surveyor reviewed R1's PASRR Level I Screens and noted the following:~ R1's date of admission and first PASRR Level I was a 30-day hospital exemption dated [DATE].~ A PASRR Level I Screen, dated [DATE], indicated R1 had a mental health disorder and was prescribed fluoxetine (an antidepresssant medication) and Wellbutrin (an antidepressant medication). A PASRR Level II Screen was not completed.~ A PASRR Level I Screen submitted for R1 on [DATE] indicated R1 had a diagnosis of depression and was prescribed fluoxetine and Wellbutrin. The PASRR Level I indicated R1 had a 30-day hospital exemption. ~ A third PASRR Level I Screen, dated [DATE], indicated R1 had a diagnosis of depression and was prescribed fluoxetine. Wellbutrin was removed. The PASRR Level I indicated R1 had a 30-day hospital exemption. A PASRR Level II Screen was not completed.On [DATE] at 11:57 AM, Surveyor interviewed Social Services Director (SSD)-D who stated SSD-D had worked as the SSD for a little over a year, did not have formal PASRR training, and was self-learning the process. SSD-D was not aware of the requirement to complete another PASRR Level I Screen if a resident remains in the facility after a 30-day exemption expires. SSD-D indicated R1 was originally admitted for rehabilitation and was supposed to transfer to another facility. SSD-D stated a new PASRR Level I Screen should be completed when there is a medication or diagnosis change. SSD-D indicated a PASRR Level I Screen was completed on [DATE] because Wellbutrin was removed. SSD-D verified PASRR Level I Screens were not submitted correctly and a PASRR Level II Screen was not completed for R1 who remained in the facility since admission on [DATE].

Based on staff and resident representative interview and record review, the facility did not ensure written notice or a choice of room/roommate was provided for 1 resident (R) (R8) of 1 sampled resident. R8's belongings were transferred to another room on 1/23/26 against the wishes of R8's Power of Attorney for Healthcare (POAHC). R8's belongings were moved back to R8's room after Ombudsman (OMB)-L contacted the facility. Neither R8 or R8's POAHC received prior written notice of the reason for the room change. In addition, R8 was not given a choice of rooms or potential roommates. Findings include: The facility's Roommates policy, dated 7/2022, indicates: The facility will strive to accommodate the medical and social compatibility of individuals when assigning rooms and roommates. Residents have the right to share a room with whomever they wish, as long as both residents are in agreement .There are some limitations to these rights. Residents do not have the right to demand that a current roommate be displaced in order to accommodate the couple that wishes to room together. In addition, residents are not able to share a room if one of the residents has a different payment source for which the facility is not certified (if the room is in a distinct part of the facility, unless one of the residents pays privately for his/her care) or if one of the individuals is not eligible to reside in a nursing home. A resident's preferences are to be taken into account when considering roommates or making room changes. When a resident is being moved at the request of the facility, the resident, family, and/or responsible party must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. A resident receiving a new roommate should be given as much advance notice as possible. Notification of the resident and/or responsible party regarding a new roommate is to be documented in the resident's medical record.From 3/8/26 to 3/10/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, vascular dementia, anxiety disorder, and major depressive disorder. R8's most recent Minimum Data Set (MDS) assessment, dated 1/30/26, indicated R8's cognition was impaired.On 3/8/26 at 9:59 AM, Surveyor interviewed Family Member (FM)-F who was also R8's activated POAHC. FM-F and R8 were in the common area outside R8's room. FM-F stated in January of 2026, Nursing Home Administrator (NHA)-A and Social Services Director (SSD)-D told FM-F that R8 had to move from R8's current room. FM-F told NHA-A and SDD-D that FM-F did not want R8 to move. When FM-F and R8 returned from breakfast, R8's belongings were being moved. FM-F stopped the move and R8's belongings were moved back to R8's room. The facility then indicated they would add another bed to R8's room and R8 received a roommate approximately one month ago. R8 had not had a roommate since R8 was admitted to the facility.On 3/8/26 at 1:30 PM, Surveyor interviewed FM-G who stated R8 had lived in the facility for two years. R8 was originally on the first floor and was moved to the second floor on 3/12/25. There were no residents on the first floor during the survey. When R8 moved to the second floor, R8 received a south facing room for maximal sun exposure and quiet. The room was located in the corner near a common space that connected to four other rooms. FM-G stated the facility attempted to move R8 into a room with a roommate in January of 2026. The roommate was known to yell and scream which was not a good match for R8 since yelling and screaming upset R8. FM-G wanted to maintain R8's comfort and safety in R8's current room. FM-F called FM-G when the facility began to move R8's belongings. FM-G called OMB-L who called the facility and indicated the facility could not move R8 without R8's consent. The move was stopped and R8 was given a roommate. FM-G stated NHA-A indicated they needed to move R8 to make room for three residents. SSD-D accompanied NHA-A during the interaction.On 3/10/26 at 11:45 AM, Surveyor interviewed SSD-D who verified R8 had not had a roommate in R8's current room which could accommodate two residents. SSD-D stated the facility had potential residents who wanted private therapy rooms for short-term rehab. SSD-D stated SSD-D informed FM-F twenty-four hours in advance of the facility's intent to move R8. SSD-D confirmed SSD-D accompanied NHA-A when FM-F was informed that R8 would be moved to a different room. SSD-D stated FM-F expressed FM-F's thoughts and asked about other rooms after being informed of R8's roommate. SSD-D stated many considerations are used to decide roommates, including bathroom placement for shared bathrooms. SSD-D stated FM-F said okay and wait until (FM-G) hears about this. SSD-D did not recall if SSD-D documented FM-F's response but stated SSD-D took FM-F's okay as permission. The move was scheduled for 1/23/26. SSD-D stated FM-G talked with NHA-A on 1/22/26 and stated FM-G did not want R8 to move, however, the facility went ahead with the move because FM-F had given the okay. SSD-D confirmed OMB-L called during a stand-up meeting on the day of R8's move. OMB-L informed the team via speaker phone that R8 was not given choices. SSD-D stated OMB-L made it sound like it was not a well thought out plan. A social services note created on 1/22/26 by SSD-D did not indicate verbal permission was given by FM-F to move R8's room. On 3/10/26 at 12:36 PM, Surveyor interviewed NHA-A who stated the facility reviewed bed availability and was trying to increase the census. They reviewed rooms that were considered semi-private that could have two residents but only had one resident who was not paying for a private room. NHA-A stated SSD-D explained how the facility determines roommates when NHA-A and SSD-D spoke with FM-F the day before the move was scheduled. NHA-A stated both NHA-A and SSD-D heard FM-F say okay to the room change. NHA-A stated the facility ultimately respected that FM-F and FM-G did not want to move R8 and informed FM-F and FM-G that they planned to move a resident in with R8 instead. NHA-A verified FM-G came to the facility on 1/22/26 and informed NHA-A that FM-G did not want R8 to move. NHA-A stated NHA-A would reconsider the move. NHA-A stated OMB-L called DON-B during morning meeting on 1/23/26 and DON-B put OMB-L on speaker phone. OMB-L told staff the move could not occur. NHA-A verified the call occurred while R8's belongings were being moved. NHA-A did not recall who stopped the move and did not think the information was documented unless SSD-D took notes. NHA-A indicated the facility was still looking at how to increase the census. On 3/10/26 at 1:29 PM, Surveyor interviewed OMB-L who confirmed FM-G contacted OMB-L and stated R8 and R8's family felt that they did not have a say in the move. OMB-L called the facility and spoke with NHA-A, DON-B, [NAME] President of Success (VPS)-C, and SSD-D. OMB-L stated the facility did not give proper notice to FM-F and did not consider FM-F and FM-G's input. OMB-L informed staff of the regulation and asked them to stop the move. On 3/10/26 at approximately 4:00 PM, Surveyor interviewed FM-F who confirmed NHA-A and SSD-D spoke to FM-F about the room change on 1/22/26 (the day prior to the attempted move). When Surveyor asked if FM-F gave verbal or written permission to move R8's room, FM-F denied that FM-F said okay or gave verbal consent and did not receive anything in writing about the room change. FM-F verified R8 was not moved but now has a roommate. Surveyor reviewed R8's census history which revealed no change in payor source during the move.

Based on staff interview and record review, the facility did not provide care and services to maintain the highest practicable physical well-being for 1 resident (R) (R1) of 2 sampled residents.R1 had a diagnosis of ascites (an abnormal accumulation of fluid within the abdominal (peritoneal) cavity). Staff did not reweigh R1 in accordance with a physician's order or notify the physician after R1 gained 9.7 pounds in less than a month. Findings include:The facility's Weight Monitoring policy, revised 12/21/22, indicates: The Interdisciplinary Team (IDT) will strive to prevent, monitor, and intervene for undesirable weight changes for our residents .6. Any weight change of five pounds or more since the last weight assessment will be retaken for confirmation .10. The nursing staff will notify the individual or responsible party, physician .of any individual with an unintended significant weight change.On 3/10/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including ascites and cirrhosis of the liver. R1's Minimum Data Set (MDS) assessment, dated 1/14/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition.Surveyor reviewed R1's physician orders and noted an order to obtain R1's weight monthly one time a day every four weeks on Saturday and obtain a re-weight if there is a change of 5 pounds since R1's last weight.Surveyor reviewed R1's weights and noted the following:~ On 1/3/26, R1 weighed 285.8 pounds.~ On 2/1/26, R1 weighed 295.5 pounds which was an increase of 9.7 pounds in less than a month. R1's medical record did not indicate R1 was reweighed.On 3/10/26 at 11:36 AM and 12:51 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who confirmed R1 gained 9.7 pounds as of 2/1/26. When asked if R1 should have been reweighed and if the physician should have been notified, LPN-E stated LPN-E had asked a Certified Nursing Assistant (CNA) to reweigh R1. LPN-E verified R1's medical record did not contain a documented re-weight and did not indicate the physician was notified.On 3/10/26 at 1:16 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who confirmed R1 should have been reweighed and the physician should have been notified. VPS-C indicated obtaining a resident's weight is the nurse's responsibility.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program to prevent the transmission of communicable disease and infection for 1 resident (R) (R14) of 8 sampled residents.Certified Nursing Assistant (CNA)-M did not appropriately change gloves and cleanse hands during incontinence care for R14. Findings include: The facility's Hand Hygiene policy, revised 11/2/22, indicates: 1. All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations in the facility.2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached Hand Hygiene Table. The Hand Hygiene Table includes the following regarding when to perform hand hygiene: After handling contaminated objects; When moving from a contaminated body site to a clean body site during resident care; After assistance with personal body functions (e.g., elimination, hair grooming, smoking). From 3/8/26 to 3/10/26, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, and diabetes mellitus type 2. R14's most recent Minimum Data Set (MDS) assessment, dated 2/3/26, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R14 had moderately impaired cognition. On 3/8/26 at 12:59 PM, Surveyor observed CNA-M and CNA-O complete incontinence care for R14. While R14 was in bed, CNA-M and CNA-O positioned R14 to change R14's brief. CNA-M removed R14's wet brief and used wipes to clean R14's perineal area. Without changing gloves and cleansing hands, CNA-M retrieved a tube of barrier cream from the night stand drawer, applied cream to R14's groin, and put the cream back in the drawer. With the same same soiled gloves, CNA-M put a clean brief underneath R14. CNA-M and CNA-O assisted R14 onto the left side and secured the brief. CNA-M put the package of wipes in the night stand drawer, put a pillow under R14's legs, and provided R14 with blankets. CNA-M then removed gloves. Without cleansing hands, CNA-M removed and replaced the garbage bag. CNA-M then sanitized hands. Immediately after the observation, Surveyor interviewed CNA-M. When asked when CNA-M should change gloves and complete hand hygiene during incontinence care, CNA-M stated after a resident's brief is changed and a new brief is applied. On 3/8/26 at 3:51 PM, Surveyor interviewed Director of Nursing (DON)-B and Infection Preventionist (IP)-N who stated staff should change gloves and complete hand hygiene after gloves are soiled during incontinence care.

Based on staff and resident representative interview and record review, the facility did not ensure an activated Power of Attorney for Healthcare (POAHC), physician, or Hospice services were notified of a change in condition for 1 resident (R) (R2) of 3 sampled residents.R2 had a change in condition on 9/25/25. R2's activated POAHC (POAHC-C), physician, and Hospice service were not notified of the change in condition.Findings include:The facility's Change in Condition of a Resident policy, revised 9/20/22, indicates the facility should immediately inform the resident, consult with the residents' physician, and notify, consistent with his or her authority, the resident's representative when there is .a significant change in the resident's physical, mental, or psychosocial status.On 1/21/26, Surveyor reviewed R2's medical record. R2 received Hospice services and had diagnoses including heart failure, COVID-19, hypertension, diabetes, and atrial fibrillation. R2's Minimum Data Set (MDS) assessment, dated 9/21/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 had intact cognition. POAHC-C assisted R2 with medical decisions. A progress note, dated 9/25/25 at 5:22 AM, indicated R2 moaned during cares, had an increased respiratory rate, was diaphoretic (excessive sweating), and did not talk. R2's blood pressure was 130/51, respirations were 26, oxygen saturation was 85%, and blood sugar was 286. R2's medical record did not indicate POAHC-C, the physician, or Hospice services were notified of R2's change in condition. A Hospice note indicated R2 passed away on 9/25/25 at 9:45 AM.On 1/21/26 at 9:44 AM, Surveyor interviewed POAHC-C who stated POAHC-C was not notified of R2's change in condition which was identified hours before R2's death. POAHC-C was upset that POAHC-C was not able to be with R2 when R2 passed away. POAHC-C was on the way to the facility when POAHC-C was notified that R2 had passed.On 1/21/26 at 12:22 PM, Surveyor interviewed Director of Hospice Services (DHS)-D who indicated the description of R2 in the progress note on 9/25/25 at 5:22 AM was a change in condition and should have been reported to Hospice at the time the change in condition was identified.On 1/21/26 at 1:07 PM, Surveyor interviewed Unit Manager (UM)-E who indicated the progress note on 9/25/25 at 5:22 AM, should have been considered a change in condition for R2. UM-E indicated POAHC-C, the physician, Hospice services, and Director of Nursing (DON)-B should have been notified.On 1/21/26 at 1:21 PM, Surveyor interviewed DON-B who indicated the progress note on 9/25/25 at 5:22 AM was a change in condition for R2. DON-B verified the change in condition should have been reported to POAHC-C, the physician, and Hospice services at the time the change in condition was identified.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R1) of 2 sampled residents or their legal representative was informed in advance of the risks and benefits of prescribed medication or consented to receive the medication. R1 was prescribed naltrexone (an opioid antagonist medication used to treat compulsive behaviors). The facility did not obtain consent prior to administering the medication to R1.Findings include:The facility's Use of Psychotropic Medications policy, dated 4/27/25, indicates: It is the intent of this policy to ensure residents only receive psychotropic medication when other non-pharmacological interventions are clinically contraindicated. Additionally, these medications should be used to treat the resident's medical symptoms and not be used for discipline or staff convenience .When a medication is used that can affect brain activity .and the documented use appears to be a substitution for another psychotropic medication rather than for the original or approved indications, the medication is subject to the requirements pertaining to psychotropic medications .Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the risks, benefits, and alternatives for the medication .The resident has the right to accept or decline the initiation or increase of a psychotropic medication .The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, treatment alternatives or other options, and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc,.) .On 9/12/25, Surveyor reviewed R1's medical record. R1 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus with neuropathy, obstructive sleep apnea, mild neurocognitive disorder with behavioral disturbance, bilateral hearing loss, and cataracts. R1's Minimum Data Set (MDS) assessment, dated 7/31/25 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1's medical record indicated R1 had an activated Power of Attorney for Healthcare (POAHC). R1's medical record indicated R1 was prescribed naltrexone 50 milligrams (mg) for sexualized behaviors on 7/8/25. The medication was discontinued on 7/24/25. On 9/12/25 at 8:55 AM, Surveyor requested a Statement of Incapacity (SOI) for R1 from Director of Nursing (DON)-B since R1 had an activated POAHC. Surveyor also requested consent for the administration of naltrexone from R1 or R1's representative.On 9/12/25 at 9:45 AM, DON-B approached Surveyor and indicated DON-B reviewed R1's POAHC paperwork, called the medical records department at the hospital that initiated the paperwork, and received confirmation that R1 was R1's own person and able to consent to medication and treatment. DON-B indicated DON-B obtained consent for naltrexone from R1's representative on 7/24/25, however, R1's representative revoked consent after reviewing the adverse effects. The medication was discontinued. DON-B indicated DON-B would look for consent or a narrative for naltrexone prior to 7/24/25.Surveyor reviewed a Consent to Medication form for naltrexone that was signed by R1's representative and dated 7/24/25. A handwritten note on the bottom of the form indicated R1's representative was informed and gave consent for the medication but called DON-B an hour later to revoke consent and discontinue the medication after reviewing the side effects.On 9/12/25 at 1:15 PM, Surveyor interviewed R1 who was not aware R1 was prescribed and administered naltrexone until R1's representative was informed and asked to give consent. R1 verified R1's representative consents to medications and treatments per R1's request. R1 indicated R1 was upset that the facility administered naltrexone without informing R1 or R1's representative which was against R1's rights. On 9/12/25 at 3:25 PM, DON-B approached Surveyor and indicated the facility did not obtain consent to administer naltrexone prior to 7/24/25 and confirmed naltrexone was administered to R1 without consent or knowledge of the medication, its intended use, and the risks and benefits.

Based on staff and resident representative interview and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R1) of 3 sampled residents.R1 had an order for gabapentin (an anticonvulsant medication used to treat nerve pain and control seizures) four times daily. R1 did not receive the scheduled medication timely as ordered.The facility's Medication Administration policy, dated 1/2025, indicates: .14. Medications are administered within 60 minutes of the scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center .On 9/12/25, Surveyor reviewed R1's medical record. R1 had diagnoses including type 2 diabetes with neuropathy and mild neurocognitive disorder with behavioral disturbance. R1's Minimum Data Set (MDS) assessment, dated 7/31/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.Surveyor reviewed R1's Medication Administration Record (MAR) which contained the following order:~ Gabapentin oral capsule 300 milligrams (mg), give 2 capsules by mouth four times daily, please give at specific scheduled time, do not give early, related to hereditary and idiopathic neuropathy. The scheduled times were: 7:30 AM, 12:00 PM, 4:00 PM, and 8:30 PM. Surveyor reviewed R1's August and September 2025 MARs (audit time stamped record) and noted the following administration times:~ On 8/27/25, R1's 4:00 PM gabapentin dose was administered at 5:42 PM.~ On 9/1/25, R1's 7:30 AM gabapentin dose was administered at 9:03 AM.~ On 9/2/25, R1's 7:30 AM gabapentin dose was administered at 9:42 AM.~ On 9/4/25, R1's 8:30 PM gabapentin dose was administered at 11:03 PM.On 9/12/25 at 11:38 AM, Surveyor interviewed Family Representative (FR)-D who indicated there were concerns that R1's gabapentin was not administered timely. On 9/12/25 at 2:50 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility's medication administration times are as follow: 6:00 AM to 10:00 AM, 10:00 AM to 2:00 PM, 2:00 PM to 6:00 PM, and 6:00 PM to 10:00 PM. DON-B verified R1's gabapentin had specific administration times of 7:30 AM, 12:00 PM, 4:00 PM, and 8:30 PM. DON-B indicated the times were requested by FR-D and ordered by the physician. DON-B indicated if medications have specific times, nurses can administer them up to one hour before or after the specific times.On 9/12/25 at 4:20 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who confirmed R1's gabapentin should be administered at the specific scheduled times and verified the medication was administered late on 8/27/25, 9/1/25, 9/2/25, and 9/4/25.

Based on staff interview and record review, the facility did not ensure staff transferred 1 resident (R) (R1) of 1 sampled resident in accordance with their plan of care and the facility's policy. On 4/20/25, R1 fell during a mechanical lift transfer and incurred bilateral distal femur fractures when Certified Nursing Assistant (CNA)-D did not follow R1's care plan or the facility's transfer policy.Findings include:The facility's Safe Resident Handling and Transfers policy, revised 8/5/22, indicates: It is the policy of this facility to ensure residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be used dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used .The facility will ensure there are appropriate amounts of varying sling sizes to accommodate residents and residents are measured correctly per manufacturer's instructions .Ensure the sling designed for the lift is used with that specific lift .Two staff must be used when transferring residents with a mechanical lift .Staff are expected to maintain compliance with safe handling/transfer practices .Resident lifting and transferring will be performed according to the resident's individual plan of care .Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device .On 6/27/25, Surveyor reviewed a facility-reported incident (FRI) that indicated on 4/20/25 at approximately 7:50 AM, R1 sat at the edge of R1's bed and CNA-D fastened a medium-size sling around R1 and attached the sling loops to a sit-to-stand lift. When CNA-D lifted R1, R1's legs buckled and R1 fell to the left. When CNA-D called for help, another CNA and Licensed Practical Nurse (LPN)-C provided assistance and lifted R1 back to the edge of the bed via lift. LPN-C assessed R1 who reported bilateral leg pain. Tylenol was administered. When LPN-C checked on R1 at approximately 9:15 AM, R1 only allowed LPN-C to lift R1's knees a few inches without screaming in pain and reported pain at a level 10 out of 10. R1 was transferred to the emergency room (ER) and diagnosed with bilateral distal femur fractures that required surgical intervention. The FRI indicated the root cause of the fall was that CNA-D did not follow R1's care plan or the facility's Safe Resident Handling and Transfers policy. On 6/27/25, Surveyor reviewed R1's medical record. R1 had diagnoses including bilateral distal femur fractures (4/20/25), fibromyalgia, unspecific dementia, age-related osteoporosis, generalized osteoarthritis, and left artificial hip joint. A Minimum Data Set (MDS) assessment, dated 5/1/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderate cognitive impairment. R1 was R1's own decision maker. A care plan indicated on 4/20/25, R1 required the assistance of two staff for all transfers with a sit-to-stand lift. The care plan was revised on 4/25/25 to indicate R1 required the assistance of two staff for all transfers with a full body lift.A progress note, dated 4/23/25 by Director of Nursing (DON)-B, indicated Primary Care Physician (PCP)-E was notified of R1's fall from the lift and that R1 was transferred with the assistance of one staff instead of two. PCP-E was informed that R1 was transferred to the ER and then to a second hospital due to bilateral distal femur fractures.An Interdisciplinary Team (IDT) meeting note, dated 4/25/25, indicated DON-B, Activity Director (AD)-F, and Nursing Home Administrator (NHA)-A were in attendance. The note indicated CNA-D completed Activities of Daily Living (ADLs) for R1 on 4/20/25 and attempted to transfer R1 into a wheelchair via mechanical lift. Prior to the transfer, R1 was sitting at the edge of R1's bed with the lift sling securely attached to the lift and the lift belt strapped around R1's waist. CNA-D indicated R1 was a few inches off the bed when R1 fell from the lift. After CNA-D called for help, LPN-C entered the room and observed R1 on the floor with R1's feet on the lift platform. R1's legs were in one direction and R1's upper body was in another direction. R1 complained of pain and stated, It hurts, both of my legs hurt. I think they're broke. R1 indicated R1 slid out of the lift as it was raised. LPN-C assessed R1's legs and noted moderate swelling to R1's left lateral knee. R1 could not participate in range of motion due to pain and was assisted back into bed. LPN-C called the on-call provider who gave an order for therapy to evaluate R1 for safe transfers on 4/21/25. As needed (PRN) Tylenol was administered for pain. When LPN-C checked back with R1, R1's pain had gotten worse and was at a level 10 out of 10. After LPN-C notified the on-call provider of R1's worsening pain and range of motion impairment, R1 was transferred to the ER. Staff were educated on the facility's lift policy which requires the assistance of two staff for all lift transfers. Mechanical lift competencies were completed. The note indicated R1 was to be transferred with a Drive brand Hoyer lift with a Drive brand large sling. On 6/27/25, Surveyor reviewed CNA-D's timecard for 4/20/25 and noted CNA-D worked from 4:15 AM to 3:13 PM. The facility's investigation indicated education was provided and contained employee sign-off sheets.A Training Log/In-Service sheet, dated 4/23/25 and presented by DON-B, indicated: Brand lifts are on the floor for transfers. Brand lifts require brand name slings. Each resident has their own sling. Slings must be tight when on but comfortable. Explain to resident what you are doing with transfers and cares. Surveyor noted the following staff did not receive the education: Registered Nurse (RN)-G, CNA-H, CNA-I, CNA-J, CNA-K, CNA-L, CNA-M, and RN-N.A Training Log/In-Service sheet, dated 4/20/25 and presented by NHA-A, indicated: Immediately report to DON/NHA incidents of misconduct, abuse, exploitation, or neglect. Immediately report all alleged mistreatment, injury of unknown cause, or falls with injury. Surveyor noted the following staff did not receive the education: RN-G, CNA-H, CNA-I, CNA-J, and CNA-L. A Safe Lifting and Movement of Residents document, dated 5/2/25 and presented by NHA-A, indicated: Manual lifting should be eliminated when feasible. Competencies of lifts for all clinical staff. RN to assess individual needs for transfer assistance. Surveyor noted CNA-I did not receive the education.A Safe Resident Handling and Transfers document, dated 5/2/25 and presented by NHA-A, indicated: Staff will inspect equipment prior to use, check care plan, two staff members must be used when transferring with any mechanical lift, staff must demonstrate competency-DON/designee to assess, staff are expected to maintain compliance with safe handling/transfer process. Surveyor noted CNA-I did not receive the education and did not complete a safe lift competency. On 6/27/25, Surveyor reviewed RN-G, CNA-H, CNA-I, CNA-J, CNA-K, CNA-L, CNA-M, and RN-N's timecards for 4/20/25 to 6/27/25 and noted the following:~ RN-G worked 6 shifts~ CNA-H worked 46 shifts~ CNA-I worked 8 shifts~ CNA-J worked 32 shifts~ CNA-K worked 7 shifts~ CNA-L worked 51 shifts~ CNA-M worked 25 shifts~ RN-N worked 52 shiftsOn 6/27/25 at 1:20 PM, Surveyor interviewed LPN-C who indicated R1 fell on 4/20/25 at approximately 7:50 AM during morning cares. LPN-C assessed R1, called DON-B, and then called NHA-A when DON-B did not respond. LPN-C confirmed CNA-D continued to provide resident care until NHA-A arrived at the facility which LPN-C estimated was around noon. On 6/27/25 at 1:29 PM, Surveyor interviewed NHA-A and DON-B. DON-B indicated the facility had different sling brands and different lift brands. DON-B indicated CNA-D did not use the appropriate sling with the mechanical lift used to transfer R1. NHA-A indicated that was suspected but could not be confirmed. NHA-A indicated NHA-A removed the sling and mechanical lift used to transfer R1 from the floor and put them in NHA-A's office to ensure the equipment was inspected by maintenance staff prior to use again, however, staff took the sling used to transfer R1 to the laundry which got mixed in with other slings. The facility then removed all non-Drive brand slings and lifts from the floor to ensure staff were trained to use a brand name sling with the same brand name lift and appropriate colored sling loops. DON-B indicated staff texted DON-B on 4/20/25 but should have called DON-B or NHA-A right away to ensure someone responded immediately. DON-B indicated DON-B did not receive the text until approximately 1:00 PM. NHA-A indicated NHA-A received a call at approximately 11:40 AM, responded immediately, and removed CNA-D from resident care. DON-B indicated staff working at the time misjudged the severity of the injury until R1 reported no relief from Tylenol and then updated DON-B incorrectly via text message. NHA-A and DON-B confirmed CNA-D did not follow R1's care plan or the facility's policy for mechanical lift transfers. DON-B indicated DON-B did not know why all staff were not educated. DON-B confirmed all staff were not educated on all subjects pertinent to R1's fall and the prevention of future falls.

Based on staff interview and record review, the facility did not ensure a potential allegation of neglect was investigated for 1 resident (R) (R1) of 1 sampled resident.On 4/20/25, R1 incurred bilateral femur fractures when staff did not transfer R1 in accordance with R1's plan of care. The facility did not thoroughly investigate the potential allegation of negelct. Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Investigation of alleged abuse, neglect and exploitation: .An immediate investigation is warranted when an allegation or suspicion of abuse, neglect or exploitation, or a report of abuse, neglect or exploitation occurs. B. Written procedures for investigations include Identifying staff responsible for the investigation .identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred .and providing complete and thorough documentation of the investigation .4. Taking all necessary actions as a result of the investigation, which may include, but are not limited to the following: Analyzing .what changes may be needed to prevent future occurrences, defining whether care provisions should be changed and/or improved to protect residents .training staff on changes made and demonstration of staff competency after training is implemented, identification of staff responsible for corrective actions .On 6/27/25, Surveyor reviewed a facility-reported incident (FRI) that indicated on 4/20/25, R1 was transferred via sit-to-stand lift from the edge of R1's bed. R1 was sitting at the edge of the bed when Certified Nursing Assistant (CNA)-D fastened a medium-size sling around R1 and attached the sling to the lift. R1 indicated R1 was ready and held the bar. As CNA-D began to lift R1, R1's legs immediately buckled and R1 fell to the left. When CNA-D called for help, another CNA and Licensed Practical Nurse (LPN)-C responded. Staff lowered the bed and lifted R1 back to the edge of the bed. LPN-C assessed R1 who complained of bilateral leg pain. LPN-C administered Tylenol and checked back with R1 at approximately 9:15 AM. R1 only allowed LPN-C to lift R1's knees a few inches without screaming in pain and reported pain at a level 10 out of 10. R1 was transferred to the emergency room (ER) and diagnosed with bilateral distal femur fractures that required surgical intervention. Surveyor noted the FRI did not contain an interview with R1 regarding the lift and sling that were used or CNA-D's technique during the transfer. Surveyor also noted residents were not interviewed to ensure there were no further allegations of neglect or improper transfers. On 6/27/25, Surveyor reviewed R1's medical record. R1 had diagnoses including bilateral distal femur fractures (4/20/25), fibromyalgia, unspecific dementia, age-related osteoporosis, anemia, and left artificial hip joint. A Minimum Data Set (MDS) assessment, dated 5/1/25, indicated R1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderate cognitive impairment. R1 was R1's own decision maker. R1's medical record contained a care plan that indicated on 4/20/25, R1 was a two-person assist for all transfers with a sit-to- stand lift. The care plan contained a revision on 4/25/25 that indicated R1 was a two-person assist for all transfers with a full body lift.On 6/27/25 at 1:55 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A did not interview other residents about transfers or care provided by CNA-D. NHA-A indicated a summary of an interview with R1 was included in the FRI.On 6/27/25 at 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B who verified residents were not interviewed to rule out further neglect by CNA-D and indicated resident interviews were missed during the investigation. Surveyor requested copy of the FRI from DON-B and confirmed the FRI did not contain an interview with R1.

Based on staff interview and record review, the facility did not ensure residents 2 residents (R) (R3 and R4) of 10 sampled residents were free from significant medication errors. R4 has a diagnosis of epilepsy and is prescribed six medications for seizures, including clobazam (a benzodiazepine used to help control seizures) and Fycompa (an anti-epileptic medication used to treat and prevent seizures). R4 did not receive clobazam between [DATE] and [DATE] because the pharmacy had not received an order for the medication. R4 did not receive Fycompa from [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], and [DATE] through [DATE] due to pharmacy issues. R4 fell from R4's wheelchair during a seizure on [DATE] and incurred a head laceration that required two staples. R3 has a diagnosis of epilepsy and is prescribed Depakote for seizures. R3's bedtime (HS) Depakote order was increased on [DATE], however, the pharmacy did not receive the order. R3 did not receive Depakote on [DATE], [DATE], [DATE], and [DATE] because R3 was out of Depakote and the facility had exhausted their contingency supply. R3 had a seizure on [DATE]. The facility's failure to ensure prescribed medications were available for residents with seizure disorders created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE] at 2:40 PM. The immediate jeopardy was removed on [DATE], 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 Medication Reconciliation policy, revised [DATE], indicates: This facility reconciles medication frequently throughout a resident's stay to ensure the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent .Medication reconciliation refers to the process of verifying the resident's current medication list matches the physician's orders for the purpose of providing the correct medications to the resident .Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. New orders should have a second nurse to review the orders for accuracy .Order medications from the pharmacy in accordance with facility procedures for ordering medications . Onfi.com indicates: Clobazam is a prescription medicine used along with other medicines to treat seizures associated with Lennox-Gastaut syndrome in people two years of age or older. Important Safety Information: Clobazam is a benzodiazepine medicine and can cause physical dependence and withdrawal reactions. Stopping or decreasing clobazam suddenly after continued use may cause serious withdrawal reactions, which can be life-threatening, including unusual movements, responses, or expressions, seizures, sudden and severe mental or nervous system changes, depression, seeing or hearing things that others do not, an extreme increase in activity or talking, losing touch with reality, and suicidal thoughts or actions. Fycompa.com indicates: Fycompa is a prescription medicine used alone or with other medicines to treat partial-onset seizures with or without secondarily generalized seizures in people with epilepsy aged 4 and older and with other medicines to treat primary generalized tonic-clonic seizures in people with epilepsy aged 12 and older. Twelve milligrams (mg) is the highest dose studied . The website indicates: Do not stop Fycompa without first talking with your healthcare provider. Stopping suddenly can cause serious problems and can cause you to have seizures more often .Because of increased likelihood for adverse reactions in elderly patients, dosing titration should proceed slowly in patients aged [AGE] years and older. Fycompa .has the potential to .lead to .withdrawal symptoms including anxiety, nervousness, irritability, fatigue, asthenia, mood swings, and insomnia. According to https://www.depakote.com/epilepsy: Depakote comes in different dosage forms for oral use. Depakote (divalproex sodium) delayed-release tablets, Depakote ER (divalproex sodium) extended-release tablets, and Depakote Sprinkle Capsules (divalproex sodium delayed release capsules) are prescription medicines used: alone or with other medicines to treat: complex partial seizures in adults and children [AGE] years of age and older, simple and complex absence seizures .with other medications to treat: patients with multiple seizure types that include absence seizures .Stopping Depakote suddenly can cause serious problems. Stopping a seizure medicine suddenly in a patient who has epilepsy can cause seizures that will not stop (status epilepticus). 1. From [DATE] to [DATE], Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including epilepsy and dementia. R4's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R4 was not cognitively impaired. R4 had an activated Power of Attorney for Healthcare ((POAHC)-F). A Neurology note prior to R4's admission, dated [DATE], indicated R4 was seen at an epilepsy clinic for an initial visit and had a long-standing history of epilepsy. R4's seizures were described as a buzz in the head followed by convulsions. R4 underwent invasive evaluation in the 1990s and was told R4 was not a surgical candidate. Since then, R4 was treated medically and reported having seizures on most days. R4 was prescribed Dilantin (an anticonvulsant medication used to treat and prevent seizures), Fycompa, and topiramate (an anticonvulsant medication used to treat and prevent seizures). R4 was also prescribed Klonopin (clonazepam) twice per day. The Neurologist recommended R4 start Onfi with an intention of weaning Klonopin and indicated R4 would be admitted to the epilepsy monitoring unit for characterization and pre-surgical work up. R4 was prescribed clobazam (Onfi) 10 mg take .5 tablet by mouth in the morning and at bedtime for seven days then one tablet (10 mg) in the morning and at bedtime. R4's medical record indicated R4 was prescribed six medications related to seizure activity, including the following: ~One 1 milligram (mg) tablet of clonazepam (a benzodiazepine that is used to treat seizures) given by mouth as needed for seizure activity. ~One 10 mg tablet of clobazam (Onfi) given by mouth two times a day for seizures. ~One 12 mg tablet of Fycompa given by mouth one time a day for seizures. On [DATE] at 1:52 PM, Surveyor interviewed R4 who indicated R4 had seizures since R4 was six years old. R4 stated R4 had approximately six seizures per day. R4 indicated R4 recently had a bad seizure, fell out of R4's wheelchair, hit R4's head on the floor, and received two staples to the back of R4's head. R4 stated that was the worst seizure R4 had in a while. R4 stated R4's seizures consist of a buzzing sound in R4's head to severe shaking and tremors. When asked if there were any issues with R4's medications, R4 could not recall and indicated R4 took a lot of medication. On [DATE] at 10:37 AM, Surveyor interviewed POAHC-F who indicated R4 had been on seizure medication most of R4's life. POAHC-F indicated the only time R4 got into trouble was when R4's medications were cut back which caused R4 to have grand mal seizures. POAHC-F indicated the facility called POAHC-F that week because R4 had missed doses of Fycompa. POAHC-F indicated the facility was playing with fire when R4 didn't receive R4's medications. POAHC-F indicated staff stated the pharmacy said the medication was expensive and the pharmacy didn't keep it in stock. POAHC-F wanted to know when a pharmacist gets to decide when a drug is too expensive. POAHC-F indicated POAHC-F needed to follow-up with the facility because it was upsetting that R4 did not receive R4's seizure medication. POAHC-F indicated R4 was seen at an epilepsy clinic earlier in the year for three to four days and they adjusted R4's medications. POAHC-F indicated R4 seemed to be doing okay but was never going to be seizure free despite medication. POAHC-F the facility only contacted POAHC-F one time regarding R4 not receiving medication. R4's June and July (2024) Medication Administration Records (MARs) indicated R4 did not receive clobazam between [DATE] and [DATE]. Multiple progress notes during that time indicated staff attempted to call the pharmacy, left messages for R4's Neurologist, talked to the Neurologist's nurse, and notified the Director of Nursing (DON) and R4's Advanced Practice Nurse Prescriber (APNP). A progress note, dated [DATE] at 5:39 AM, indicated R4 informed a Certified Nursing Assistant (CNA) that R4 had two seizures that morning at 4:48 AM. R4 indicated there was buzzing in R4's head but R4 did not lose consciousness. R4 indicated that was a usual symptom and R4 could tell when a seizure was coming on. A progress note, dated [DATE], indicated staff notified R4's physician that R4 reported two unwitnessed seizures at 4:48 AM. R4 reported the seizure activity included buzzing in R4's head and no loss of consciousness. R4 was prescribed Dilantin and received R4's scheduled dose at 6:00 AM. The physician indicated R4 was on several seizure medications and asked if R4 received all of R4's seizure medications. The note indicated R4 was followed by a physician for seizures and Neurology was updated. A hand-written note indicated staff called the pharmacy on [DATE] and was told the pharmacy did not have a prescription for clobazam. R4's physician was notified. R4 began receiving clobazam on [DATE]. R4's [DATE] MAR indicated R4 did not receive Fycompa from [DATE] through [DATE]. A physician notification, dated [DATE], indicated R4 stated R4 had more seizures this past week than ever before. R4's Fycompa prescription ran out last week and a new script was needed. The note asked the physician to send a prescription to the pharmacy if Fycompa was still part of R4's treatment plan. The physician indicated DON-B would contact Neurology. An order was sent but needed price verification. R4's September and [DATE] MARs indicated R4 did not receive Fycompa from [DATE] through [DATE] and [DATE] through [DATE]. R4 was administered as needed (PRN) clonazepam for seizures/seizure activity on [DATE], [DATE], [DATE], and [DATE]. A progress note, date [DATE], indicated R4 approached the DON and stated R4 continued to have small seizures every day. A Neurology referral was requested and an appointment was scheduled for February 2025. R4's [DATE] MAR indicated R4 did not receive Fycompa from [DATE] through [DATE]. A progress note, dated [DATE] at 7:39 PM, indicated R4 reported seizure activity. A progress note, dated [DATE] at 5:46 PM, indicated R4 was administered clonazepam for seizure activity. On [DATE], R4 had a seizure in the dining room. R4 fell out of R4's wheelchair and hit R4's head on the floor. R4 had a laceration on the back of the head which required two staples in the emergency room (ER). On [DATE], the facility added an intervention to R4's care plan for anti-roll back bars on the wheelchair. Surveyor did not observe anti-roll back bars on R4's wheelchair until [DATE]. R4's November and [DATE] MARs indicated R4 did not receive Fycompa from [DATE] through [DATE] and had several self-reported seizures during that timeframe. A progress note, dated [DATE] at 5:17 PM, indicated there was no further seizure activity observed by staff, however, R4 reported three seizures that day. A progress note, dated [DATE] at 8:10 AM, indicated R4 had a small unwitnessed seizure with no signs of distress. A progress note, dated [DATE] at 11:55 AM, indicated R4 reported a seizure and requested PRN clonazepam. A progress note, dated [DATE] at 11:00 AM, indicated the writer spoke to the pharmacy regarding R4's Fycompa because R4 hadn't received the medication in two days. The pharmacy stated Fycompa was costly and they would send it that night. POAHC-F was updated that R4 did not receive the medication. R4's Nurse Practitioner (NP) advised staff to monitor for changes. A progress note, dated [DATE] at 10:04 PM, indicated R4 was out of Fycompa and the last dose administered was on [DATE]. R4 reported having seizures, however, there was no change from when R4 had the medication to when R4 did not. R4 mostly reported having seizures when R4 was in the dining room. The pharmacy stated Fycompa would be delivered that night. A progress note, date [DATE] at 10:39 PM, indicated R4 was out of Fycompa. R4 stated R4 had a seizure in the dining room during supper. There was no increase noted in R4's reported seizures. The pharmacy indicated Fycompa would be delivered that night. Surveyor noted R4 received PRN clonazepam and had approximately twenty seven documented seizures. Surveyor noted fifteen of R4's seizures occurred when R4 was not on seizure medication. Twelve of R4's seizures occurred after R4 took all of R4's seizure medication. On [DATE] at 1:03 PM, Surveyor interviewed Director of Nursing (DON)-B. When asked what staff should do if a medication is unavailable, DON-B indicated staff should contact the pharmacy to send the medication, contact the resident's physician and ask what they would like staff to do, contact the resident's decision maker, and inform DON-B. DON-B indicated staff should reorder a medication when there are 5 doses left. DON-B indicated the facility provided staff education on [DATE] due to issues with medications not being available, however, not all staff had received the education yet. DON-B also indicated DON-B reviewed daily reports to ensure medications were not missed. When Surveyor informed DON-B about R4's clobazam and Fycompa, DON-B indicated Fycompa was the drug that helped R4 the most because R4 had tried everything. DON-B indicated Fycompa was a high-cost medication that insurance did not always cover and DON-B had to sign a pre-authorization for the medication each time. DON-B acknowledged it was important to take seizure medications consistently and indicated prescribed medications should be administered. If medications were not administered, DON-B confirmed staff should notify the resident's physician and decision maker and receive instruction from the physician on what to do. On [DATE], Surveyor attempted to call R4's APNP and Case Manager but did not receive return calls. 47248 2. On [DATE], Surveyor reviewed R3's medical record. R3 had diagnoses including seizures, major depression, dementia with behaviors, and anxiety. R3's MDS assessment, dated [DATE], had a BIMS score of 4 out of 15 which indicated R3 had severely impaired cognition. R3 had a court appointed Guardian for healthcare decisions. R3 had physician orders for one 250 mg and one 500 mg tablet of Depakote (for a total of 750 mg) in the AM and two 500 mg tablets of Depakote (for a total of 1000 mg) at bedtime (HS) for seizures. A progress note, dated [DATE] at 12:02 AM, indicated R3 was on follow-up for what could have been a seizure on the AM shift. R3 did not have any seizures that shift and R3's cognition was at baseline. A progress note, dated [DATE] at 2:36 PM, indicated R3 was out of divalproex (Depakote) 500 mg. The pharmacy stated a 30-day supply was sent on [DATE] and were unable to send more at that time. A progress note, dated [DATE] at 9:45 AM, indicated R3 was out of divalproex 500 mg. The computer indicated refills were received on [DATE] but there were no cards. The pharmacy said they would send the medication that night. A progress note, dated [DATE] at 9:15 AM, indicated R3 was out of divalproex 250 mg and a dose was taken from contingency. The pharmacy said fifteen tablets were sent on [DATE] but the card was gone. A progress note, dated [DATE] at 9:16 AM, indicated R3 was out of divalproex 500 mg tablets which were on order since [DATE] and were not sent by the pharmacy. The pharmacy stated a 15-day supply was sent on [DATE] and they could not send a refill until [DATE]. A progress note, dated [DATE] at 8:53 AM, indicated: Divalproex sodium oral tablet delayed release 250 mg give 1 tablet by mouth one time a day for seizures. Take 1 (250 mg) tablet daily along with 1 (500 mg) tablet to equal an AM dose of 750 mg. Unavailable, contingency empty. A progress note, dated [DATE] at 3:42 PM, indicated the pharmacy was asked about R3's Depakote orders for 750 mg every AM and 1000 mg every PM (dated [DATE]). The pharmacy stated they never received the order for 1000 mg every PM. The facility depleted Depakote in the Nexsys (an automated medication dispensing machine). The NP was notified R3 had not received Depakote and had a small seizure that day. The writer faxed the pharmacy an order clarification. The pharmacy indicated the medication would be sent that night. R3's [DATE] MAR indicated R3's [DATE] HS dose of Depakote was not given. On [DATE] at 1:03 PM, Surveyor interviewed DON-B who confirmed R3 had an order to increase R3's HS dose of Depakote to 1000 mg on [DATE]. DON-B indicated nursing staff did not notify DON-B that the increased Depakote order was not received by the pharmacy or that nursing staff were consistently removing Depakote from the facility's contingency. DON-B verified DON-B was not made aware that R3's HS Depakote order was not received or filled by the pharmacy until R3 had missed doses on [DATE] and [DATE] and had a seizure on [DATE]. DON-B acknowledged it was important to take seizure medications consistently and indicated prescribed medications should be administered. If medications were not administered, DON-B confirmed staff should notify the resident's physician and decision maker and receive instruction from the physician on what to do. On [DATE] at 2:47 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who could not recall if R3's Depakote 750 mg AM dose was administered on [DATE]. LPN-I indicated if LPN-I charted that the dose was administered then it would have been administered. LPN-I indicated the facility usually had enough Depakote in contingency to administer the medication as pharmacy would not fill the order. On [DATE] at 9:25 AM, Surveyor contacted R3's Guardian but did not receive a return call. The failure to provide seizure medications for residents with seizure disorders created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it had completed the following: 1. Reviewed orders and medications on-hand to ensure medications were in-house and available to administer. 2. Notified physicians, families, and residents of missing doses of medication on or prior to [DATE]. 3. Educated staff on the facility's policy for when medication is unavailable. 4. Initiated audits to ensure medications were administered as ordered.

Based on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) had current certification for specialized infection prevention and control training. This had the potential to affect all 31 residents residing in the facility. IP-J's certification in a specialized infection prevention and control program was expired and no longer valid. Findings include: Centers for Medicare & Medicaid Services (CMS) Memo QSO-,d+[DATE]-NH, revised [DATE], indicates: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities which was implemented in three phases: .Phase 3 ([DATE]) .regulations which require nursing homes to have an Infection Preventionist who has specialized training onsite at least part-time to effectively oversee the facility's infection prevention and control program. On [DATE] at 8:15 AM, Surveyor requested IP-J's certificate of completion for specialized training in infection prevention and control from Nursing Home Administrator (NHA)-A. On [DATE] at 1:25 PM, Surveyor interviewed IP-J who indicated IP-J had certificates from modules of the program but could not find IP-J's certificate of completion for infection prevention and control training. IP-J indicated IP-J would obtain the certification and provide it to Surveyor. On [DATE] at 3:13 PM, IP-I approached Surveyor and indicated IP-J found IP-J's certificate of completion for infection prevention and control training, however, the certification had expired. IP-J indicated Director of Nursing (DON)-B was looking for DON-B's certificate because IP-J worked under DON-B. IP-J confirmed IP-J was the facility's designated IP and DON-B did not monitor the infection prevention and control program.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy in 2 of 2 medication storage rooms. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. On 12/2/24, Surveyor observed expired syringes and medications in 2 of 2 medication storage rooms. Findings include: The facility's Administering Medication Storage/Storage of Medication policy, dated 1/2024, indicates: Medications and biologicals are stored properly following manufacturers' or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration .Procedures: 14) Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal .15) Medications awaiting destruction that cannot be disposed of immediately should be recorded on a log to include the name of the individual(s) storing the medication, resident name, the prescription number if applicable, the quantity of the medication, the strength of the medication and date of disposition . On 12/2/24 at 12:27 PM, Surveyor observed two medication storage rooms and noted the following: ~ Four unlabeled, undated open aluminum packages of ipratropium bromide ~ Sixty-nine unlabeled and undated pink sodium chloride saline vials not in their original packaging ~ Nine Once Care 1 milliliter (ml) insulin syringes that expired on 1/31/24 ~ Thirty Assure 1 ml syringes that expired on 1/25/23 ~ One bottle of B-12 vitamin 1000 micrograms that expired on 9/24 ~ One bottle of oyster shell with calcium 250 milligrams and vitamin D that expired on 5/24. Surveyor confirmed with Assistant Director of Nursing (ADON)-D that the medications and supplies were opened, unlabeled, and/or expired. ADON-D indicated medications and supplies should be in their original packaging, labeled, and disposed of appropriately when expired. On 12/2/24 at 12:30 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the expired medications should have been disposed of in the Drug Buster.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 4 residents (R) (R18, R2, R11, and R80) of 4 residents. R18 had suspected Clostridium difficile (C. diff) but was not on the facility's infection surveillance line list. R2 was treated for a urinary tract infection (UTI) with antibiotic medication but was not on the facility's infection surveillance line list. R11 had diagnoses including infection and inflammatory reaction due to indwelling urethral catheter and a stage 3 pressure ulcer of the sacral region. R11 was not on enhanced barrier precautions (EBP). R80 was treated for osteomyelitis (bone infection) with intravenous antibiotics administered through a peripherally inserted central catheter (PICC). R80 was not on EBP. Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, revised 8/8/24, indicates: It is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high-contact resident care activities .An order for EBP will be initiated for residents with any of the following: Wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (central lines, peripherally inserted central catheters (PICCs) .urinary catheters .) even if the resident is not known to be infected or colonized with an MDRO .Implementation of EBP: .Make gowns and gloves available immediately near or outside the resident's room .Personal protective equipment (PPE) for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room .Position a trash can inside the resident's room and near the exit for discarding PPE after removal prior to exit of the room or before providing care for another resident in the same room. The Infection Preventionist (IP) will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education . The facility's Infection Prevention and Control Program policy, revised 3/14/23, indicates: .1. The designated IP is responsible for oversight of the program and serves as a leader to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infection and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement .The IP serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility .Nursing staff participate in surveillance through assessment of residents and reporting changes in condition to physicians and management staff per protocol .D. Non-licensed staff participate in surveillance through timely communication to licensed staff members regarding notable observations involving residents or staff. 1. On 12/4/24, Surveyor reviewed R18's medical record. R18 had diagnoses including cognitive communication deficit, legal blindness, vascular dementia, and anxiety. R18's Minimum Data Set (MDS) assessment, dated 9/2/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R18 had moderately impaired cognition. R18 made R18's own healthcare decisions. R18's medical record indicated R18 was tested for C. diff ova (a lab test to check for parasites or eggs in the stool) on 11/1/24. Surveyor noted the results were negative on 11/4/24 pending repeat ova testing. On 12/4/24, Surveyor reviewed the facility's infection surveillance line list for November 2024 and noted R18 was not on the list. (See interview under example 2.) 2. On 12/4/24, Surveyor reviewed R2's medical record. R2 had diagnoses including including heart failure and hypertension and was currently being treated for a UTI. R2's MDS assessment, dated 11/20/24, had a BIMS score of 10 out of 15 which indicated R2 had moderately impaired cognition. R2 had an activated decision maker. R2's medical record indicated R2 was diagnosed with a UTI and prescribed ciprofloxacin (an antibiotic) on 11/17/24. On 12/4/24, Surveyor reviewed the facility's infection surveillance line list for November 2024 and noted R2 was not on the list. On 12/4/24 at 10:43 AM, Surveyor interviewed Infection Preventionist (IP)-J who indicated the facility's policy was to investigate the infection and sensitivity when a resident was prescribed an antibiotic. When asked why R2 wasn't on the infection surveillance list, IP-J stated, I must have missed that. IP-J indicated the facility identified a significant amount of UTIs through the infection line list and were working on a plan for prevention. IP-J indicated R18 was not on the infection surveillance line list because R18 was not positive for C. diff when the test results came back. IP-J indicated if a resident is not positive for an infection, staff do not document the infection and initiate surveillance or precautions until a positive result is received. 3. On 12/2/24, Surveyor reviewed R11's medical record. R11 had diagnoses including infection and inflammatory reaction due to indwelling urethral catheter and a stage 3 pressure ulcer of the sacral region. R11's MDS assessment, dated 11/17/24, had a BIMS score of 9 out of 15 which indicated R11 had moderately impaired cognition. R11 had an activated decision maker. On 12/2/24 at 10:38 AM and on 12/3/24 at 8:05 AM, Surveyor noted there was not an EBP sign on or near R11's door or a PPE cart near R11's room. On 12/4/24 at 10:14 AM, Surveyor noted there was an EBP sign and PPE cart provided for R11. R11's medical record contained an order, dated 12/3/24 at 2:00 PM, for EBP related to wounds. On 12/4/24 at 10:16 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who was unsure why or when EBP was discontinued for R11 since R11 had wounds and a catheter and was on precautions for a long time due to methicillin-resistant Staphylococcus aureus (MRSA) infection. ADON-B indicated EBP should not have been discontinued for high-contact cares for R11 which were completed daily. ADON-D put on EBP sign on R11's door and PPE equipment in R11's room on 12/4/24. On 12/4/24 at 12:23 PM, Surveyor interviewed IP-J who was unsure why EBP was discontinued for R11. IP-J indicated EBP should have remained for R11 as R11 had chronic wounds and a catheter for an extended period of time. 4. On 12/2/24, Surveyor reviewed R80's medical record. R80 had a diagnosis of osteomyelitis of vertebra, lumbar region upon admission on 11/22/24. R80's MDS assessment, dated 11/25/24, had a BIMS score of 15 out of 15 which indicated R80 was not cognitively impaired. R80 was R80's own decision maker. R80's medical record contained orders for ceftriaxone sodium intravenous solution 2 grams once daily for antibiotic, daily and as needed wound care orders for the right foot, mid-back, and sacrum, and a PICC line dressing change every Monday night. R80's medical record did not contain an order for EBP. On 12/2/24 at 10:40 AM and on 12/3/24 at 8:19 AM, Surveyor noted there was no EBP sign on or near R80's door or PPE cart near R80's room. On 12/4/24 at 10:23 AM, Surveyor noted there was an EBP sign and PPE cart provided for R80. On 12/4/24 at 10:23 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who was unsure when EBP was initiated for R80 and had not seen EBP previously for R80. CNA-K indicated CNA-K currently used EBP during high-contact cares but did not use EBP during high-contact cares for R80 prior to 12/4/24. On 12/4/24 at 10:34 AM, Surveyor interviewed IP-J who indicated IP-J noticed R80 was not on EBP on 12/4/24 and initiated EBP for R80. IP-J confirmed R80 should have been on EBP upon admission due to R80's wounds and PICC line.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 4 of 8 employees reviewed for caregiver background checks. The facility did not complete background checks within a 4-year time frame for Certified Nursing Assistant (CNA)-L, CNA-M, CNA-N, and CNA-P. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks including re-checks, will be completed consistent with applicable state laws and regulations. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement . On 12/3/24 Surveyor requested background check and registry information for CNA-L, CNA-M, CNA-N, and CNA-P. Surveyor reviewed the background check information and noted CNA-L, CNA-M, CNA-N, and CNA-P were hired by the facility on 12/1/19. CNA-P's caregiver background check was completed on 11/10/19. CNA-L and CNA-M's caregiver background checks were completed on 11/13/19. CNA-N's caregiver background check was completed on 11/14/19. Surveyor noted CNA-L, CNA-M. CNA-N, and CNA-P's caregiver background checks were past the 4-year background check time frame. On 12/3/24 at 11:30 AM, Surveyor interviewed Business Office Manager (BOM)-O who indicated the regional recruiter was responsible for completing background checks. BOM-O indicated BOM-O would check to see if those were the most current background checks for CNA-L, CNA-M, CNA-N, and CNA-P. On 12/4/24 at 8:00 AM, Surveyor reviewed background checks for the above CNAs with an issue date of 12/3/24. On 12/4/24 at 12:00 PM, Surveyor interviewed BOM-O who confirmed background checks for CNA-L, CNA-M, CNA-N, and CNA-P were rerun on 12/3/24. BOM-O confirmed the original background checks provided to Surveyor were from 11/2019 and were out of compliance.

Based on staff, resident, and resident representative interview and record review, the facility did not ensure 1 resident (R) (R17) of 1 resident reserved the right to make choices about an aspect of their life that was significant to them. R17 was removed from the dining room table where R17 usually sat and moved to a table where staff assisted residents with eating. The facility did not consult with R17 or R17's Power of Attorney (POA) prior to the change. Findings include: The facility's Resident Rights policy, revised 7/2022, indicates: To ensure that resident rights are respected, protected, and promoted. To inform a resident of their rights and provide an environment in which they can be exercised .Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. Residents will be treated with respect and dignity and care for each resident will be given in a manner and an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality .17. The resident has the right and this facility promotes and supports the right to make choices about aspects of his/her life in the facility that are significant to the resident .26. The resident has the right to be fully informed, in advance about the care and treatment and of any changes in the care or treatment that may affect the resident's well-being . On 12/3/24, Surveyor reviewed R17's medical record. R17 had diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, transient ischemic attack (stroke), and dementia. R17's Minimum Data Set (MDS) assessment, dated 11/28/24, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R17 had severe cognitive impairment. R17 had an activated POA for healthcare decisions. R17's care plan indicated R17 was at risk for nutritional status change related to diabetes, history of stroke, mental status deficits, and history of repeated urinary tract infections (UTIs). The care plan contained an intervention to supervise/assist with eating as needed. R17's dementia care plan contained an intervention to attempt to provide consistent routines/caregivers. A progress note, dated 11/17/24, indicated R17 was moved to the feeder table after R17 asked someone to feed R17 at lunch on 11/16/24 and had trouble standing for extended periods of time in the EZ Stand (lift). On 12/2/24 at 8:20 AM, Surveyor observed R17 eating breakfast independently in the dining room without assistance. On 12/2/24 at 9:56 AM, Surveyor interviewed R17 who indicated missing the ladies that R17 sat with in the dining room. R17 indicated R17 did not like the dining room table where R17 currently sat. R17 stated those were all my ladies and we just talked all the time. R17's POA was also interviewed and indicated they were not part of the conversation and did not have the ability to advocate for R17 to stay at the table where R17 previously sat and knew the residents. R17's POA indicated R17 expressed dislike of R17's new table and indicated R17's choice of dining table and a consistent routine were not provided. On 12/2/24 at 12:02 PM, Surveyor observed R17 eating lunch independently in the dining room without assistance. On 12/3/24 at 8:07 AM, Surveyor observed R17 eating breakfast independently in the dining room without assistance. On 12/4/24 at 8:05 AM, Surveyor observed R17 eating breakfast independently in the dining room without assistance. On 12/4/24 at 9:31 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A expects residents and POAs to be involved in the discussion of a table move and why a move is necessary. NHA-A was unsure if R17 or R17's POA were included in a discussion regarding the move. When Surveyor indicated the move occurred on 11/17/24, NHA-A reviewed the progress note that indicated R17 moved to the feeder table after R17 asked staff to feed R17 at lunch and had trouble standing for extended periods in the EZ Stand. NHA-A indicated a one time request for assistance did not constitute a move to another table. NHA-A indicated NHA-A was confused on how that was missed in stand-up meeting and indicated feeder table was not appropriate language. On 12/4/24 at 10:27 AM, Surveyor interviewed DON-B who indicated R17 began to roll back from the table when food was placed in front of R17 and R17's meal consumption was approximately 50% at the time of the move. DON-B indicated R17 was moved to the feeder table to receive more assistance. DON-B indicated R17 had increased food consumption since being moved to the feeder table and socialized at the table with residents and staff. DON-B confirmed a resident should be consulted prior to a table move but indicated DON-B did not always consult POAs. DON-B was unsure if there was a discussion with R17 and R17's POA regarding the need to move R17 to a different table. DON-B verified if a resident or POA declined a table move, a resident who required more assistance could remain at their present table and staff could sit with the resident at their table of choice.

Based on staff interview and record review, the facility did not ensure the medical record for 1 resident (R) (11) of 13 sampled residents contained a signed advance directive. R11 was admitted to the facility on [DATE]. R11's medical record contained a signed statement of incapacity (SOI). R11's medical record did not contain a signed advance directive. Findings include: The facility's admission agreement indicates: .E. Provision of Advanced Directive and Legal Representative Designation. You are asked to participate in advance care planning discussions, including providing a complete and current copy of any advance directive or any other written statement of your desires regarding treatment options or designation of health care agent or other person with any authority to make healthcare decisions on your behalf, and any document authorizing an attorney in fact, health care agent, or guardian to act on your behalf . From 12/2/24 to 12/4/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, and congestive heart failure. R11's Minimum Data Set (MDS) assessment, dated 3/19/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R11 had intact cognition. R11 had an activated Power of Attorney for Healthcare (POAHC). R11's medical record contained a scanned unsigned POAHC document dated 11/15/24 and an SOI that was signed on 5/16/24. On 12/3/24 at 3:00 PM, Surveyor interviewed Director of Nursing (DON)-B regarding why R11's paperwork was not signed by R11's spouse who was R11's named POAHC. DON-B was not aware that the paperwork was not signed and indicated DON-B would have Social Services Director (SSD)-C speak to Surveyor. On 12/4/24 at 11:11 AM, Surveyor interviewed SSD-C who verified R11's paperwork was not signed and was unsure why. SSD-C indicated the facility should have obtained R11's POAHC's signature when R11 was admitted to the facility.

Based on staff and resident representative interview and record review, the facility did not notify a Physician, Guardian and/or Power of Attorney for Healthcare (POAHC) of changes in condition for 2 residents (R) (R3 and R4) of 13 sampled residents. R3 did not received prescribed Depakote for seizures on 11/13/24, 11/17/24, 11/25/24 and 11/26/24. R3 had seizures on 8/30/24 and 11/26/24. R3's Physician and Guardian were not notified of R3's change in condition. R4's Physician and POAHC were not notified when the facility was not able to provide R4 with prescribed seizure medication. Findings include: The facility's Change in Condition of the Resident policy, revised 9/20/22, indicates: A facility should immediately inform the resident, consult with the resident's Physician, and notify consistent with his or her authority, the resident representatives when there is an accident which results in injury, and has the potential for requiring Physician intervention, a significant change in the resident's physical, mental or psychosocial status, or a need to alter treatment significantly .Documentation needs to include, but is not limited to the following: Description of the change in condition noted and assessment or observation of findings .Notification of provider .Notification of responsible party . The facility's Medication Administration: General Guidelines policy, dated 1/24, indicates at Section 7.1-2: If two consecutive doses of a vital medication are withheld or refused, the Physician is notified. 1. On 12/4/24, Surveyor reviewed R3's medical record. R3 had diagnoses including dementia with behaviors, seizures, and anxiety. R3's Minimum Data Set (MDS) assessment, dated 11/26/24, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R3 had severely impaired cognition. R3 had a court-appointed Guardian for healthcare decisions. R3 had orders for 750 milligrams (mg) of Depakote in the AM and 1000 mg of Depakote at bedtime (HS) for seizures. A progress note, dated 9/1/24 at 12:02 AM, indicated R3 was on follow-up for what could have been a seizure on the 8/30/24 AM shift. R3's medical record did not indicate R3's Physician or guardian were notified. A progress note, dated 9/20/24 at 2:36 PM, indicated the facility was out of Depakote 500 mg. The pharmacy indicated they sent a 30-day supply on 9/6/24 and were unable to send more at that time. R3's medical record did not indicate R3's Physician or Guardian were notified. A progress note, dated 10/11/24 at 9:45 AM, indicated R3 was out of Depakote 500 mg. The computer indicated refills were received on 10/9/24 but were no cards. The pharmacy indicated they would send the medication that night. R3's medical record did not indicate R3's Physician or Guardian were notified. A progress note, dated 10/14/24 at 9:15 AM, indicated the facility was out of R3's Depakote 250 mg and a dose was taken from contingency. The pharmacy said 15 tablets were sent on 10/9/24 but the card was gone. R3's medical record did not indicate R3's Physician or Guardian were notified. A progress note, dated 11/12/24 at 9:16 AM, indicated the facility was out of R3's Depakote 500 mg which was on order since 11/11/24 and was not sent by the pharmacy. The pharmacy said a 15-day supply was sent on 11/4/24 and they could not send a refill until 11/16/24. R3's medical record did not indicate R3's Physician or Guardian were notified. A progress note, dated 11/17/24 at 8:53 AM, indicated the facility was out of R3's Depakote 250 mg and did not have any in contingency. R3's medical record did not indicate R3's Physician or Guardian were notified. R3's November 2024 Medication Administration Record (MAR) indicated R3 did not received Depakote on 11/13/24, 11/17/24, and 11/25/24. R3's medical record did not indicate R3's Physician or Guardian were notified. R3's medical record indicated R3's Physician was notified of a seizure and missing medication on 11/26/24, however, R3's Guardian was not notified. On 12/4/24 at 1:03 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B could not find Physician or Guardian notification for R3's missing Depakote doses or seizures. DON-B indicated when a medication is not available and not administered, DON-B expects staff to notify the resident's Physician and representative. 43361 2. From 12/2/24 to 12/4/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including dementia and epilepsy. R4's MDS assessment, dated 9/16/24, had a BIMS score of 14 out of 15 which indicated R4 was not cognitively impaired. R4 had an activated POAHC (POAHC-F). R4 was prescribed the following medications: ~ One 10 mg tablet of clobazam (Onfi) by mouth two times a day for seizures ~ One 12 mg tablet of Fycompa given by mouth one time a day for seizures Surveyor noted R4 did not receive clobazam between 6/11/24 and 7/2/24 because the pharmacy did not have a prescription to fill. R4's medical record indicated staff attempted to call R4's Neurologist on several occasions to get a prescription with no response. On 6/13/24, staff notified R4's Physician that R4 had seizure activity on 6/13/24 (after missing 4 doses of the medication). The Physician asked if R4 was provided all of R4's epilepsy medications. Staff handwrote on a note that the pharmacy did not have a prescription and listed several dates where they attempted to contact R4's Neurologist for a prescription. R4's medical record indicated Fycompa was not provided from 7/2/24 through 7/10/24, 9/20/24 through 10/1/24, 10/21/24 through 10/29/24, 11/13/24 through 11/21/24, and 11/29/24 through 12/2/24. R4's medical record indicated R4's Physician was only notified after the two missed doses on 9/21/24. R4's medical record indicated POAHC-F was only notified on 12/2/24. On 12/3/24 at 1:03 PM, Surveyor interviewed DON-B who verified staff should notify R4's Physician and POAHC-F when medications are missed. Surveyor requested Physician and POAHC notification for the other times the facility did not have R4's prescribed medication but the information was not provided. DON-B indicated the facility began staff education on 12/2/24 to be sure to notify the Physician and POA for any missed doses of medication. On 12/4/24 at 10:37 AM, Surveyor interviewed POAHC-F who indicated the facility called POAHC-F that week because R4 had missed doses of Fycompa. POAHC-F could not recall any other time staff called POAHC-F regarding R4 missing medications.

Based on staff interview and record review, the facility did not ensure 3 residents (R) (R231, R81, and R26) of 4 sampled residents received a timely copy of a Notice of Medicare Non-Coverage (NOMNC) form when their Medicare services ended. The facility did not provide a NOMNC form (used to inform Medicare beneficiaries when their covered services are ending and their appeal rights) to R231, R81, and R26 at least two calendar days before their Medicare services ended. Findings include: The Centers for Medicare and Medicaid Services (CMS) form CMS-10123 indicates a NOMNC form must be delivered at least two calendar days before Medicare-covered services end or the second-to-last-day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48-hour requirement .The provider must ensure the beneficiary or representative signs and dates the NOMNC form to demonstrate the beneficiary or representative received the notice and understands the termination decision can be disputed. On 12/4/24, Surveyor reviewed a NOMNC form for R231 that indicated R231's Medicare services ended on 7/7/24. Surveyor noted R231's Power of Attorney for Health Care (POAHC) signed the form on 7/8/24. On 12/4/24, Surveyor reviewed a NOMNC form for R81 that indicated R81's Medicare services ended on 11/28/24. Surveyor noted R81 signed the form on 11/27/24. On 12/4/24, Surveyor reviewed a NOMNC form for R26 that indicated R26's Medicare services ended on 11/27/24. Surveyor noted R26 signed the form on 11/26/24. On 12/4/24 at 10:54 AM, Surveyor interviewed Social Services Director (SSD)-C who confirmed residents should be notified and NOMNC forms should be signed two days prior to the end of their Medicare services.

Based on record review, staff and visitor interviews, the facility did not ensure that 1 (resident #1) of 7 sampled residents were free from abuse. Resident #2 had a history of [REDACTED]. The facility implemented interventions to prevent further inappropriate sexual behavior towards other female residents, but staff did not follow the interventions. On 11/12/15, resident #2 was observed by a visitor to walk up to resident #1 and grab resident #1's breast. Resident #2 immediately turned and walked away after grabbing resident #1's breast. Findings include: On 11/16/15, surveyor # reviewed resident #2's medical record. According to the face sheet, with a print date of 11/16/15, resident #2 was diagnosed on [DATE] with Dementia without behavioral disturbance. Surveyor # reviewed the facility's investigation regarding an inappropriate sexual behavior incident that occurred on 09/08/15. The completed investigation indicated resident #2 was witnessed rubbing resident #3's leg in an inappropriate manner. A witness statement was located in the investigation that indicated AA (Activity Aide)-A brought resident #2 to an activity and then a visitor approached AA-A and stated the visitor had observed resident #2 touching resident #3's leg down to the pelvic area. AA-A indicated in the written witness statement that the visitor stated she observed resident #2 touching the pelvic area of resident #3 and then touched himself in the the genital region. AA-A separated the residents after the reported incident. The progress notes of resident #2 documented on 09/08/15 at 2:30 PM, that staff reported visitors witnessed resident #2 touching a female resident on the leg with his hand in an inappropriate manner. When resident #2 was approached regarding his actions, resident #2 yelled at the SW (Social Worker) and demanded the SW get out of his room. Resident #2 was separated from all other residents Immediate intervention is 1 on 1 supervision while the resident is outside of his room. Resident #2's medical record included an entry regarding the incident dated 09/08/15, but did not contain any specific information that would indicate touching of a sexual nature (refers to touching on the leg). The facility had a plan of care, with a revision date of 05/19/15, for At times resident may have behaviors of swearing and also exhibit inappropriate sexualized talk to staff and an intervention of 1:1 supervision outside of room was initiated on 09/08/15. This intervention was discontinued on 11/11/15 and a motion sensor was placed in the resident's door way on 09/10/15. Although the plan of care did not indicate the facility placed resident #2 on 15 minute checks, there was documentation located in the medical record that 15 minute checks were implemented after 1:1 monitoring was discontinued on 11/11/15. The plan of care indicated resident #2's targeted behaviors were swearing and inappropriate sexualized talk towards staff. The facility sent another self-report to the state agency on 11/12/15, that indicated resident #2 was observed by a visitor to grab resident #1's breast. The visitor reported the incident to CNA (Certified Nursing Assistant)-B. The medical record of resident #2 indicated on 11/12/15 at 11:48 a.m., a visitor reported to staff that the resident inappropriately touched a female resident. Resident #2's medical record did not include any specific documentation regarding the incident beyond the report of inappropriate touching. On 11/16/15 at 8:30 a.m., surveyor # interviewed CNA-C regarding resident #2. CNA-C stated resident #2 had a previous incident of touching a female resident inappropriately (the incident 09/08/15). Resident #2 was placed on 1:1 supervision and motion sensors were placed outside resident #2's door after the 09/08/15 incident. CNA-C stated after a while, the 1:1 supervision was discontinued but the motion sensors continued at night, as there are only two staff in the facility on night shift. CNA-C indicated she could not recall when the 1:1 supervision had discontinued, but it had been a while. On 11/16/15 at 8:50 a.m., surveyor # interviewed CNA-D regarding resident #2. CNA-D verified resident #2 had a previous incident of inappropriate sexual touching with a female resident a few months prior. CNA-D indicated she thought resident #2 touched a female resident on the breast or maybe the crotch, but she couldn't recall specifics. CNA-D stated resident #2 was placed on 1:1 supervision for a while and motion sensors were placed in the doorway of the hall and the bathroom. CNA-D indicated the 1:1 supervision was only for a while and then was stopped, but the motion sensors continued. Surveyor # asked if resident #2 was supervised when out of his room, and CNA-D stated staff were told to keep an eye on the resident when out of his room. CNA-D indicated resident #2 likes to sit in the recliner in the lounge area. Surveyor # asked if it was always possible to supervise resident #2 when out of the room and CNA-D responded no, there are call lights to be answered and other residents need assistance. CNA-D indicated the most recent incident she was familiar with was that a visitor reported resident #2 had touched resident #1 in the breast or crotch, wasn't sure, but the incident was something sexual. CNA-D indicated resident #2 is currently on 1:1 supervision again. On 11/16/15 at 9:00 a.m., surveyor # interviewed CNA-E regarding resident #2 regarding resident #2. CNA-E stated on 09/08/15, it was reported by a visitor that resident #2 had touched resident #3 in the crotch over her clothing. CNA-E stated motion sensors were placed in his room and staff were directed to keep an eye on resident #2 when out of his room and not to place resident #2 next to female residents. CNA-E indicated staff would check resident #2's whereabouts in between caring for other residents. CNA-E stated resident #2 was not directed to have someone supervising him at all times. CNA-E indicated recently a visitor reported resident #2 was masturbating (she didn't believe that allegation) and wasn't sure if resident #2 was saying something sexual to resident #1, but was placed on 1:1 supervision when out of his room after a recent incident with resident #1. On 11/16/15 at 9:20 a.m., surveyor # interviewed INHA (Interim Nursing Home Administrator)-F regarding resident #2. INHA-F stated on 11/12/15, visitor-G reported to CNA-B that resident #2 grabbed resident #1's breast and that resident #2 was masturbating. INHA-F stated CNA-B separated the residents and reported the incident to a supervising nurse and then was reported to the INHA. INHA-F indicated staff questioned if resident #2 was really masturbating, but the resident does move his private parts around. Surveyor # asked INHA-F specific details of the incident and INHA-F stated she believed resident #2 did not have his genitals exposed, but indicated she really did not know. INHA-F stated resident #2 is on 1:1 supervision when out of his room. INHA-F indicated resident #2 had an incident with another female resident on 09/08/15, but wasn't aware of any specifics surrounding the incident. INHA-F stated according to the report, motion sensors were placed to notify staff when the resident left his room, but wasn't aware if any specific staff were to supervise resident #2. INHA-F stated there was a day last week that the motion sensors were discontinued as resident #2 did not have any further sexual behaviors. INHA-F stated visitor-G reported that resident #2 walked towards resident #1 on 11/12/15. INHA-F indicated resident #2 ambulates independently in the facility. INHA-F stated the SW would interview other residents to ensure other residents hadn't witnessed any inappropriate sexual behavior from resident #2. On 11/16/15 at 9:40 a.m., surveyor # interviewed visitor-G regarding the incident that occurred on 11/12/15. Visitor-G verified she witnessed the event on 11/12/15. Visitor-G stated she was sitting at the round table in the lounge, and resident #1 was also seated in her w/c (wheelchair) and was sitting across the table from her. Visitor-G indicated resident #2 was seated in a recliner (was approximately 6 feet from the round table), and appeared to be masturbating over his clothing. Visitor-G stated when she looked at resident #2 he would say, Do you want some sugar? Visitor-G indicated she tried to ignore resident #2. Visitor-G indicated she wasn't sure if resident #2's hand was cupped around his penis or if he was just patting himself. Visitor-G reported that resident #2 stood from the recliner with the assistance of a wheeled walker and walked up to resident #1, grabbed her left breast with his right hand and then turned and walked away. Visitor-G stated she stood and went to find a staff person as there wasn't any staff in sight. Visitor-G indicated she located CNA-B in a resident's room and told her of the incident. Visitor-G indicated CNA-B joined resident #2 in the hall and walked with the resident down the hall. Visitor-G stated she didn't know what to do when she observed resident #2 grab resident #1 in the breast. Visitor-G stated if resident #2 grabbed her she would have reacted differently. Visitor-G indicated later that day she received a phone call from INHA-F asking to write a statement. Visitor-G stated no staff from the facility had ever asked her the specifics to what she had witnessed. Visitor-G indicated she wrote a statement and dropped the statement at the facility the next day. Visitor-G stated she is at the facility every day from 8:00 a.m. to 12:00 p.m., and she observes staff in and out of resident rooms, and resident #2 is frequently in the lounge area unsupervised. On 11/16/15 at 10:30 a.m., surveyor # interviewed DON (Director of Nursing)-H regarding resident #2. DON-H stated there was suppose to be 1:1 supervision for resident #2 when his is out of his room after the incident on 09/08/15. On 11/11/5, the medical record of resident #2 was reviewed and it appeared there hadn't been any further inappropriate sexual behavior towards other residents, so the 1:1 supervision was discontinued and resident #2 was placed on 15 minute checks. Surveyor # and DON-H reviewed resident #2's plan of care. DON-H verified the plan of care does not identify inappropriate sexual touching towards other residents, but only addressed sexually inappropriate verbal statements towards staff. DON-H stated SW-I updates the plan of care for any behaviors of residents. On 11/16/15 at 10:35 a.m., surveyor # conducted a telephone interview with AA-A regarding resident #2. AA-A stated a family member of resident #3 reported to her on 09/08/15, that she had observed resident #2 rubbing resident #3's pelvic area with his hand. AA-A indicated as the family member was telling her of the observation, she also observed resident #2 rubbing resident #3's pelvic area. AA-A stated resident #2 was seated in the recliner in the lounge and resident #3 was seated in her w/c right next to the recliner. AA-A indicated she observed resident #2 leaning over the arm of the recliner and touching/rubbing over resident #3's vaginal area over her clothing. AA-A indicated she removed resident #3 from the area and reported the observation to SW-I. Surveyor # asked AA-A if she had told SW-I that she had observed resident #2 rubbing resident #3's vaginal area. AA-A stated she thought she had, as she talked with her hands so she assumed she also demonstrated the observation. Surveyor # asked AA-A if any staff from the facility asked her the specifics of the observation and AA-A replied no. On 11/16/15 at 12:08 p.m., surveyor # interviewed SW-I regarding resident #2. SW-I stated the INHA would complete any correlating interviews regarding the investigation. SW-I stated social services and nursing complete the behavior care plans. SW-I and surveyor # reviewed resident #2's plan of care for behaviors. SW-I verified the targeted behaviors that staff are monitoring are swearing and inappropriate sexualized talk towards staff. SW-I indicated the care plan had not been updated to reflect resident #2's sexual behavior towards female residents. SW-I indicated staff would not know what type of behaviors resident #2 was displaying towards other residents by reading the plan of care. SW-I stated she recalled AA-A telling her that a visitor had reported resident #2 was rubbing resident #3's pelvic area and the SW had assumed the pelvic area meant over the vaginal area. SW-I stated she did not ask any specific question of AA-A regarding the incident. SW-I indicated when CNA-B told her a visitor reported that resident #2 grabbed resident #1's breast, she did not ask any questions regarding the specific events of the incident. SW-I stated she only asked if resident #1 was ok and the CNA stated yes. SW-I indicated she observed resident #1 and #2 during lunch and both residents appeared fine. Surveyor # asked if SW-I had interviewed either residents immediately after the incident was reported and SW-I stated no as the residents were going to lunch. SW-I stated resident #1 would have probably recalled the event if she would have interviewed resident #1 immediately after the incident. SW-I indicated she interviewed resident #1 after lunch and she thought resident #1 would have remembered the incident as it had been a tragic event, but resident #1 did not recall the sexual contact by resident #2.

Based on record review, family, and staff interviews, the facility did not implement their policies and procedures to minimize the risk of residents acquiring, transmitting, or experiencing complications from Pneumococcal pneumonia. The facility did not ensure residents' who had not been vaccinated for pneumonia were given the opportunity to be vaccinated. The facility had not implemented its policies and procedures in relation to identifying residents who had not been vaccinated for pneumonia and offering residents' the opportunity to be vaccinated. On 3/5/14, the survey team was provided with a list of all 42 current residents residing in the facility and their [MEDICATION NAME] immunization status. It was noted that 34 of these residents' [MEDICATION NAME] immunizations were received outside of the facility. It was noted that the facility failed to identify the remaining 8 residents who were eligible to receive the Pneumococcal vaccine and not been given the opportunity to receive or decline the vaccine. Residents #12's and #13's medical record did not include documentation regarding their Pneumococcal vaccine status. Residents #5's, #11's #14's, and #15's medical records indicated the [MEDICATION NAME] was not administered because there was "no record per WIR (Wisconsin Immunization Registry) and/or review of medical records." Resident #15 had a physician order [REDACTED]. The resident's medical record did not include documentation that the [MEDICATION NAME] vaccine was offered, declined, or given. Resident #16 received a dose of Pneumococcal vaccine on 3/11/2003. The facility did not offer resident #16 the opportunity to receive a second dose of the vaccine. Resident #17 refused the Pneumococcal vaccination in 2012. The resident's medical record did not include documentation that the [MEDICATION NAME] vaccine was re-offered declined, or given again in 2013. The facility's failure to implement their policies and procedures of an effective immunization program led to the finding of Immediate jeopardy beginning 1/7/14. The facility was informed of the immediate jeopardy on 3/6/14 and submitted a removal plan that was accepted on 3/6/14. The Immediate Jeopardy was removed on 3/19/14 when the facility completed staff education of appropriate policies and procedures and implemented monitoring. This is evidenced by: According to CMS (Centers for Medicare and Medicaid) State Operations Manual at F (federal) tag 334, the intent of this regulatory requirement is assuring the receipt of vaccinations is essential to the health and well being of long-term care residents. Establishing an immunization program facilitates the achievement of this objective....Pneumococcal pneumonia, a type of bacterial pneumonia, is a common cause of hospitalization and death in older people. People [AGE] years or older, are two to three times more likely than the younger population to get Pneumococcal infections. According to the CDC (Centers for Disease Control and Prevention), Vaccine Information Statement dated 10/6/09, "Pneumococcal disease is caused by Streptococcus pneumoniae bacteria. It is a leading cause of vaccine-preventable illness and death in the United States. Pneumococcal pneumonia kills about 1 out of 20 people who get it...All adults [AGE] years of age and older should get Pneumococcal [MEDICATION NAME] vaccine... A second dose is recommended for people [AGE] years and older who got their first dose when they were younger than 65 and it has been 5 or more years since the first dose." According to the CDC Recommendations and Reports MMWR (Morbidity and Mortality Weekly Report), Prevention of Pneumococcal Disease, dated April 4, 1997 indicated, "Mortality: Pneumococcal infection causes an estimated 40,000 deaths annually in the United States accounting for more deaths than any other vaccine-preventable bacterial disease. Approximately half of these deaths potentially could be prevented through the use of vaccine. Case-fatality rates are highest for meningitis and bacteremia, and the highest mortality occurs among the elderly and patients who have underlying medical conditions...Persons with Uncertain Vaccination Status: To help avoid the administration of unnecessary doses, every patient should be given a record of the vaccination. However, providers should not withhold vaccination in the absence of an immunization record or complete medical record. The patient's verbal history should be used to determine prior vaccination status. When indicated, vaccine should be administered to patients who are uncertain about their vaccination history...Persons Aged Greater then or equal to [AGE] years: All persons in this category should receive the Pneumococcal vaccine, including previously unvaccinated persons and persons who have not received vaccine within 5 years (and were <[AGE] years of age at the time of vaccination). All persons who have unknown vaccination status should receive one dose of vaccine... Revaccination: Persons aged greater then or equal to [AGE] years should be administered a second dose of vaccine if they received the vaccine greater then or equal to 5 years previously and were aged less then [AGE] years at the time of primary vaccination. Elderly persons with unknown vaccination status should be administered one dose of vaccine..." The facility's policy and procedure titled," [MEDICATION NAME]" states upon admission verification that the medication has been given is obtained from: A. Resident B. Family C. Resident's Family Physician. The procedure included: (3.1) If the resident has never had the [MEDICATION NAME], the RN (Registered Nurse) will obtain an order for [REDACTED].*Contraindications: A. Allergy to eggs. B. Elevated temperature and acute illness. C. [MEDICAL CONDITION](human immunodeficiency virus) positive-will require a specific physician's orders [REDACTED]. (3.2) The [MEDICATION NAME] vaccine will be offered annually to the resident who did not receive the vaccine due to refusal or Medical contraindications depending on the resident's physician preference. (3.3) A second dose will be offered per CDC's recommendations per VIS (Vaccine Information Statements) and resident's physician preference. (3.4) Annual review to assure compliance. (4.1) Documentation is to be maintained in the medical record. On 3/5/14 at 10:00 a.m., surveyor # conducted the infection control task with DON (Director of Nursing)-C. Surveyor # interviewed DON-C regarding the facility's immunization program for vaccinating residents. DON-C stated she was designated as the facility's ICP (Infection Control Preventionist). In addition, DON-C stated she is responsible for all the resident's influenza vaccines and she tracks and monitors all of the residents for the influenza vaccines. DON-C indicated at the beginning of the flu season she provides information and consent forms to the residents and then takes a resident rooster and administers the influenza vaccines. DON-C indicated that all influenza vaccines are completed within a few days. DON-C stated if a resident refuses the influenza vaccine, she will again re-offer it throughout the year. DON-C verified she monitors newly admitted residents for their influenza vaccine status. Surveyor # then interviewed DON-C regarding how the [MEDICATION NAME] vaccines were monitored, DON-C stated, "the MDS (minimum data set) coordinator is responsible for tracking and monitoring all residents' [MEDICATION NAME] vaccinations." On 3/5/14 at 10:20 a.m., surveyor # interviewed MDS Coordinator-E regarding monitoring and reviewing resident's [MEDICATION NAME] vaccines. MDS coordinator-E stated "I only monitor and follow-up with the influenza vaccines and the two-step TB skin test...I don't know if the facility has a system in place to monitor and follow-up with the [MEDICATION NAME]." Surveyor then asked how MDS-Coordinator-E was made aware a resident's immunization status and how she enters this information on to the MDS assessment. MDS Coordinator-E stated when completing the MDS, she will look at the immunization status in the medical record, look information up on the WIR website or contact previous doctor's offices for the required information. MDS Coordinator-E stated "if no information is found, I will mark the section as "not offered" on the resident's MDS. I do not pursue it any further." Surveyor # requested and was provided the list of all 42 active in-house resident's [MEDICATION NAME] immunization status. The information indicated that 34 of the facility's in-house residents received their [MEDICATION NAME] immunizations outside of the facility. In addition, the remaining 8 in-house residents, who were eligible to receive the [MEDICATION NAME] vaccine had not been given the opportunity to receive or decline the vaccine as evidenced by the following: 1. Resident #12's face sheet dated 12/9/13, indicated the resident was admitted to the facility on [DATE] and the resident was [AGE] years of age. Review of the [MEDICATION NAME] immunization status list for resident #12 was blank. The resident's most recent MDS assessment dated [DATE], indicated the Pneumococcal vaccine was offered and decline. The resident's medical record did not include documentation that the [MEDICATION NAME] vaccine was offered and declined and did not include a [MEDICATION NAME] vaccine consent form. 2. Resident #13's face sheet dated 11/11/13, indicated the resident was admitted to the facility on [DATE] and the resident was [AGE] years of age. Review of the [MEDICATION NAME] immunization status list for resident #13 was blank. The resident's most recent MDS assessment dated [DATE] indicated the Pneumococcal vaccine was not up to date, and that the vaccine was not offered. The resident's medical record did not include documentation that the [MEDICATION NAME] vaccine was not up to date and that the vaccine was not offered and did not include a [MEDICATION NAME] vaccine consent form. 3. Resident #15's face sheet dated 3/3/14, indicated the resident was admitted to the facility on [DATE] and the resident was [AGE] years of age. Review of the [MEDICATION NAME] immunization status list for resident #15 indicated, "no record of per WIR...resident has not seen a doctor for decades per admission paperwork." The resident's most recent MDS assessment dated [DATE] indicated the Pneumococcal vaccine was not up to date and that the vaccine was not offered. Resident #15's medical record included a physician's orders [REDACTED]." Documentation that the influenza vaccine had been given was located in the resident's medical record. The resident's medical record did not include documentation that the [MEDICATION NAME] vaccine was offered. On 3/6/14 at 8:30 a.m., surveyor # interviewed MDS coordinator-E regarding the above order. MDS Coordinator-E stated "Resident #15 received the influenza vaccine. I don't know why (resident #15) didn't receive the [MEDICATION NAME] order was not followed through." 4. Resident #5's face sheet dated 10/4/13, indicated the resident was re-admitted to the facility on [DATE] and the resident was [AGE] years of age. Review of the [MEDICATION NAME] immunization status list for resident #5, indicated, "no record of pneumo per WIR or per Affinity Central medical records." The resident's most recent MDS assessment dated [DATE] indicated that the Pneumococcal vaccine was not up to date and that the vaccine was not offered. Surveyor # interviewed resident #5's APOA (Activated Power of Attorney)-G via the phone on 3/4/14 at 3:00 p.m. APOA-G indicated resident #5 did not have the Pneumococcal vaccine and the facility did not provide any type of consent or information regarding the vaccine. APOA-G stated "I have received an influenza vaccine consent in the mail." 5. Resident #14's face sheet dated 12/26/13, indicated the resident was admitted to the facility on [DATE] and resident was [AGE] years of age. Review of the [MEDICATION NAME] immunization status list for resident #14, indicated, "no record per WIR and Affinity medical records". The resident's most recent MDS assessment dated [DATE] indicated the Pneumococcal vaccine was not up to date, and that the vaccine was not offered. 6. Resident #11's face sheet dated 7/22/13, indicated the resident was re-admitted to the facility on [DATE] and the resident was [AGE] years of age. Review of the [MEDICATION NAME] immunization status list for resident #11, indicated, "no record per WIR and medical records at the doctor's office". The resident's most recent MDS assessment dated [DATE] indicated the Pneumococcal vaccine was up to date. 7. Resident #16's face sheet dated 1/27/2014 indicated, the resident was admitted to the facility on [DATE] and the resident was [AGE] years of age. Review of the [MEDICATION NAME] immunization status list for resident #16, indicated he received a dose on 3/11/2003, when the resident was [AGE] years of age. The resident's medical record did not include documentation that facility staff offered the second dose of the [MEDICATION NAME] vaccine. 8. Resident #17's face sheet dated 3/3/2014 indicated the resident was re-admitted to the facility on [DATE] and the resident was [AGE] years of age. Review of the [MEDICATION NAME] immunization status list for resident #17, indicated he had refused the [MEDICATION NAME] in 2012. The resident's medical record did not include documentation that the facility staff re-offered the [MEDICATION NAME] vaccine again in 2013. On 3/5/14 at 3:15 p.m., surveyor # interviewed DON-C. DON-C verified that the facility follows the CDC's current standards of practice for the Pneumococcal vaccine. DON-C informed the surveyor that the monitoring of all vaccinations should be the role of the infection control preventionist. DON-C stated "I assumed MDS Coordinator-E was taking care of it because she has to enter all the resident's data onto the MDS." The surveyor then questioned DON-C if the Quality Assessment and Assurance Committee have ever discussed the Pneumococcal immunizations rates. DON-C stated "We talk about the influenza vaccine rates, but we don't talk about the Pneumococcal vaccine rates...because we don't have them." During daily exit with the facility staff on 3/5/14 at 3:30 p.m., NHA (Nursing Home Administrator)-B stated "You have opened our eyes to this issue." NHA-B stated all residents who have not had the Pneumococcal vaccine will be asked, or their responsible party will be called to request consent for refusal or approval of the vaccine. On 3/6/14 at 8:00 a.m., surveyor # spoke with MDS coordinator-E. MDS coordinator-E stated "DON-E and myself review and take care of all the admitting paper work for new admissions. It is not the responsibility of the floor nurses to monitor the Pneumococcal vaccines, unless the nurse is given an order to give it." On 3/6/14 at 8:30 a.m., surveyor # interviewed RN-D regarding Pneumococcal vaccines for residents in the facility. RN-D stated "DON-C takes care of it. She (DON-C) has all the consents in her office. She also takes care of all the admission orders [REDACTED] On 3/6/14 at 1:30 p.m., surveyor # interviewed LPN (Licensed Practical Nurse)-A regarding Pneumococcal vaccines for residents in the facility. LPN-A stated "I'm not in charge of monitoring the vaccines. If there was an order for [REDACTED]. The failure to have a system in place for ensuring that residents were offered the opportunity to be vaccinated against pneumonia, created a finding of immediate jeopardy, given the morbidity rates for the elderly who develop pneumonia. This was removed when the facility completed the following: 1. All residents identified as not having documentation of denial or have been offered the [MEDICATION NAME] vaccine have been identified and appropriate steps to ensure compliance implemented. 2. All new admissions will be offered [MEDICATION NAME] vaccine within 5 days but not to exceed 2 weeks. 3. Infection control Nurse, MDS (minimum data set) Nurse and Administrator will be re-educated on 3/6/14 on policy [MEDICATION NAME]. All Nursing staff will be re-educated to policy and procedure [MEDICATION NAME] by Director of Nursing by end of 3/6/14. 4. Infection Control Nurse will monitor and track the [MEDICATION NAME] policy for compliance with administration and documentation of declinations.

Based on record review and staff and family interviews, the facility did not ensure sufficient fluid intake to prevent dehydration for 1 out of 7 residents sampled resulting in hospitalization with acute dehydration and [MEDICAL CONDITION]. Resident #1 was admitted to the facility at risk for dehydration related to a [DIAGNOSES REDACTED]. The facility identified a significant weight loss, and the physician added an antidepressant which placed resident #1 at a higher risk for dehydration. Resident #1 also had episodes of vomiting and diarrhea which again increased the risk for dehydration. There was no evidence that the facility identified these risks and/or developed a plan of care to address resident #1's needs. In addition, the Registered Dietitian's assessments contained assumed rather than actual amounts consumed. Resident #1 was hsopitalized for acute [MEDICAL CONDITION] and dehydration and required IV fluids. Findings include: The facility's policy of Hydration Assessments dated 7/1/02 indicated they were to: 1. Identify residents at risk for dehydration and assess for signs and symptoms of dehydration. 2. Complete a monthly assessment on all resident not exhibiting symptoms. Complete Symptom Pursuit if acute clinical symptoms of dehydration present or weekly if any of the following listed below: a) Suspicion of increased output and/or decreased intake. The facility's policy on Intake and Output Monitoring dated 11/1/08 indicated to track and assess all oral fluid intake and fluid losses from urine and emesis for residents with a physician's orders [REDACTED]. The facility had not approached resident #1's physician for an order for [REDACTED]. Resident #1's face sheet dated 1/27/12 indicated that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was his own person and able to make his needs known despite periodic confusion. Resident #1's MDS (minimum data set) dated 1/19/12 indicated he was able to eat and drink with minimal assistance (set up). It indicated he had a history of [REDACTED]. Resident #1's weight on this assessment was 134 pounds and he was on a mechanical soft diet with thin liquids. physician's orders [REDACTED]. Resident #1's care plan on dated 1/11/12 indicated he was able to feed self. The care plan did not address hydration. A dietary note and assessment dated [DATE] indicated resident #1's daily caloric requirement was 1455 with total daily fluid requirements of 1830 cc's (cubic centimeters). The assessment further indicated a monthly hydration assessment was to be done and he had not been eating well. On 1/25/12 the facility identified that resident #1 was losing weight due to his poor appetite and had a 9.7 pound weight loss in the past 7 days. His care plan was revised to start on med pass 4 oz. (ounces) twice daily and add a serving of ice cream three times a day. The facility also talked with the family to change his diet soda, which they provided him, to regular soda to provide more calories. Although the facility made changes to resident #1's care plan to address his weight loss, they did not assess is fluid intakes or develop a care plan to closely monitor fluid intakes despite being at a higher risk of dehydration due to a decline in his meal intake. Review of the facility's records finds that intake documentation is vague indicating intakes of less than 75% or less than 240 cc's intake but no specifics for these possible wide ranging amounts. On 1/31/12 the facility had a care plan conference for resident #1 with his family. Resident #1's poor meal intake and weight loss was discussed but no further changes were made to his care plan to address adequate hydration. On 2/1/12 resident #1 was seen by his physician who noted he agreed to change his diet to general. He addressed on-going problems with anticoagulation and depression. On 2/3/12, the physician ordered [MEDICATION NAME] 50 mg (milligrams) for treatment of [REDACTED]. According to www.drugs.com, side effects of [MEDICATION NAME] include diarrhea, increased sweating, loss of appetite, nausea, stomach upset, vomiting, and weight loss. Even though this placed resident #1 at an increased risk for dehydration, the facility did not identify the risk and did not develop a plan to meet resident #1's needs. On 2/3/12 a dietary note indicated resident #1 had a significant weight loss of 7% in the past 30 days and was refusing to eat most meals. They indicated he had his diet upgraded to a general diet following a review by speech therapy and his request but this had not improved his appetite. The note indicated resident #1 was only taking 1 or 2 bites of his meals. It indicated, "He drinks soda at a meal and some other liquids." Continues on med pass. The dietary note did not include an accurate assessment of resident #1's fluid intakes. The 2/3/12 Nutritional Risk Meeting Note indicated resident #1's weight is down to 124.9 pounds and has a poor appetite. Upgraded to general diet from mechanical soft. Receives med pass 4 oz. twice a day and also will be starting a health shake at meals. Tried one today and he drank it well. There is no evidence that the facility identified the risk for dehydration and did not develop a care plan or begin intake and output monitoring. On 2/3/12 the facility completed a "Hydration Assessment" for resident #1 which indicated no signs and symptoms of dehydration but indicated that he at times was unable to obtain fluids because of his [MEDICAL CONDITION]. The inability to obtain fluids independently is a risk factor for dehydration. Despite this information, there were no changes to resident #1's plan of care. Resident #1 was at risk for dehydration on admission on 1/10/12. He was at increased on 1/25/12 by the Nutrition Risk Committee. The facility did not complete Symptom Pursuit and hydration assessments until 2/3/12. On 2/4/12 nurses notes showed resident #1 had episodes of emesis of at least 2 cups of undigested food and 2 episodes of diarrhea. The physician and family were updated. The physician was consulted and indicated to assess every shift and update as needed. Resident #1 was placed on room isolation due to his illness. On 2/4/12 a "Hydration Assessment" for resident #1 indicated suspicion of decreased intake. The documentation for intake on this date indicated ate less than 75%, ate a bowl of oatmeal, 100% of supplement accepted, took in greater than 480 cc's, accepted a morning snack, water, and ice cream, sick, ate less than 75% for supper, less than 240 cc's and refused his afternoon and bed time snacks. There was no measures taken to ensure adequate documentation of his intake of liquids to ensure his hydration needs were being met with this further risk of dehydration due to his emesis and diarrhea. There was no revision to resident #1's care plan to address the on-going need to offer him fluids or to offer additional types of fluids such as jello or popsicles, etc. due to his GI illness. On 2/5/12 a "Hydration Assessment" for resident #1 indicated that at times resident #1 was unable to obtain fluids because of [MEDICAL CONDITION] weakness. At this point the facility added an approach to his care plan to "assist with obtaining fluid". The documentation of intake on this date was listed as ate less than 75%, took in 300 - 359 cc's liquid, refused AM snack, accepted 240 - 299 cc's liquid, refused HS snack. On 2/6/12 an intake record showed resident #1 took in less than 75% breakfast and less than 240 cc's of liquid. He accepted an AM snack and sips of kool-aide. The facility had records of stool output for resident #1 beginning on 1/30/12 but none for urine. On 2/22/12 at 11:50 a.m. NHA-A (Nursing Home Administrator) verified the facility did not have documentation of resident #1's urine output because he didn't flag for dehydration. The facility had not developed a care plan to monitor output of urine when resident #1 became ill on 2/4/12 to ensure his hydration needs were being met. On 2/6/12 resident #1 was set for discharge to an assisted living facility in the afternoon. Resident #1's son came to see him around 9:45 a.m. and told the facility he was concerned with the way resident #1 looked and acted. According to nurses notes dated 2/6/12 the facility called resident #1's physician to inform him of family's wish to transfer resident #1 to the ER (emergency room ). Resident #1's physician ordered transfer to the ER. Nurses notes indicated that at 10:00 a.m. resident #1 was transferred to Calumet Medical Center by ambulance. During an interview with surveyor # on 2/22/12 at 8:20 a.m., Family-E indicated resident #1 had a marked weight loss since admission to the facility on [DATE] and wasn't eating or drinking at the facility. She indicated when resident #1 went to the hospital on [DATE], the hospital also indicated that he had not been urinating and that he was very dehydrated. Following hydration at the hospital resident #1 required a catheter to be inserted. The ER report for resident #1 dated 2/6/12 indicated he had not been eating well for about a week. had a history of [REDACTED]. Was on [MEDICATION NAME] (a diuretic). The physical assessment showed mucous membranes were slightly dry and he had no [MEDICAL CONDITION]. Resident #1 was given an admitting [DIAGNOSES REDACTED]. Resident #1 was admitted to the acute care setting. Labs for resident #1 were drawn on admission to the hospital on [DATE] which were as follows: Sodium - 143 (normal 134 - 143) Potassium - 3.9 (normal 3.6 to 5.1) BUN - 89 (normal 8 - 26) Creatinine - 3.94 (normal .61 to 1.24) Glucose - 175 (normal 60 - 99) Calculated Serum Osmolarity was 335.3 mmol/KG (millimoles per liter/Kilogram). Standards of Practice from the University of Iowa College of Nursing Research Institutes indicates greater than 300 mmol/KG would indicate dehydration. The history and physical dated 2/6/12 for resident #1 indicated his creatinine was 3.94 compared with 1.82 on 12/13/11 with a BUN of 89 compared with 38 on 12/13/11. The assessment resulted in a [DIAGNOSES REDACTED]. The hospital discharge summary for resident #1 dated 2/10/12 indicated his [DIAGNOSES REDACTED]. It indicated that on admission to the hospital on [DATE] resident #1 was quite lethargic and lab results showed acute [MEDICAL CONDITION], significant [MEDICAL CONDITION], elevated INR and was admitted for IV fluid resuscitation. Resident #1 was admitted to a swing bed unit. Surveyor # reviewed of RD-C's (Registered Dietitian) calculation of resident #1's daily fluid intake 1/30/12 through 2/5/12. The calculations showed identical amounts of intakes each day for meds pass fluid and supplement (360 cc's), water pitcher (480 cc's), and soda or Snapple (240 cc's). MAR (medication administration records) dated 1/30/12 showed resident #1 refused one 4 oz. med pass supplement, refused one on 2/4/12, and did not take either on 2/5/12. RD-C's calculations for these dated included the full 360 cc's for med pass. During a phone interview with surveyor # on 2/22/12 at 12:10 p.m., RD-C indicated she reviewed resident #1's record after he had been discharged from the facility to the hospital on [DATE]. RD-C indicated she felt resident #1's fluid intake was adequate based on her calculations from 1/30/12 through 2/5/12. RD-C said that to get those calculations she took a general assumption of 480 cc's of water pitcher intake and 240 cc's daily of soda or Snapple. RD-C said she got this information from nurse aides who would tell her they changed the water pitcher each shift or offer a can of soda with each meal and took into account that resident #1 would have taken all his medication pass supplements. RD-C's assumption was that resident #1 was consuming all of the fluids that were given to him and did not include accurate monitoring. RD-C indicated that if a resident took in less that 240 cc's for 3 consecutive meals they would be put on I and O and resident #1 had not met that criteria. On 12:10 p.m. at 2/22/12, surveyor # spoke again with RD-C. RD-C verified that resident #1 was at risk of dehydration as he had a significant weight loss from 134 to 124.9 pounds in less than 30 days and was on [MEDICATION NAME]. She indicated that even though resident #1 was taking in less than 75% of his meals, he was accepting his supplements and drank his regular soda. RD-C was not able to give exact amounts of these intakes. She indicated resident #1's hydration assessments showed no signs and symptoms of dehydration and she did not know how he could have been dehydrated when he left for the hospital on [DATE]. RD-C confirmed that resident #1 had been on their nutrition check list since 1/25/12 due to poor intake of food and fluids. During an interview with surveyor # on 2/22/12 at 8:45 a.m. NHA-A and DON-B (Director of Nursing) indicated that resident #1 ate fairly well on admission to the facility but partway through his stay began refusing meals and had a decreased appetite and weight loss around 1/25/12. DON-B indicated that resident #1 was assessed for depression on 2/1/12 and seen by his physician as this was about the time he found out he could not go home but would have to go to an assisted living facility. She indicated his physician did put him on [MEDICATION NAME] by 2/3/12 as his symptoms of depression were not improving. DON-B verified resident #1 was not put on any I&O during this time. She indicated he drank his white soda but didn't know exactly how much and that they had not seen signs and symptoms of dehydration, just weight loss. She verified he was at risk of dehydration. NHA-A said resident #1's documentation showed intakes of less than 75% and verified this was not defined more. She verified that on 2/4/12 resident #1 had been isolated to his room due to GI upset and emesis and diarrhea and had been assisted to eat that morning by staff. DON-B indicated resident #1 had a clear liquid diet ordered by his physician on 2/4/12 and didn't have significant intake that day because what he took in at breakfast was vomited and he had several episodes of diarrhea. DON-B indicated on 2/5/12 resident #1 felt better and began taking in about 50% of his liquid diet. DON-B verified that resident #1's physician had not stopped his diuretic despite his emesis and diarrhea because of cardiac concerns. DON-B and NHA-A verified there had not been a care plan developed to ensure specific monitoring of resident #1's liquid intake amounts or of his output to ensure his hydration needs were being met. During an interview with surveyor # on 2/22/12 at 11:55 a.m. CNA - D indicated she worked with resident #1 and indicated he had a decline in his eating and drinking around the end of January. She indicated that towards the end of his stay he was taking in less than 25%. She indicated the facility documentation could only be coded for less than 75% and didn't narrow it down any further. CNA-D indicated resident #1 drank his soda and usually not much else. She indicated that at times there would be soda left in the can, a half or more at times and that it was discarded if he was given a new one. CNA-D indicated the same for the water pitcher which varied as to what he drank but that wasn't recorded.