Every finding on record at Luther Home

Based on interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse for 1 of 8 staff reviewed for caregiver background checks. The facility did not have completed Department of Justice (DOJ) or Government Findings Reports for Certified Nursing Assistant (CNA)-E. Findings include: The facility's Abuse, Neglect, and Exploitation Prevention and Reporting Policies and Procedures, dated September 2024, do not include the facility's background check procedure on new and existing employees. On 7/9/26, Surveyor reviewed a sample of 8 staff for caregiver background checks, including CNA-E. CNA-E had a hire date of 11/6/24. CNA-E's Background Information Disclosure (BID) form was completed on 11/6/24, however, the facility did not have DOJ or Government Findings Reports on file for CNA-E. On 7/9/26 at 10:57 AM, Surveyor interviewed Human Resources Director (HR)-F who confirmed the facility did not complete DOJ and Government Findings Reports for CNA-E prior to 7/9/26.

Based on interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R1) of 5 sampled residents. On 6/20/26, the facility was informed of an allegation of abuse involving R1. The allegation of abuse was not reported to the SA.Findings include:The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised September 2024, indicate: .It is the responsibility of our employees, attending physicians, family members, visitors, volunteers, contractors, etc., to immediately report any incident or suspected incident of neglect or physical or verbal resident abuse .to the Administrator or designee .6) Upon receiving notification of abuse, witnessed or suspected, the Administrator and/or his/her designee will immediately begin an investigation .The Administrator and/or designee will also report any allegations of abuse immediately or at least within twenty-four (24) hours of receiving the notification to the SA.R1 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, visual hallucinations, malignant neoplasm of brain, major depressive disorder, anxiety, and post-traumatic stress disorder (PTSD). R1 had an activated Power of Attorney ((POA)-G) to assist them with healthcare decisions. An admission Minimum Data Set (MDS) assessment, dated 5/29/26, stated R1's Brief Interview for Mental Status (BIMS) score was 5 out of 15, indicating severe cognitive impairment. The assessment indicated R1 had hallucinations or delusions in the 7 days prior. R1 was frequently incontinent of bladder, always incontinent of bowel, and required substantial/moderate assistance for toileting hygiene and bed mobility.On 7/9/26 at 10:38 AM, Surveyor interviewed POA-G who stated they informed R1's nurse on 6/20/26 that R1 stated a Certified Nursing Assistant (CNA) enetered their room the night before when they were sleeping. R1 stated they could feel the CNA's breath on their neck and the CNA was rubbing up against their body. POA-G stated they told the nurse they wanted an incident report completed and wanted to know why the CNA was in R1's room. POA-G stated R1 was upset about the incident and could still recall the incident after several days. POA-G stated R1 informed them that no one spoke with R1 about the incident. POA-G stated they contacted Social Worker (SW)-I for a copy of the incident report but did not receive any follow-up.On 7/9/26 at 12:57 PM, Surveyor interviewed SW-I who was aware that R1 reported that a CNA brushed up against them. SW-I confirmed POA-G requested a copy of the incident report, but stated there was not one completed yet. SW-I stated Nursing Home Administrator (NHA)-A was aware of the incident and said SW-I only gets involved at the request of NHA-A.On 7/9/26 at 1:01 PM, Surveyor interviewed NHA-A who stated they received a call from Licensed Practical Nurse (LPN)-H on 6/21/26 who reported that POA-G stated R1 was upset because a CNA rubbed up against them and it made them uncomfortable. NHA-A stated they did not report the incident to the SA because it was not an allegation of abuse and POA-G just wanted R1 to not have male caregivers. NHA-A did not speak with R1, POA-G, or the CNA involved regarding the concern. NHA-A stated LPN-H would have talked to R1 and was the only one who spoke with POA-G. NHA-A stated LPN-H was instructed to get a statement from the CNA.On 7/9/26 at 1:14 PM, Surveyor interviewed LPN-H who verified POA-G reported to them on 6/21/26 that R1 was upset because CNA-J rubbed up against them the previous night. LPN-H stated they reported the information to NHA-A who instructed LPN-H to get a statement from CNA-J. LPN-H stated they did not feel it was anything sexual. LPN-H stated they spoke to R1 but did not specifically ask about the concern. LPN-H verified they did not know how R1 felt about the incident because they did not ask R1 or POA-G.On 7/9/26 at 3:00 PM, Surveyor interviewed CNA-J who stated they were told to write a statement and put it under Assistant Director of Nursing (ADON)-C's door. CNA-J stated they entered R1's room to see if they needed to be changed and turned them during midnight cares. CNA-J stated they were told to stay off the unit but administration did not speak to them about the concern.On 7/9/26 at 2:47 PM, Surveyor interviewed R1 who verified they told POA-G that a CNA entered their room on the night shift and rubbed up against them in bed. R1 stated when they first arrived at the facility, they were not sure what was real and what was not. R1 did not recall staff asking them about the incident.On 7/9/26 at 5:13 PM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B. NHA-A confirmed the incident was not reported to the SA. NHA-A stated if it was an allegation of abuse, NHA-A would have instructed LPN-H to do an investigation and it would have been reported. NHA-A stated they were going on vacation when the information was reported to them. NHA-A stated DON-B is responsible for reporting allegations to the SA when they are on vacation. DON-B stated they were also on vacation at the time of the incident. NHA-A could not state who was responsible for investigating and reporting allegations of abuse in the absence of NHA-A and DON-B.

Based on interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 5 sampled residents. On 6/20/26, the facility was informed of an allegation of abuse involving R1. The facility did not thoroughly investigate the allegation of abuse.Findings include:The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised September 2024, indicate: .All reports of resident abuse, neglect .shall be immediately and thoroughly investigated .1. Should an incident or suspected incident of abuse, neglect .be reported, the Administrator and/or his/her designee will investigate the alleged incident .2. The individual conducting the investigation will, at a minimum, and when necessary: .b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview employees (on all shifts) who had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members .; and j. Review all events leading up to the alleged incident .R1 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, visual hallucinations, malignant neoplasm of brain, major depressive disorder, anxiety, and post-traumatic stress disorder (PTSD). R1 had an activated Power of Attorney ((POA)-G) to assist them with healthcare decisions. An admission Minimum Data Set (MDS) assessment, dated 5/29/26, stated R1's Brief Interview for Mental Status (BIMS) score was 5 out of 15, indicating severe cognitive impairment. The assessment indicated R1 had hallucinations or delusions in the 7 days prior. R1 was frequently incontinent of bladder, always incontinent of bowel, and required substantial/moderate assistance for toileting hygiene and bed mobility.On 7/9/26 at 10:38 AM, Surveyor interviewed POA-G who stated they informed R1's nurse on 6/20/26 that R1 stated a Certified Nursing Assistant (CNA) enetered their room the night before when they were sleeping. R1 stated they could feel the CNA's breath on their neck and the CNA was rubbing up against their body. POA-G stated they told the nurse they wanted an incident report completed and wanted to know why the CNA was in R1's room. POA-G stated R1 was upset about the incident and could still recall the incident after several days. POA-G stated R1 informed them that no one spoke to R1 about the incident. POA-G contacted Social Worker (SW)-I for a copy of the incident report but did not receive any follow-up.On 7/9/26 at 12:57 PM, Surveyor interviewed SW-I who was aware R1 reported that a CNA brushed up against them. SW-I verified POA-G requested a copy of the incident report, but stated there was not one completed yet. SW-I stated they were not involved with the investigation and Nursing Home Administrator (NHA)-A would have been involved.On 7/9/26 at 1:01 PM, Surveyor interviewed NHA-A who reported receiving a call from Licensed Practical Nurse (LPN)-H on 6/21/26 that POA-G stated R1 was upset because a CNA rubbed up against them and it made them uncomfortable. NHA-A stated they did not personally speak with R1, POA-G, or the CNA involved about the allegation and LPN-H would have been the one to do so. NHA-A stated LPN-H was instructed to get a statement from the CNA.On 7/9/26 at 1:14 PM, Surveyor interviewed LPN-H who verified POA-G reported to them on 6/21/26 that R1 was upset because CNA-J rubbed up against them the previous night. LPN-H stated they reported the information to NHA-A who instructed them to get a statement from CNA-J. LPN-H stated they did not feel it was anything sexual. LPN-H stated they spoke with R1 but did not specifically ask them or POA-G about the concern and did not know how they felt about the incident. LPN-H stated they told CNA-J to write a statement, but did not read the statement or obtain statements from any other staff or residents.On 7/9/26 at 3:00 PM, Surveyor interviewed CNA-J who stated they were told to write a statement and put it under Assistant Director of Nursing (ADON)-C's door. CNA-J stated they entered R1's room to see if they needed to be changed and turned R1 during midnight cares. CNA-J stated they were told to stay off the unit, but administration did not speak to CNA-J about the concern and they heard about it from other staff.On 7/9/26 at 2:47 PM, Surveyor interviewed R1 who verified they told POA-G that a CNA entered their room on the night shift and rubbed up against them in bed. R1 stated when they first arrived at the facility, they were not sure what was real and what was not. R1 did not recall staff asking them about the incident.On 7/9/26 at 5:13 PM, Surveyor again interviewed NHA-A who stated it was not allegation of abuse, just that POA-G wanted R1 not to have male caregivers. NHA-A stated if it was an allegation of abuse, NHA-A would have instructed LPN-H to do an investigation. NHA-A confirmed an investigation was not completed.

Based on interview and record review, the facility did not ensure the comprehensive care plan contained pertinent hospital discharge instructions for 1 resident (R) (R1) of 5 sampled residents. R1's hospital discharge summary contained instructions to sit for a maximum of one hour while up in their wheelchair for a maximum of 2-3 hours total per day. R1's care plan did not contain the instructions.Findings include: R1 was admitted to the facility on [DATE] and had diagnoses including unstageable pressure injuries resulting from a fall at home and being on the ground for several days. The wounds opened after admission and turned into chronic stage 3/4 buttock pressure injuries which required wound vac therapy. A discharge summary from a hospital stay from 6/9/26 to 6/18/26 related to sepsis and infected pressure injuries included instructions that R1 should only sit up for a maximum of one hour at a time, mainly just for meals and only for a maximum of 2-3 hours total per day. A discharge summary from a hospital stay from 6/27/26 to 7/6/26 related to sepsis and chronic stage 3/4 pressure injuries included instructions that R1 should only sit up for a maximum of one hour at a time, mainly just for meals and only for a maximum of 2-3 hours total per day. R1's care plan did not indicate they should only sit up for a maximum of one hour at a time, mainly just for meals and only for a maximum of 2-3 hours total per day. R1's nursing care card, with hand written updates on 5/22/26, 6/3/26, 6/18/26, and 7/7/26, did not indicate they should only sit up for a maximum of one hour at a time and for a maximum of 2-3 hours per day. On 7/9/26 at 1:25 PM, Surveyor interviewed Registered Nurse (RN)-D and Assistant Director of Nursing (ADON)-C who stated they encourage R1 to only stay in their wheelchair for one hour at a time, but at times R1 does not want to comply. RN-D and ADON-C stated R1 attempts to self-transfer at times. ADON-C and Surveyor reviewed a care care posted inside R1's closet. The care card did not include instructions to sit up for a maximum of one hour at a time and for a maximum of 2-3 hours total per day. ADON-C stated the instructions should have been on the care card. RN-D stated R1 is repositioned every two hours when in bed and is in their wheelchair for meals, therapy, and activities for one hour at at time. RN-D stated the instructions were written somewhere which is why RN-D was aware. RN-D verified the instructions were in R1's discharge summary but not on their care plan or care card. On 7/9/26 at 2:56 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who stated they reposition R1 every two hours and try to have R1 sit in the wheelchair for no more than one hour at a time. CNA-E stated they know to do that even though it is not on R1's care card. On 7/9/26 at 3:10 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R1's care plan and care card did not indicate R1 should sit up for a maximum of one hour at a time and for no more than a total of 2-3 hours per day.

Based on interview and record review, the facility failed to protect the right to be free from verbal abuse by staff for 1 resident (R) (R4) of 4 residents in a total sample of 8 residents.Staff witnessed Certified Nursing Assistant (CNA)2 be verbally abusive to R4.Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, reviewed September 2024, revealed: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Causes could reasonably be expected to cause mental or emotional damage to a client, including harm to client's psychologic or intellectual functioning that is exhibited by anxiety, depression, withdrawal, regression, outward aggressive behavior, agitation, or fear of harm or death, or a combination of these behaviors. Review of the Face Sheet tab located in the electronic medical record (EMR) revealed R4 was admitted to the facility on [DATE] with diagnoses that included dementia and bipolar disorder. Review of a Significant Change Assessment, located in the Minimum Data Set (MDS) tab of the EMR with an Assessment Reference Date (ARD) of 3/16/26, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R4 had severely impaired cognition. In addition, R4 was able to make themself understood and was able to understand others. Review of the 4/20/26 Facility Investigation provided by the Director of Nursing (DON) revealed a witness stated CNA2 spoke to R4 in a loud and harsh manner after R4 requested to be put into bed. Review of the 4/20/26 written statement by the Health Information Manager (HIM) revealed they were on the unit writing in orders when they heard CNA2 being verbally abusive and yelling at R4 to stop sliding down in their wheelchair on three separate occasions. CNA2 got in R4's face and told them to knock it off. CNA2's partner (CNA1) and Licensed Practical Nurse (LPN)2 were present. CNA2 was not directed to stop yelling at R4 by CNA1 or the charge nurse. The second occurrence was with CNA2 yelling at R4. CNA2 told LPN2 to lay R4 down and CNA2 would pass lunch trays. The charge nurse told CNA2 that laying R4 down was an urgent matter so R4 would not fall out of their chair. CNA2 proceeded to pass lunch trays and said R4 was just playing games if everyone just understood that. R4 was put into bed by CNA1 and LPN2. Review of the 4/20/26 written statement by CNA1 revealed CNA2 stated they didn't want to do too much and didn't want to be there approximately 15 minutes into the shift. CNA1 witnessed CNA2 yell at R4. When R4 got back to the common area with a coloring supplies, R4 was yelling that they wanted to lay down. CNA2 got next to R4 on the side closest to their face and started to yell that R4 needed to stop yelling and needed to stay there. CNA2 stated staff would not bring R4 back to their room or lay them down and CNA2 was not playing their games. When R4 started to scoot to the edge of the wheelchair, CNA2 yelled that they would not boost R4 back up either. CNA2 ripped out a pillow that Hospice had placed underneath R4's legs due to leg pain and said the pillow did not need to be there. LPN2 asked staff to put R4 to bed as that was the safest place, however, CNA2 refused to help and said they couldn't do anything with R4 due to no male caregivers. CNA1's statement indicated CNA2 always used that excuse so they didn't have to do anything, however, CNA2 could help transfer if it did not have to do with cares or toileting. The statement indicated CNA1 was going to transfer R4 alone, which they knew they shouldn't, but LPN2 helped put R4 into bed. The Facility Investigation did not indicate LPN2 was interviewed as a potential witness. Review of an undated written statement by CNA2 revealed CNA2 believed the allegations against them were false but was deeply saddened and sorry if anybody believed they abused a resident. CNA2 did not want anyone to think or feel that way and stated they would take full responsibility for their actions. Review of the Conclusion to the 4/20/26 Facility Investigation revealed the Administrator documented, We believe the statements of the witnesses (HIM) and (CNA1) are credible and that (CNA2) did not treat (R4) with kindness and respect .Appropriate disciplinary action was taken with (CNA2). During an observation on 6/29/26 at 9:03 AM, R4 was seated in a Broda chair at the dining table. Staff were talking to residents at the table. R4 did not show any fear of the staff. No behaviors were noted. During an interview on 6/29/26 at 2:12 PM, CNA1 verified they were part of the investigation with CNA2 and indicated CNA2 stated they would not help CNA1. CNA1 stated R4 had an intervention for no male caregivers, however, if it was a female and no cares were involved, they could help. CNA1 indicated CNA2 said shut up and I don't care if you fall to R4. CNA1 did not report the abuse to administration and stated, That was my fault. CNA1 stated CNA2 was suspended shortly after the incident and did not return. When asked if R4 had crying or increased behaviors after the incident, CNA1 stated, No, not really but (R4) just sat there and became very quiet. During an initial interview on 6/30/26 at 8:17 AM, the Administrator stated, (CNA2) was a good aide but we had to let (them) go. It was (CNA2's) tone of voice and how (they) addressed people. I don't think (CNA2) meant any harm. When asked if staff were educated on abuse during or after the investigation, the Administrator stated, I don't think there was any staff education. When asked if the Social Services Designee (SSD) had addressed the issue of possible trauma with R4, the Administrator stated, No, I don't think so. During an interview on 6/30/26 at 10:47 AM, LPN2 was asked if the Administrator had interviewed them during the investigation. LPN2 stated, No. (The Administrator) did not interview me. It surprised me that (they) didn't. I worked the next day and was waiting to talk to the Administrator, but (they) did not come and see me. When asked if LPN2 was a mandatory reporter if they heard or witnessed abuse, LPN2 stated, I am not sure whether I am a mandatory reporter or not. During an interview on 7/1/26 at 10:10 AM, the SSD was asked about their role during an abuse investigation and stated, I usually hear about (allegations of abuse) from the Administrator and then (they) tell me to go and interview residents. When asked if they were involved in the investigation of verbal abuse toward R4, the SSD said, I do not think I was involved other than taking statements from residents. In a follow-up interview on 7/1/26 at 10:55 AM, the Administrator was asked why LPN2 was not interviewed during the investigation and stated, I hand those (interviews) off to HR (Human Resources), so I don't have an answer to this question. When asked if law enforcement was notified of the abuse investigation, the Administrator stated, No. When asked why R4's care plan was not updated with any new interventions, the Administrator stated, We had talked about doing this as a team. I always ask if something needs to be changed (on the care plan). I have a check list for any investigation, however, updating the care plan was not on my check list nor was notifying law enforcement.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 residents (R) of the 61 residents residing in the facility. The facility did not ensure transmission-based precautions (TBP) were implemented for R53 for Norovirus (The most common cause of gastroenteritis, characterized by non-bloody diarrhea, vomiting, and stomach pain. The virus is highly contagious and spread through contaminated food or water or person-to-person contact, contaminated surfaces, or through air from the vomit of an infected person.) Licensed Practical Nurse (LPN)-K did not complete appropriate hand hygiene during medication administration.Housekeeper (HK)-G did not use appropriate disinfecting solution to mop residents' floors on a unit with a Norovirus outbreak. In addition, the housekeeping department did not have a policy or procedure to ensure appropriate cleaning and disinfection was completed. Findings include: The facility's Infection Control Precautions policy, revised 6/4/19, indicates: Both standard and transmission-based precautions (TBP) are used as appropriate to prevent the spread of communicable disease .Standard Precautions: Use standard precautions when giving care to all residents regardless of diagnosis or presumed infection status. This includes personal protective equipment (PPE) such as gloves, gowns, masks, and goggles when exposure to blood or body fluids, secretions and excretions, non-intact skin, or mucous membranes is anticipated. The type of PPE used depends on the type of exposure anticipated. Hand hygiene is always required following any patient contact and after a dirty task, following removal of gloves, and before proceeding to a clean task. Wash hands for 20 seconds with soap and warm water, if visibly soiled. (NOTE: Soap and water must always be used after using the bathroom yourself and when assisting a resident who has a Clostridioides difficile (C. diff) diagnosis or Norovirus). Transmission-Based Precautions: Based on the mode and risk of transmission, TBP add an additional layer of protection in addition to standard precautions when factors indicate increased risk of transmission .Contact Precautions: Use for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident care items .instances for adding contact precautions may include highly transmissible organisms such as C. diff, herpes, and other transmissible conditions such as impetigo, lice, scabies, rash of unknown origin, conductivities, heavily draining wounds, etc . The facility's Infection Prevention and Control Program policy, revised 5/31/19, indicates: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection .Hand Hygiene Protocol: All staff shall wash their hands when coming on duty, between resident contact, after handling contaminated objects, after personal protective equipment (PPE) removal, before/after eating, before/after toileting, and before going off duty. Staff shall wash their hands before and after performing resident care procedures. Hands shall be washed in accordance with the facility's established hand washing procedure. Isolation Protocol: Standard precautions shall be observed for all residents. A resident with an infection or communicable disease shall be placed on isolation precautions as recommended by current Centers for Disease Prevention and Control (CDC) guidelines for isolation precautions. A copy of these guidelines are available at each nurses' station . The facility's Hand Hygiene/Glove Use policy, revised June 2018, indicates: Proper hand hygiene technique is used to prevent transmission of infectious disease .All employees are required to perform hand hygiene before and after resident contact, before and after performing any procedure, between tasks that are dirty and clean, after sneezing or blowing their nose, after using the toilet, before handling food, and when hands become obviously soiled .1) Antiseptic Gel Use: When appropriate to use antiseptic hand gel, thoroughly distribute enough hand gel to cover both hands and vigorously rub hands together covering all surfaces of the hands and fingers. Rub hands until dry .Hand gel is the preferred method of hand hygiene. With the exceptions listed below for soap and water handwashing. Handwashing: 1. Turn on water to a warm temperature; 2) Wet hands with water; 3) Using a liquid soap from a dispenser, rub hands together vigorously for at least 15 seconds. Be sure to wash all surfaces, including backs of hands, wrists, between fingers, and under fingernails; 4) Rinse hands well under warm running water; 5) Dry hands with paper towels .Turn faucet off with a clean, dry paper towel .Hands must be washed with soap and water: a) When hands are visibly soiled; b) After using the bathroom; c) When working with a resident who has Clostridioides difficile (C. diff) or suspected C. diff or Norovirus. The facility's Routine Cleaning and Disinfection policy, revised February 2020, indicates: It is the policy of [NAME] Home to ensure the provision of routing cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infection to the extent possible .9. Disinfectant solution will be prepared fresh daily and changed frequently in order to ensure effectiveness. a. Follow manufacturer recommendations for dilution and frequency of changing disinfectant solution. b. Follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection. c. Change solution after cleaning a room under transmission-based precautions (TBP). Clean and disinfect any equipment that enters the room before use in other locations. d. Verify products used to clean and disinfect surfaces in rooms under TBP are effective against the pathogen of concern. 1.On 12/8/25, Surveyor reviewed R53's medical record. R53 had diagnoses including diabetes type 2, presence of indwelling catheter, and renal disease and was on contact precautions due to Norovirus. R53's Minimum Data Set (MDS) assessment, dated 12/2/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R53 had intact cognition. On 12/8/25 at 8:10 AM, Director of Nursing (DON)-B confirmed the D wing was in a Norovirus outbreak. On 12/8/25 at 8:55 AM, Surveyor observed R53 in a recliner. R53's door contained a sign that indicated R53 was on contact precautions. The sign indicated staff should don a gown, gloves, and a mask before entering the room. The sign also indicated staff should complete hand hygiene and remove personal protective equipment (PPE) prior to exiting the room. Surveyor interviewed R53 who confirmed R53 was on contact precautions for Norovirus and indicated many residents were ill. R53's call light was activated at the time. On 12/8/25 at 8:59 AM, Surveyor observed Certified Nursing Assistant (CNA)-D enter R53's room wearing a mask but no other PPE. CNA-D obtained items in the room for R53, touched surfaces, emptied a basin, and removed items from the room per R53's request. Surveyor observed CNA-D exit the room and sanitize hands. Surveyor interviewed CNA-D who indicated CNA-D should have worn the appropriate PPE and followed standard and contact precautions prior to and after exiting the room. CNA-D indicated CNA-D did not so do because CNA-D was in a rush. On 12/8/25, Surveyor noted five additional residents on the D wing were on contact precautions due to Norovirus. On 12/9/25 at 9:00 AM, Surveyor noted contact precautions were initiated for two residents on the B wing due to Norovirus. On 12/10/25 at 8:05 AM, Surveyor noted contact precautions were initiated for three additional residents on the B wing due to Norovirus. On 12/10/25 at 12:05 PM, Surveyor interviewed DON-B who verified the Norovirus outbreak began on 12/6/25 on the D wing and confirmed the outbreak spread to the B wing. DON-B indicated staff should adhere to the facility's policy and procedure for donning and doffing PPE for residents on TBP to prevent the spread of illness. 2. On 12/9/25 at 8:21 AM, Surveyor observed LPN-K prepare and administer medication to R22. After administering R22's medication, LPN-K washed hands with soap and water for five seconds in R22's room. (Surveyor counted from the beginning to the end of the water running.) On 12/9/25 at 8:45 AM, Surveyor observed LPN-K prepare and administer medication to R8. After administering R8's medications, LPN-K washed hands for five seconds with soap and water in R8's room. (Surveyor counted from the beginning to the end of the water running.) Immediately after the observations, Surveyor interviewed LPN-K who verified LPN-K did not wash hands for the recommended twenty seconds to ensure LPN-K's hands were adequately cleaned to prevent the spread of infectious agents, especially during the facility's Norovirus outbreak. On 12/10/25 at 12:07 PM, Surveyor interviewed DON-B related to hand washing during acute gastroenteritis outbreaks such as Norovirus. DON-B stated hand sanitizer is the best thing to use if hands are not visibly soiled; however, staff should use soap and water during a suspected Norovirus outbreak. Immediately after the interview, Surveyor requested the facility's policy pertaining to disinfection procedures from Nursing Home Administrator (NHA)-A. 3. On 12/9/25 at 9:15 AM, Surveyor observed Housekeeper (HK)-G clean R20's room on the D wing which contained four halls. Surveyor observed one housekeeping cart on the unit that contained one mop bucket and a mop with a reusable head. Immediately after observing HK-G clean R20's room, Surveyor interviewed HK-G who stated bathrooms are shared between two rooms and HK-G had already cleaned the room's shared bathroom which was the last room on the D wing. HK-G stated R20 did not want the floor mopped. HK-G swept the room after cleaning and disinfecting other areas. R20 was not on TBP at the time of the observation. When Surveyor asked if HK-G had a specific cleaning order for resident rooms, HK-G stated no; however, HK-G tried to clean rooms that residents were not in first. HK-G stated R20's was the last room to clean in that hall of the four halls on the D wing. When Surveyor asked about the solution in the mop bucket, HK-G indicated there was a virus going around the D wing and stated the bucket contained one capful of bleach and cold water. HK-G was not aware of a policy or directions to refer to regarding which disinfectant products to use or how to mix the bleach and water. HK-G used a pre-mixed Virex solution for a smaller bucket that was on top of the housekeeping cart. HK-G filled the bucket and put multiple cloths in the bucket to use for surfaces. HK-G stated HK-G only changed the bleach water if the water became cloudy. HK-G stated there was only one housekeeper and one cart on the D wing so HK-G may change the water once; however, there were usually two housekeepers and two carts on the D wing and the water usually lasted through all of the rooms. On 12/10/25 at 12:37 PM, Surveyor interviewed Housekeeping Supervisor (HS)-H on the D wing. Surveyor informed HS-H of the observation with HK-G and asked for the facility's policy and procedure for the disinfectant used for mopping residents' rooms during a gastrointestinal outbreak. HS-H stated if bleach is used, staff should use one cup of bleach per one bucket of water. HS-H was unsure why HK-G used bleach when the facility has Virex which is effective against all viruses. HS-H indicated HK-G should not have used one capful of bleach per one bucket and stated mop heads should be changed every three to four rooms. When Surveyor requested the facility's policy for disinfecting, HS-H was not aware of a policy or procedure and stated Surveyor should ask Nursing Home Administrator (NHA)-A. On 12/10/25 at 12:58 PM, NHA-A provided Surveyor with the facility's Routine Cleaning and Disinfection policy. The policy did not contain specifics for outbreaks or products that staff should use to clean and disinfect.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R8) of 1 sampled resident with a Guardian was protectively placed at the facility. R8 had a legal Guardian at the time of admission on [DATE]. R8's medical record included an order for Guardianship of person and estate dated 9/21/22. R8's medial record did not contain an order for protective placement.Findings include:State Statute Chapter 55.03(4) indicates: The law requires a court-ordered protective placement for any resident admitted to a nursing home who has a legal Guardian and whose nursing home stay exceeds sixty days, only to be extended with court approval (State Statute Chapter 55.05(b)). Protective placement is reviewed annually (State Statute Chapter 55.18) to determine if placement continues to be least restrictive and in the best interest of the individual.On 12/8/25, Surveyor reviewed R8's medical record. R8 had diagnoses including schizophrenia, seizure disorder, and anxiety disorder. R8's Minimum Data Set (MDS) assessment, dated 12/2/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R8 had severely impaired cognition. R8 had a court-ordered Guardian for health and financial decisions. R8's medical record did not contain a protective placement order. On 12/9/25 at 2:25 PM, Surveyor interviewed R8's Guardian ((GD)-E) who confirmed R8 had been under court-ordered Guardianship since 2022. GD-E confirmed R8 did not have a protective placement order and was not aware that a protective placement order was required for R8 to reside in the facility. GD-E stated R8's managed care organization (MCO) case worker informed GD-E that R8 did not require a protective placement order. GD-E also stated the facility had not informed GD-E that a protective placement order was needed. On 12/9/25 at 12:18 PM and 1:25 PM, Surveyor interviewed Social Worker (SW)-C who could not locate a protective placement order for R8. SW-C indicated SW-C started at the facility in June of 2025 and did not complete an audit for missing resident documentation. SW-C stated SW-C did not receive training on protective placement and did not know protective placement requirements. SW-C confirmed R8 was not protectively placed at the facility and stated SW-C would work with GD-E and the county to obtain protective placement for R8.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R2 and R22) of 2 sampled residents were provided a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form which is used to inform residents of the potential liability for payment (daily cost of care and services at the facility).The facility did not provide an ABN form to R2 when R2's Medicare Part A benefits ended on 10/10/25 and R2 remained in the facility. The facility did not provide an ABN form to R22 and when R22's Medicare Part A benefits ended on 11/25/25 and R22 remained in the facility. Findings include:The Centers for Medicare & Medicaid Services (CMS)-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) form indicates: The ABN provides information to the beneficiary so the beneficiary can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .The ABN is only issued if the beneficiary intends to continue services and the skilled nursing facility believes the services may not be covered under Medicare.The facility's Advance Beneficiary Notices policy, dated March 2025, indicates: If services are being terminated and the beneficiary wants to continue receiving care that is no longer considered medically reasonable and necessary, the facility shall issue an ABN prior to furnishing non-covered care.1. From 12/8/25 to 12/10/25, Surveyor reviewed R2's medical record. R2's Medicare Part A services ended with a last covered day of 10/10/25. The facility issued a Notice of Medicare Non-coverage (NOMNC) form to R2 with a signature date of 10/8/25. R2 remained in the facility. The facility did not provide R2 or R2's representative with an ABN form or provide evidence that R2 or R2's representative were aware of the facility's private pay cost. 2. From 12/8/25 to 12/10/25, Surveyor reviewed R22's medical record. R22's Medicare Part A services ended with a last covered day of 11/25/25. The facility issued a NOMNC form to R22 with a signature date of 11/20/25. R22 remained in the facility. The facility did not provide R22 or R22's representative with an ABN form or provide evidence that R22 or R22's representative were aware of the facility's private pay cost.On 12/10/25 at 8:23 AM, Surveyor interviewed Social Worker (SW)-C who verified SW-C did not provide ABN forms to R2 and R22 and indicated SW-C was not familiar with the form. SW-C indicated SW-C verbally informed R2 and R22 of the per day cost to remain in the facility.On 12/10/25 at approximately 5:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility did not have a signed ABN form for R2 or R22; however, SW-C was provided education to ensure ABN forms are provided to residents who choose to remain in the facility after discharge from Medicare Part A services.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents was free from abuse.The facility was aware of verbal abuse directed at R2 by R2's activated Power of Attorney for Healthcare (POAHC) on 10/16/25. An investigation was not completed and the facility did not implement measures to protect R2 from future abuse. A second occurrence of verbal abuse directed at R2 by POAHC-M occurred on 12/8/25. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised June 2025, indicates: .You as an individual employee have a moral and legal responsibility to make sure each resident is free from abuse. The Administration of this facility takes very serious this duty. Abuse, in general, is any act that inflicts physical, emotional, or mental harm upon a resident .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish From 12/8/25 to 12/10/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility in May of 2021 and had diagnoses including Alzheimer's disease, dementia, diabetes mellitus type 2, and depression. R2's most recent Quarterly Minimum Data Set (MDS) assessment, dated 11/25/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R2 had moderately impaired cognition. R2 had an activated Power of Attorney for Healthcare ((POAHC)-M). On 12/8/25 at approximately 3:11 PM, Surveyor was in the C wing nurses' station and heard someone yelling down the hall. The individual said, .I'm going to leave. I'm going to walk out . in a loud and aggressive tone. Surveyor also heard, .Get .from there or I'm going to beat your head in! When Surveyor asked Registered Nurse (RN)-I (who was also in the nurses' station) if RN-I heard the yelling, RN-I stated RN-I was not sure. Surveyor informed RN-I of the statements Surveyor heard coming from down the hall. RN-I stated POAHC-M was visiting R2. RN-I walked to R2's room and then returned to the nurses' station and made a phone call. RN-I informed the person on the other end that POAHC-M was loud and aggressive and asked if it was something RN-I needed to worry about. On 12/8/25 at 3:40 PM, Surveyor interviewed Director of Nursing (DON)-B and asked if RN-I had informed DON-B of what Surveyor reported. DON-B stated yes and indicated the facility completed an investigation a couple weeks prior because POAHC-M was loud according to staff. DON-B stated Social Worker (SW)-C was notified of what occurred earlier and went to R2's room. On 12/9/25 at 12:28 PM, Surveyor interviewed SW-C who stated SW-C spoke with R2 and POAHC-M on 12/8/25 but did not document the conversation. SW-C stated SW-C received an e-mail from RN-I on 12/8/25 that stated POAHC-M was hollering in R2's room. At approximately the same time, Assistant Director of Nursing (ADON)-L called SW-C regarding the yelling. SW-C went to R2's room and asked if POAHC-M needed help. POAHC-M stated POAHC-M was scolding R2 because the Certified Nursing Assistants (CNAs) stated R2 was being uncooperative. SW-C stated R2 let out a nervous chuckle during the conversation like R2 may be used to (POAHC-M) yelling at (R2) and POAHC-M looked down in a shameful manner. SW-C stated POAHC-M acknowledged that POAHC-M should talk nicer to R2. SW-C confirmed SW-C heard POAHC-M speak loudly to R2 in the past which is how POAHC-M communicates. When Surveyor asked what RN-I and ADON-L told SW-C on 12/8/25, SW-C printed an e-mail from RN-I that stated, .I don't know if you are aware of the situation with (R2) and (POAHC-M), regarding how (POAHC-M) speaks loudly and aggressively with (R2). (POAHC-M) is here right now and we could hear (POAHC-M) down the hall. I went in there and asked if all was well and (POAHC-M) said it is. Not sure if this is how they are or what. Could you just come speak with (POAHC-M), if possible. (POAHC-M) is here right now. Thanks Surveyor informed SW-C of what Surveyor heard POAHC-M yell on 12/8/25. SW-C was not aware of what POACH-M yelled and just knew there was yelling. SW-C stated the words made the hair on the back of SW-C's neck stand up and it should have been looked into. On 12/9/25 at 12:50 PM, Surveyor interviewed DON-B who was aware that POAHC-M was loud. DON-B stated DON-B was in ADON-L's office when RN-I called ADON-L on 12/8/25. DON-B stated ADON-L then called SW-C who went to R2's room. DON-B confirmed the facility had not began an investigation yet. When Surveyor asked if RN-I told DON-B exactly what Surveyor heard and reported, DON-B was not aware. Surveyor informed DON-B of what Surveyor heard coming from R2's room and requested the facility's investigation for the previous incident between R2 and POAHC-M that DON-B mentioned on 12/8/25. On 12/9/25 at 1:02 PM, DON-B provided Surveyor with two witness statements from an incident between R2 and POAHC-M on 10/16/25. DON-B stated Nursing Home Administrator (NHA)-A had the statements and informed Surveyor that NHA-A requested a witness statement from Surveyor regarding the incident on 12/8/25. DON-B indicated the incident on 10/16/25 occurred when POAHC-M was upset with staff for not making R2 use a repositioning wedge. Surveyor reviewed the witness statements from staff who heard R2 cough and heard POAHC-M say, I hope you choke. One of the statements indicated POAHC-M became angry with R2 when R2 refused to reposition with a pillow under R2's side because it made R2 hurt worse. POAHC-M yelled and swore loudly at R2 and said R2 was going to die. On 12/9/25 at 4:40 pm, Surveyor interviewed DON-B regarding the 10/16/25 incident between R2 and POAHC-M. DON-B stated DON-B did not know exactly what happened and indicated it was a long time ago. DON-B stated when someone has to report an incident they report to DON-B or someone else; however, NHA-A decides what is investigated. On 12/9/25 at 1:28 PM, Surveyor interviewed NHA-A about the 10/16/25 incident between R2 and POAHC-M. NHA-A was informed of the incident during morning report. NHA-A stated POAHC-M was upset that staff did not make R2 use a repositioning wedge but was not necessarily abusive to R2. NHA-A stated NHA-A was not aware of the choking comment until DON-B provided the two employee statements on approximately 10/18/25. NHA-A stated the two statement were the extent of the facility's investigation. The facility did not take further steps to ensure POAHC-M did not abuse R2 again.

Based on staff interview and record review, the facility did not ensure an allegation of verbal abuse was reported to the State Agency (SA) for 1 resident (R) (R2) of 3 sampled residents. On 10/16/25, the facility was informed of an allegation of verbal abuse toward R2 by R2's activated Power of Attorney for Healthcare (POAHC). The allegation of abuse was not reported to the SA. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised June 2025, indicates: .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Reporting Abuse: It is the responsibility of our employees, attending physicians, family members, visitors, volunteers, contractors, etc., to immediately report any incident or suspected incident of neglect or physical or verbal resident abuse .to the Administrator or his/her designee Immediately means upon witnessing an incident or as soon as knowledge of an incident or suspected incident is obtained .1. [NAME] Home will not condone resident abuse by anyone, including staff, physicians, consultants, volunteers, or staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. All staff, residents, family members, visitors, etc., must report incidents of resident abuse or suspected incidents of abuse .3. Employees .must report any suspected abuse or incidents of abuse to the Administrator .Director of Nursing . and/or a member of the Social Work staff immediately. Abuse or suspected abuse may be reported in writing using the Resident Rights-Potential Violation Report Form. This form can be used even when the initial report is made verbally. These forms are available at each nursing station, the Social Work office, and from the Administrator. When an incident of abuse or suspected abuse is received by someone other than the Administrator, the Administrator shall be notified immediately regardless of the day of the week or time of day. Immediately means upon witnessing an incident or as soon as knowledge of an incident or suspected incident is obtained .The Administrator or his/her designee will also report any allegations of abuse immediately or at least within twenty-four hours of receiving notification to the Division of Quality Assurance (DQA). The initial report will be submitted to DQA via on-line reporting .From 12/8/25 to 12/10/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility in May of 2021 and had diagnoses including Alzheimer's disease, dementia, diabetes mellitus type 2, and depression. R2's most recent Quarterly Minimum Data Set (MDS) assessment, dated 11/25/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R2 had moderately impaired cognition. R2 had an activated Power of Attorney for Healthcare ((POAHC)-M). On 12/8/25 at 3:40 PM, Surveyor interviewed Director of Nursing (DON)-B regarding an incident between R2 and POAHC-M that occurred on 12/8/25. DON-B was aware of the incident and indicated the facility did an investigation a couple weeks ago because POAHC-M was loud (on 10/16/25) according to staff.On 12/9/25 at 1:02 PM, DON-B provided Surveyor with two witness statements related to the 10/16/25 incident between R2 and POAHC-M. DON-B stated Nursing Home Administrator (NHA)-A had the statements and that was all that was provided to DON-B. An undated statement from Certified Nursing Assistant (CNA)-N indicated CNA-N worked on R2's unit with two other staff on 10/16/25. Staff had to reposition R2 in order to set up a new air mattress. POAHC-M was in the room and agreed to how staff positioned R2; however, POAHC-M became angry and wanted a pillow under R2's side to relieve pressure from R2's buttocks. Staff tried multiple times to place the pillow under R2, however, R2 refused and stated the pillow made R2 hurt worse. Staff informed POAHC-M they could not force R2 to use the pillow. POAHC-M yelled and swore loudly at R2 and said R2 was going to die. Staff at the nurses' station on the opposite end of the hall could hear POAHC-M. When R2 coughed after staff brought R2's dinner tray, staff heard POAHC-M laugh and say, I hope you choke. The statement indicated the nurse on the unit did not address the situation so staff went to another unit to ask a nurse to talk to POAHC-M. A statement by Staff (STF)-O, dated 10/18/25, indicated STF-O walked past R2's room on 10/16/25 and heard R2 cough. STF-O then heard POAHC-M say, Good. I hope you choke. On 12/9/25 at 1:28 PM, Surveyor interviewed NHA-A regarding the 10/16/25 incident between R2 and POAHC-M. NHA-A was informed of the incident during morning report after it occurred. NHA-A stated POAHC-M was upset that staff did not make R2 use a repositioning wedge but was not necessarily abusive to R2. NHA-A was not aware of the choking comment until DON-B provided NHA-A with two employee statements on approximately 10/18/25. NHA-A verified the allegation of abuse was not reported to the SA.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R2) of 3 sampled residents. On 10/16/25, the facility became aware of an allegation of verbal abuse toward R2 by R2's activated Power of Attorney for Healthcare (POAHC). The allegation of abuse was not thoroughly investigated. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised June 2025, indicates: .All reports of resident abuse, neglect, and injuries of unknown source shall be immediately and thoroughly investigated .1. Should an incident or suspected incident of abuse, neglect, or injury of an unknown source be reported, the Administrator and/or his/her designee will investigate the alleged incident. 2. The individual(s) conducting the investigation will, at a minimum, and when necessary: a. Review the resident's medical record to determine events leading up to the incident; b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; d. Interview the resident (as medically appropriate); e. Physically examine the resident for potential injuries; f. Interview the resident's physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview employees (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members .; and j. Review all events leading up to the alleged incident .4. Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. 5. While the investigation is being conducted, accused individuals not employed by [NAME] Home will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator .7. The individual in charge of the investigation will consult daily with the Administrator concerning the progress of the investigation .9. The results of the investigation will be reduced to written form. 10. The investigator will give a copy of the investigation report to the Administrator within four working days of the reported incident .12. The Administrator or his/her designee will provide a written report of all abuse allegations and appropriate action taken to the State Agency and any other state, federal, or local agency as may be required by regulation within five working days of the reported allegation . From 12/8/25 to 12/10/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility in May of 2021 and had diagnoses including Alzheimer's disease, dementia, diabetes mellitus type 2, and depression. R2's most recent Quarterly Minimum Data Set (MDS) assessment, dated 11/25/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R2 had moderately impaired cognition. R2 had an activated Power of Attorney for Healthcare ((POAHC)-M). On 12/8/25 at 3:40 PM, Surveyor interviewed Director of Nursing (DON)-B regarding an incident between R2 and POAHC-M that occurred on 12/8/25. DON-B was aware of the incident and indicated the facility did an investigation a couple weeks ago because POAHC-M was loud on 10/16/25. On 12/9/25 at 1:02 PM, DON-B provided Surveyor with two witness statements for the 10/16/25 incident between R2 and POAHC-M. DON-B stated NHA-A had the statements and that is all that was provided to DON-B. An undated statement from Certified Nursing Assistant (CNA)-N indicated CNA-N worked on R2's unit with two other staff on 10/16/25. Staff had to reposition R2 in order to set up a new air mattress. POAHC-M was in the room and agreed to how staff positioned R2; however, POAHC-M became angry and wanted a pillow under R2's side to relieve pressure from R2's buttocks. Staff tried multiple times to place the pillow under R2, however, R2 refused and stated the pillow made R2 hurt worse. Staff informed POAHC-M they could not force R2 to use the pillow. POAHC-M yelled and swore loudly at R2 and said R2 was going to die. Staff at the nurses' station on the opposite end of the hall could hear POAHC-M. When R2 coughed after staff brought R2's dinner tray, staff heard POAHC-M laugh and say, I hope you choke. The statement indicated the nurse on the unit did not address the situation so staff went to another unit to ask a nurse to talk to POAHC-M. A statement by Staff (STF)-O, dated 10/18/25, indicated STF-O walked past R2's room on 10/16/25 and heard R2 cough. STF-O then heard POAHC-M say, Good. I hope you choke. On 12/9/25 at 4:40 PM, Surveyor interviewed DON-B regarding the 10/16/25 incident between R2 and POAHC-M and the facility's process for investigating an incident. DON-B could not recall exactly what happened and indicated the incident occurred a while ago. DON-B stated when staff have to report an incident they report to DON-B or someone else; however, NHA-A decides what is investigated. On 12/9/25 at 1:28 PM, Surveyor interviewed NHA-A regarding the 10/16/25 incident between R2 and POAHC-M. NHA-A was informed during morning report after the incident occurred. NHA-A stated POAHC-M was upset that staff weren't making R2 use a repositioning wedge but was not necessarily abusive to R2. NHA-A was not aware of the choking comment until DON-B provided the two employee statements to NHA-A on approximately 10/18/25. NHA-A verified the statements were the extent of the facility's investigation.

Based on staff interview and record review, the facility did not provide Preadmission Screening and Resident Review (PASRR) services for 1 resident (R) (R8) of 24 sampled residents. The facility did not contact the state mental health authority to pursue PASRR Level I or II screening for R8 who had a mental illness diagnosis.Findings include:The facility's Resident Assessment-Coordination with PASRR Program policy, revised June 2023, indicates: The facility coordinates assessments with the Preadmission Screening and Resident Review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort. All individuals with a mental disorder or intellectual disability who apply for admission to the facility will be screened in accordance with the state's Medicaid rules for screening. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or intellectual disability authority has determined as appropriate for admission .Recommendations, such as any specialized services, from a PASRR Level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transition of care .On 12/8/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, seizure disorder, and anxiety disorder. R8's Minimum Data Set (MDS) assessment, dated 12/2/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 10 which indicated R8 had severe cognitive impairment. R8 had a court-ordered Guardian for healthcare and financial decisions. R8's medical record did not contain PASRR Level I or Level II Screen.On 12/9/25 at 12:18 PM and 1:25 PM, Surveyor interviewed Social Worker (SW)-C who verified R8's medical record did not contain a PASRR Level I or Level II Screen and confirmed PASRR Level I and Level II Screens were not completed for R8. SW-C indicated SW-C started at the facility in June of 2025 and did not receive training on PASRR requirements.

Based on staff interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice for 1 resident (R) (R1) of 22 sampled residents. The facility did not accurately document and treat R1's injured right ankle after R1 was lowered to the ground on 11/16/25. Findings include: The facility's Falls: Prevention/Management/Documentation policy, dated January 2009, indicates: .Successful management of falls includes a variety of facility-wide and individual approaches in order to reduce the risk for falls and fall-related injuries to the residents of this facility .A fall occurs whenever unplanned movement from a higher level to a lower level occurs. This includes lowering a resident to the floor to prevent injury from an uncontrolled downward movement .5. All falls will be recorded on the 24-hour report board and follow-up assessment will continue for three shifts. Follow-up will include: vital signs, check for injury, and changes in range of motion or evidence of pain . From 12/8/25 to 12/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility in September of 2025 and had diagnoses including Alzheimer's disease unspecified, dementia without behavioral disturbance, pneumonia, sepsis, long term use of anticoagulants, and weakness. R1's most recent Minimum Data Set (MDS) assessment, dated 9/30/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1 had severely impaired cognition. R1's medical record contained the following documentation regarding a fall with major injury that occurred on 11/16/25: ~ Between 4:10 AM and 4:35 AM on 11/16/25, a Certified Nursing Assistant (CNA) lowered R1 to the ground while taking R1 to the bathroom. No injuries were noted at the time of the fall. ~ An entry on 11/16/25 at 5:44 AM indicated there was no apparent injury noted and the physician was notified via the facility's electronic health record system which was also used for communication. ~ An entry on 11/16/25 at 6:36 PM indicated a message from Licensed Practical Nurse (LPN)-J to R1's provider indicated R1 was lowered to the floor and was unable to put pressure on R1's left foot/ankle. R1 reported pain, refused to walk, and had a hard time transferring to and from R1's chair. There was no bruising or swelling at that time. ~ An entry on 11/17/25 at 11:09 AM indicated the facility received a message from R1's provider to obtain an X-ray of the left foot and left tibia/fibula (lower leg bones). The provider also stated to continue Tylenol and update the provider if the X-ray was negative but pain persisted over the next week. (R1's medical record did not indicate when the X-ray of the left foot/ankle was obtained; however, the results were available on 11/19/25 at 4:30 PM.) ~ An entry on 11/19/25 at 4:30 PM indicated the facility received a message from R1's provider that there were no acute concerns. R1 had osteopenia (lower than normal bone density) which would be addressed. R1 appeared to have dementia and had an activated Power of Attorney (POA). An X-ray of the left foot was obtained with 3 + views. ~ An entry on 11/20/25 at 12:16 PM indicated Registered Nurse (RN)-I sent a message to R1's provider that indicated R1 fell on [DATE] which resulted in an ankle injury. The message indicated the provider was mistakenly told that R1's left ankle was injured; however, R1 needed an X-ray of the right ankle which was bruised, swollen, and painful. RN-I requested an order for an X-ray of R1's right foot and right tibia/fibula. ~ An entry on 11/20/25 at 12:20 PM indicated a message was sent from an LPN at the provider's office clarifying the X-ray order which originally stated foot and ankle; however, the new request only stated ankle. ~ An entry on 11/20/25 at 2:22 PM indicated a message was sent from R1's provider to the LPN that indicated the order was for a tibia/fibula and ankle or (sic) right. ~ An entry on 11/21/25 at 3:17 PM indicated an RN from the provider's office messaged the facility regarding R1's right tibia/fibula X-ray results which showed an acute distal fibular fracture. The provider sent the following orders: STAT (immediate) referral to an orthopedist; non-weight bearing to right lower extremity until evaluated with orthopedics; and update provider on R1's pain. ~ An entry on 11/21/25 at 3:18 PM indicated an RN from the provider's office messaged the facility that an ortho referral was sent to (named hospital) and asked the facility to respond to the provider's question. (The facility did not respond until 11/25/25 at 6:24 AM). ~ An entry on 11/24/25 at 6:24 AM indicated LPN-J messaged the provider and indicated R1 was in significant pain when R1 tried to use the foot. The message indicated staff used a lift for R1 and were keeping R1 non-weight bearing which helped. R1 only complained of pain with use of the foot and received scheduled Tylenol. ~ An entry on 11/24/25 at 10:21 AM indicated the provider messaged the facility and asked that R1 see an orthopedic surgeon as soon as possible. The message contained an order for tramadol 25 milligrams (mg) three times daily (TID) as needed for additional pain relief. (The facility indicated an orthopedic surgery consult was scheduled for 11/24/25 at 2:15 PM.) On 12/10/25 at 3:55 PM, Surveyor interviewed Director of Nursing (DON)-B who stated R1 received scheduled acetaminophen twice daily and R1's medical record did not indicate R1 had pain. R1 was prescribed tramadol after an orthopedic appointment but did not receive any doses of tramadol or any PRN acetaminophen. DON-B verified the original message to the provider mentioned the wrong foot which prolonged R1's treatment and healing.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R41) of 22 sampled residents.The facility did not ensure R41's Average Volume Assured Pressure Support (AVAPS) machine was in working condition and did not follow orders to apply R41's AVAPS machine while sleeping.Findings include:The [NAME] Medical (which makes R41's AVAPS model - [NAME] LM150TD) User Guide indicates: .2.1.1 c. Always keep an alternative means of ventilation available in order to avoid life threatening situations if the device fails .According to Zimnoch et al. in the Journal of Clinical Medicine an article on Non-Invasive Ventilation (NIV), published [DATE]: Non-invasive ventilation modalities such as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and AVAPS are a cornerstone in the management of acute and chronic respiratory failure. Inappropriate discontinuation or lack of NIV support when indicated has been shown to increase the risk of escalation to invasive ventilation, longer hospital stays, and increased morbidity due to failure of adequate respiratory support.On [DATE], Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, moderate persistent asthma, acute on chronic diastolic (congestive) heart failure, morbid (severe) obesity with alveolar hypoventilation, dependence on supplemental oxygen, and obstructive sleep apnea. R41's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R41 had intact cognition.R41 had a physician order (dated [DATE]) for AVAPS to be worn daily when napping and sleeping.On [DATE] at 10:14 AM, Surveyor interviewed R41 who indicated R41 was upset that R41's AVAPS machine was not applied the night before. R41 indicated staff put water in the wrong place, didn't know what they were doing, and didn't know how to use the machine. R41 indicated the machine no longer worked due to staffs' error. R41 stated R41 was not supposed to sleep without the machine because R41 had high carbon dioxide (hypercapnia). R41 indicated R41 asked staff to have the machine looked at so R41 didn't have to go without it again. R41 stated R41 almost died in the past due to high carbon dioxide and reiterated that R41 must wear the AVAPS machine while sleeping.On [DATE], Surveyor reviewed R41's plan of care and nursing care card (which was posted in R41's room as a quick reference) and noted neither indicated that R41 used an NIV device. R41's care plan also did not mention respiratory care including oxygen or AVAPS machine use.On [DATE] at 10:44 AM, Surveyor observed R41 asleep in R41's room without the AVAPS machine. Surveyor did not enter the room as R41 had become ill and was on contact precautions.On [DATE] at 9:32 AM, Surveyor observed R41 awake in bed. Surveyor donned personal protective equipment (PPE) and entered the room to interview R41 who indicated R41 was still upset. R41 stated R41 had not worn the AVAPS machine for the past couple nights because staff had called the company to fix it. R41 again indicated R41 was told R41 must wear the AVAPS machine when sleeping because R41's doctor stated R41 had high carbon dioxide and it was dangerous not to wear it. R41 stated R41 told staff the machine needed to be fixed and R41 needed the machine to sleep. R41 indicated R41 had worn the machine to sleep before the machine broke on the evening of [DATE].On [DATE] at 9:51 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated R41 had a CPAP machine. CNA-F indicated the machine did not work and CNA-F needed to call the company to have it fixed but had not had time. CNA-F was aware R41 did not use the machine that day and the night prior, but thought it was because R41 was ill and didn't want to vomit into the mask. CNA-F indicated CNA-F was told in morning report on [DATE] that the AVAPS machine wasn't working. CNA-F didn't know the machine wasn't working on [DATE] or [DATE] and did not work those days.On [DATE], Surveyor reviewed R41's [DATE] Treatment Administration Record (TAR) which contained a physician order for R41 to use the AVAPS machine while napping or sleeping. The TAR indicated R41 used the AVAPS machine while napping/sleeping for all shifts in December to date, including the days the machine was not working (starting on the evening of [DATE]).On [DATE] at 2:45 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should have called the company for repair of the device as soon as they knew it wasn't working. DON-B indicated initials on the TAR for the AVAPS application indicated the order was completed/followed that shift. DON-B indicated staff should not indicate on the TAR that the AVAPS machine was used it it was broken. DON-B indicated AVAPS use should have been on R41's care plan and nursing care card. DON-B stated it was not on R41's care plan because R41 was a newer admission and DON-B had been on vacation the week prior. Surveyor requested the facility's CPAP/AVAPS policy.On [DATE] at 2:54 PM, Surveyor interviewed DON-B who indicated R41 wanted the facility to call R41's daughter so R41's daughter could call the company and get the AVAPS machine repaired. DON-B again indicated the facility should have contacted R41's daughter and/or the company for repair at least by the morning of [DATE].On [DATE], DON-B provided Surveyor with the facility's CPAP policy, dated [DATE]. The policy referred to cleaning CPAP devices but did not address CPAP/AVAPS orders or use. DON-B later confirmed via email that the facility did not have any other policies related to CPAP/AVAPS use.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 2 residents (R) (R25 and R41) of 22 sampled residents.Medications were observed on a table in R25's room. R25 did not have a self-administration of medication assessment that indicated R25 could safely and accurately self-administer medication. In addition, R25 did not have physician orders for the medications.Medications were observed on R41's counter. R41 did not have a self-administration of medication assessment that indicated R41 could safely and accurately self-administer all of the medications. In addition, R41 did not have a physician order for 1 of the medications.Findings include: The facility's Self-Administration of Medication policy, dated 8/2008, indicates: .1. If the resident chooses to self-administer drugs, the Interdisciplinary Team (IDT) must assess the resident's cognitive, physical, and visual abilities to carry out this responsibility. 2. The IDT will determine the resident's ability to participate in self-administration of their medication and inform the resident of their decision which will be evaluated on an ongoing basis. 3. A physician's order will be obtained and recorded in the chart. The order also needs to include which specific medications can be kept at the bedside. 4. Transcribe the physician's order on the Medication Administration Record (MAR). 5. Provide equipment to facilitate self-administration. (Lock box, large print MAR, etc.) 6. Nurse to check with resident daily for appropriate medication administration. 7. Licensed nurse to monitor for medication side effects and provide ongoing education. 8. Licensed nurse to complete self-administration of medication assessment monthly as condition warrants for ongoing evaluation and technique. 9. IDT to review for appropriateness at a minimum quarterly as well as with cognitive and mobility changes and with significant change in status. 10. Place on resident care plan, review and revise as needed.1. On 12/8/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including acquired absence of other specified parts of digestive tract (colectomy), nausea with vomiting, abdominal pain, and slow transit constipation. R25's Minimum Data Set (MDS) assessment, dated 10/27/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R25 had intact cognition.On 12/8/25 at 10:37 AM, Surveyor interviewed R25 and observed medication in R25's room. Surveyor noted a bottle of Refresh Tears eye drops and a bottle of vitamin C pills on a stand near the door. The medications were visible from the right side of the hallway and R25's door was partially open. Neither of the medications contained a pharmacy label. R25 indicated the medications belonged to R25.Surveyor reviewed R25's MAR which did not contain orders for the medications. In addition, R25's plan of care did not indicate R25 could self-administer medication or have medication at the bedside. R25's medical record contained a self-administration of medication assessment, dated 10/20/23, that indicated R25 was forgetful and not able to self-administer medication. On 12/9/25 at 10:24 AM, Surveyor noted R25's door was open. R25 had a guest in the room and was in bed. Surveyor again observed Refresh Tears eyedrops and vitamin C pills on the stand near the door and within eye sight from the hallway.On 12/10/25 at 9:40 AM, Surveyor observed Refresh Tears eyedrops and vitamin C pills on a stand near the door of R25's room and in eye sight from the hallway. Surveyor interviewed R25 who stated the eyedrops and vitamin C pills had been there a long time and were from home. R25 indicated R25's spouse visited every other day and often gave R25 the medication.2. On 12/8/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, moderate persistent asthma, acute on chronic diastolic (congestive) heart failure, morbid (severe) obesity with alveolar hypoventilation, dependence on supplemental oxygen, and obstructive sleep apnea. R41's MDS assessment, dated 11/27/25, had a BIMS score of 14 out of 15 which indicated R41 had intact cognition.On 12/8/25 at 10:14 AM, Surveyor observed R41's room and noted Biofreeze gel and Cepacol throat spray on R41's counter. Neither medication contained a pharmacy label. Surveyor also observed containers of nystatin powder and nystatin cream with pharmacy labels. Surveyor observed a bottle of One A Day vitamins on a bedside tray. Surveyor interviewed R41 who indicated staff gave R41 the medications. R41 indicated R41 required a lift for transfers and needed staff assistance to get around the room.Surveyor reviewed R41's plan of care and nursing care card. The nursing care card was posted in R41's room as a quick reference for care but did not indicate that R41 could have bedside medications. R41's plan of care indicated R41's medications should be administered as ordered and staff should monitor R41 for efficacy and adverse effects. R41's plan of care did not indicate that R41 was approved to self-administer medication or keep medication at the bedside.Surveyor reviewed R41's MAR which contained the following orders: ~ Nystatin cream 100000 units/gram (gm); twice daily as needed. The order did not indicate the medication could be kept at the bedside or self-administered.~ Nystatin powder 100000 units/gm; daily as needed. The order did not indicate the medication could be kept at the bedside or self-administered.~ Menthol gel (Biofreeze); Apply twice daily to elbows and legs for pain. May keep at bedside if desired. The order did not indicate the medication could be self-administered.R41's MAR did not contain an order for Cepacol throat spray.A self-administration of medication assessment, dated 11/21/25, indicated R41 could self-administer medication.On 12/9/25 at 9:24 AM, Surveyor observed R41 asleep in R41's room. Surveyor did not enter the room because R41 had become ill and was on contact precautions.On 12/10/25 at 9:32 AM, Surveyor observed R41 awake in bed. Surveyor donned personal protective equipment (PPE) and entered the room to interview R41. Surveyor observed nystatin cream, nystatin powder, and Cepacol throat spray on the counter. R41 indicated staff applied the nystatin medications to R41 and left the medications on the counter.On 12/10/25 at 10:24 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated residents should not have medication in the room unless they have a physician's order for beside medication and a self-administration of medication assessment. DON-B indicated each medication should be approved for self-administration and bedside storage. DON-B stated residents who wish to keep medication at the bedside or self-administer medication should be assessed monthly. DON-B confirmed all resident medications must have a physician's order in order to be administered by staff or self-administered by the resident. DON-B stated care plans should also address bedside medication and self-administration of medication. DON-B was not sure why R25 and R41 had medications in their rooms that did not have orders. DON-B stated R25's spouse visited daily and often completed R25's cares. DON-B indicated staff should still check on R25 even though family helps daily. DON-B confirmed R25 and R41 were not able to self-administer medication.On 12/10/25 at 10:45 AM, DON-B approached Surveyor and indicated R41 had an approved self-administration of medication assessment; however, it was not for the medications that were in R41's room. DON-B indicated the medications were removed from R25 and R41's rooms.

Based on family representative interview, staff interview and record review, the facility did not notify a Power of Attorney for Healthcare (POAHC) about an allegation of abuse for 1 resident (R) (R1) of 3 sampled residents. On 8/30/24, Certified Nursing Assistant (CNA)-E alleged Licensed Practical Nurse (LPN)-D pushed R1 back into R1's wheelchair when R1 attempted to stand up. Staff did not notify R1's POAHC of the allegation of abuse. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised 6/20/21, indicates: Abuse Investigations .8) The Administrator will keep the resident and/or his/her representative informed of the progress of the investigation .11) The administrator will inform the resident and/or his/her representative of the results of the investigation and corrective action taken within 4 working days of the completion of the investigation. On 10/30/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, and bipolar disorder. R1's Minimum Data Set (MDS) assessment, dated 9/4/24, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severe cognitive impairment. R1 had an activated POAHC. On 10/30/24, Surveyor reviewed a facility-reported incident (FRI) investigation, dated 9/11/24, that indicated CNA-E alleged LPN-D pushed R1 back into R1's wheelchair when R1 attempted to stand up. The investigation did not indicate R1's POAHC (POAHC-C) was notified of the allegation of abuse. On 10/30/24 at 10:57 AM, Surveyor interviewed POAHC-C via telephone. POAHC-C indicated POAHC-C was not informed of the allegation of abuse. POAHC-C indicated the first time POAHC-C heard of the alleged abuse was when Surveyor called. On 10/30/24 at 2:06 PM, Surveyor interviewed Director of Nursing (DON)-B who verified there was no documentation to confirm POAHC-C was notified of the allegation of abuse. DON-B indicated POAHC-C was informed on a case-by-case basis which was determined by Nursing Home Administrator (NHA)-A. DON-B indicated since there was no injury, POAHC-C wasn't notified. On 10/30/24 at 2:42 PM, Surveyor interviewed NHA-A who confirmed POAHC-C was not notified of the allegation of abuse but should have been notified.

Based on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 (Licensed Practical Nurse (LPN)-D) of 1 contracted staff reviewed for a caregiver background check. The facility did not ensure a thorough and timely caregiver background check was completed for LPN-D. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a review date of September 2024, indicates: Not only does the mission of our organization demand that residents be free from abuse, but so do Wisconsin and Federal regulations .In order to comply with the requirements of the Elder Justice Act, [NAME] Home will .4) Refrain from employing any individual who has been prohibited from a long-term care facility because of failure to report a suspicion of a crime against a resident of a long-term care facility. LPN-D was hired on 10/27/23. On 10/30/24 at 3:30 PM, Surveyor requested LPN-D's caregiver background check information from Nursing Home Administrator (NHA)-A. NHA-A indicated Human Resources (HR) was responsible for completing caregiver background checks for new staff. At 3:35 PM, NHA-A informed Surveyor that NHA-A was unable to obtain LPN-D's background check information because HR had left for the day. Surveyor requested NHA-A submit LPN-D's background check information via email. NHA-A indicated NHA-A would send the information via email the next day. On 10/31/24 at 11:15 AM, Surveyor emailed NHA-A and again requested LPN-D's background check information. Surveyor did not receive a response and has not received a Background Information Disclosure (BID) form, Department of Justice (DOJ) criminal background check letter, or Integrated Background Information System (IBIS) letter for LPN-D as of this writing.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 3 sampled residents. On 8/30/24, Certified Nursing Assistant (CNA)-E alleged Licensed Practical Nurse (LPN)-D pushed R1 back into R1's wheelchair when R1 attempted to stand up. LPN-D was not provided abuse education prior to returning to resident care on 9/13/24. Findings include: The facility's Abuse, Neglect and Exploitation Prevention and Reporting Policies and Procedures, revised 6/20/21, indicates: Abuse Investigations .6) Employees of [NAME] Home who have been accused of resident abuse will be suspended from duty until the Administrator has reviewed the results of an investigation. If it is determined that an employee requires any training, the training must be completed before the employee is allowed to return to work. On 10/30/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, and bipolar disorder. R1's Minimum Data Set (MDS) assessment, dated 9/4/24, indicated R1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R1 had severe cognitive impairment. R1 had an activated Power of Attorney for Healthcare (POAHC). On 10/30/24, Surveyor reviewed a facility-reported incident (FRI) investigation, dated 9/11/24, that indicated CNA-E alleged LPN-D pushed R1 back into R1's wheelchair when R1 attempted to stand up. The investigation indicated R1, other residents, and staff were interviewed and contained written statements from CNA-E and LPN-D. The alleged abuse was reported to the State Agency (SA) within the appropriate timeframe. On 10/30/24, Surveyor reviewed education on the facility's Abuse, Neglect, and Exploitation policy, dated 9/10/24, related to reporting incidents to administration in a timely manner. Surveyor reviewed the education sign-in sheets and noted LPN-D's name and signature were not on the sign in-sheets. On 10/30/24 at 1:27 PM, Surveyor called LPN-D but was unable to leave a message. On 10/30/24 at 2:06 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated if LPN-D's name and signature were not on the education sheets, the facility did not have LPN-D's education. DON-B indicated staff are provided abuse education during orientation, annually, and as needed. DON-B agreed LPN-D should have been educated before LPN-D returned to work.

Based on observation, staff interview, and record review, the facility did not ensure food was stored in a sanitary manner. This practice had the potential to affect multiple residents residing in the facility. Kitchen equipment and food storage areas were not in a clean and sanitary condition. Findings include: On 8/19/24 at 9:15 AM, Kitchen Supervisor (KS)-D stated the facility follows the Food and Drug Administration (FDA) Food Code. The 2022 FDA Food Code documents at 3-305.11 Food Storage: Except as specified in paragraph (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 centimeters (6 inches) above the floor. The 2022 FDA Food Code documents at 3-305.12 Food Storage, Prohibited Areas: Food may not be stored: .(F) Under sewer lines that are not shielded to intercept potential drips; (G) Under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed; (H) Under open stairwells; or (I) Under other sources of contamination. The 2022 FDA Food Code documents at 4-501.11 Good Repair and Proper Adjustment: Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable (FDA Food Code 2022 Annex 3). The facility's contracted service's Food Storage Policy, dated 3/30/24, indicates: Sufficient storage facilities will be provided to keep food safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants .Racks and other storage surfaces should be clean and protected from splashes, overhead pipes, and contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). During an initial kitchen tour on 8/19/24 at 9:23 AM, Surveyor and KS-D observed the walk-in freezer and noted packages and boxes of food on the shelving units. The shelves and seal near the door entrance contained extensive frost. In addition, the back third of the freezer contained significant ice buildup. Surveyor noted solid ice hung from the ceiling, motor/fan units, and shelves and there was thick ice buildup on the walls and in two lines on the floor. The ice on the floor was higher than 1.5 inches high where it appeared to drip down in two rows of solid ice humps affixed to the floor. There were flat areas of ice around the ice humps and the floor of the freezer was slippery. Ice on the fans, ceiling, walls, and shelves appeared to collect from dripping condensation or water in the back of the freezer. KS-D indicated the frost near the door probably occurred when the door was left open and stated the frost and ice would be addressed with maintenance staff. KS-D verified the ice on the floor, walls, and shelves was a problem. KS-D used KS-D's hand to brush off the frost build up on shelving near the door/entrance. On 8/20/24 at 9:42 AM, Surveyor interviewed KS-D who stated KS-D spoke with Maintenance Staff (MS)-G regarding the ice buildup and MS-G ordered a new gasket for the freezer door. Surveyor and KS-D again viewed the walk-in freezer. The ice observed on the floor, walls, ceiling, motor/fan units, and shelves was still present and in the same condition. The frost near the door/entrance was removed. KS-D stated the ice in the back of the freezer had not been cleaned up because it would just keep happening. On 8/20/24 at 12:50 PM, Surveyor interviewed KS-D, Certified Dietary Manager (CDM)-F, and Regional Manager (RM)-E. CDM-F was not sure how long the freezer has been collecting and dripping ice but stated it had been that way for a few months. CDM-F chopped the ice with a [NAME] every few days to knock it down and clear it off. CDM-F mentioned the issue to maintenance staff a couple of times. RM-E stated the last time RM-E was in the walk-in freezer was approximately one and a half months prior to the survey and the ice buildup was happening then. KS-D started in May of 2024 and stated the freezer had been malfunctioning and collecting ice buildup since then. On 8/20/24 at 12:57 PM, Surveyor interviewed MS-G who initially stated MS-G was made aware of the issue the day prior and ordered a new seal for the freezer door to prevent frost near the entrance. When Surveyor and MS-G viewed the ice buildup in the freezer, MS-G acknowledged the ice buildup was an ongoing issue which had been occurring for awhile. MS-G previously removed ice from the ceiling, shelves, and floor. MS-G stated the buildup happens because kitchen and food vendor staff leave the door open too long while the motor is on which causes condensation and dripping water on the floor, walls, ceiling, motor/fan units, and shelves. On 8/20/24 at 1:06 PM, MS-G showed Surveyor two signs (one on the freezer door and one near a switch outside the door) that indicate staff should turn off the freezer to prevent ice buildup when loading/unloading/keeping the door open. MS-G stated the ice collection from dripping condensation was a safety issue for the food in the freezer and potential staff injury and needed to be addressed.

Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R31, R30, and R32) of 3 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of the transfers. R31 was transferred to the hospital on 1/16/24 and 6/5/24. R31, R31's representative, and the Ombudsman were not provided with written notice of the transfers. R30 was transferred to the hospital on 6/8/24. R30, R30's representative, and the Ombudsmen were not provided with written notice of the transfer. R32 was transferred to the hospital on 8/19/24. R32, R32's representative, and the Ombudsmen were not provided with written notice of the transfer. Findings include: The facility's Transfers and Discharges document, dated 12/1/08, indicates: As members of the Interdisciplinary Team, Social Services staff will participate in all room transfers and discharges including room changes, transfers between facilities, and transfers between distinct parts within the same building .Transfers and discharges should be handled appropriately to assure proper notification and assistance to residents and families in accordance with federal and state specific regulations .The Social Services Director will ensure systems are implemented to provide written notification to the resident and family prior to the transfer. If the resident has been adjudicated, the legal guardian will be notified of the transfer .The timing of the notification will be based on state and federal regulations. The resident and their family will be notified verbally for unplanned acute transfers (the written notice will follow the verbal notification as soon as possible). A copy of the written notice of transfer is to be included in the resident's record. 1. From 8/19/24 to 8/21/24, Surveyor reviewed R31's medical record. R31 had diagnoses including Alzheimer's dementia and chronic obstructive pulmonary disease (COPD) with associated chronic respiratory failure frailty and deconditioning. R31's Minimum Data Set (MDS) assessment, dated 6/10/24, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R31 had severely impaired cognition. R31's medical record indicated R31 was transferred to the hospital on 1/16/24 due to complications of COPD, shortness of breath, and a possible urinary tract infection. Surveyor also noted R31 was transferred to the hospital on 6/5/24 due to a low oxygen level, shortness of breath, coughing, and vomiting. R31's medical record did not indicate a written transfer notice was provided to R31, R31's representative, or the Ombudsman. On 8/20/24, Surveyor requested transfer notifications for R31 from Nursing Home Administrator (NHA)-A who indicated transfer notifications were not provided for R31's hospital transfers on 1/16/24 and 6/5/24. 2. From 8/19/24 to 8/21/24, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident, hemiplegia (paralysis on one side of the body), muscle weakness, dysphasia (difficulty swallowing), and renal failure. R30's MDS assessment, dated 7/16/24, had a BIMS score of 9 out of 15 which indicated R30 had moderately impaired cognition. R30 had an activated Power of Attorney (POA). R30's medical record indicated R30 was transferred to the hospital on 6/18/24 for dehydration. R30's medical record did not indicate a transfer notice was provided to R30, R30's POA, or the Ombudsman. 3. From 8/19/24 to 8/21/24, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with diagnoses including kidney failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), and venous insufficiency. R32's MDS assessment, dated 7/16/24, had a BIMS score of 8 out of 15 which indicated R32 had moderately impaired cognition. R32 had an activated POA. R32's medical record indicated R32 was transferred to the hospital on 1/9/24 for evaluation of tachycardia (an increased heart rate), diaphoresis (excessive sweating), and increased lethargy. R32's medical record did not indicate a transfer notice was provided to R32, R32's POA, or the Ombudsman. On 8/20/24 at 1:15 PM, Surveyor interviewed Social Services (SSD)-C who stated SSD-C was responsible for transfer notifications including notification to the Ombudsman. Surveyor requested transfer notifications sent to the Ombudsman. On 8/21/24 at 7:45 AM, Surveyor received a list of residents who were emergently transferred within the last six months. Surveyor observed a note from SSD-C on the list that indicated there were no notifications sent to the Ombudsman since the previous Social Services Director left. On 8/21/24 at 8:08 AM, Surveyor interviewed SSD-C who stated when SSD-C receives notification of a transfer, SSD-C files the notification and does not provide the resident and/or their representative with a written notification. SSD-C confirmed the facility's policy and procedure for transfer notices was not being followed.

Based on resident and staff interview and medical record review, the facility did not ensure Resident (R) wishes regarding code status were clearly and accurately identified for 2 of 22 residents (R38 and R39) investigated for Advance Directives. R38 verbalized the desire to be a full code. R38's medical record was inconsistent, identifying R38 as both a full code and a Do Not Resuscitate (DNR). Additionally, when R38 expressed a desire to be full code, the facility did not change the record until the next day. R39's medical record did not reflect R39's wishes to be DNR. Facility failure to clearly identify resident wishes for resuscitation created a finding of immediate jeopardy that began on [DATE]. Regional Field Operations Director notified NHA (Nursing Home Administrator)-A of the immediate jeopardy on [DATE] at 4:10 PM. The facility removed the jeopardy on [DATE]; however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Additionally, the facility did not ensure a Power of Attorney for Health Care (POAHC) document was obtained or offered to create (in the absence of an existing document) for 2 of 22 sampled residents (R) (R33 and R46.) R33 was admitted to the facility on [DATE]. R33 did not have a POAHC document in R33's medical record. R46 was admitted to the facility on [DATE]. R46 did not have a POAHC document in R46's medical record. Findings: 1. Facility policy titled [NAME] Home - Resident's Rights Regarding Treatment and Advance Directives, with a revised date of ,d+[DATE], stated, During the care planning process, [NAME] Home will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to the Advance Directives, that copies of Advance Directives would be placed in the resident's chart and communicated to staff, and Any decision making will be documented in the resident's medical record and communicated to the interdisciplinary team. On [DATE] at 10:00 AM, Surveyor conducted a medical record review for R38, which indicated R38 was last admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's medical record indicated R38's cognition was intact. R38 had a guardian and was protectively placed. R38's spouse was R38's guardian, was active in R38's life and assisted R38 in decision making per R38. On [DATE] at 12:30 PM, Surveyor observed that R38 had 3 paper medical record charts that identified R38 as a Do Not Resuscitate (DNR). An orange sticker on the chart binder was printed with the letters DNR. R38's face sheet located just inside the chart cover, identified R38 as a Full Code. R38's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 1:10 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G and asked where LPN-G would look for a resident's code status if LPN-G came upon a resident who was pulseless and non-breathing. LPN-G stated to Surveyor, I would look at the face sheet inside the chart. R38's face sheet indicated R38 was a full code. On [DATE] at 1:15 PM, Surveyor interviewed R38 who stated, I want to stay a full code. On [DATE] at 1:30 PM, Surveyor interviewed Director of Nursing (DON)-B and advised DON-B of Surveyor's conversation with R38 in which R38 indicated R38 wished to be a full code. DON-B indicated being at a meeting with R38 and R38's guardian/spouse previously in which R38 and R38's guardian/spouse decided R38 would be a DNR and indicated the DNR form was signed and dated. Surveyor was provided the DNR form dated and signed by R38's guardian and provider on [DATE]. DON-B stated R38 was a DNR. I'll fix that now. DON-B called another staff person with Surveyor present and directed staff person to change R38's face sheet to read DNR. Surveyor reiterated that R38 stated R38 wanted to be a full code. Surveyor indicated there needed to be another discussion with R38 and guardian/spouse. DON-B then called social services while Surveyor was in the room and directed social services to arrange for a meeting with R38's guardian/spouse. On [DATE] at 1:47 PM, DON-B approached Surveyor and stated DON-B didn't mean during previous discussion that DON-B would just change R38 to a DNR and planned to meet with R38 and guardian/spouse to talk about R38's code status again and was going to try to get the guardian/spouse into the facility tomorrow. Surveyor asked DON-B what would be done in the meantime as R38's medical records were not clear as to code status and R38 indicated wanting to be a full code. DON-B then called social services and requested a meeting be set up with spouse for this same day, [DATE], if possible, to discuss R38's code status. On [DATE] at 1:55 PM, Surveyor was notified that a meeting with R38's guardian/spouse was arranged for the following day, [DATE] at 11:00 AM. On [DATE] at 7:45 AM, Surveyor reviewed R38's paper chart which included a revised face sheet indicating R38 was DNR. On [DATE] at 8:00 AM, Surveyor met with and interviewed Nursing Home Administrator (NHA)-A and DON-B. Surveyor asked DON-B if DON-B had talked to R38 and R38's guardian/spouse about R38's desire to be a full code and DON-B indicated DON-B had not called R38's guardian/spouse and had not talked to R38 the previous day stating they were meeting on same date ([DATE] at 11:00 AM) to discuss the code status. Surveyor asked DON-B if DON-B had R38's face sheet revised to indicate R38 was a DNR and DON-B indicated yes and stated, I thought the paperwork all had to match, be the same as the DNR document so I had the face sheet changed to read DNR. Surveyor asked DON-B if the change had been made knowing R38 desired to be a full code and DON-B indicated a meeting was scheduled with R38 and R38's guardian/spouse on same date at 11:00 AM. Surveyor asked DON-B if R38 had become pulseless and non-breathing between the time the face sheet was revised to read DNR on [DATE] and the meeting with R38 and R38's guardian/spouse on this date at 11:00 AM. DON-B indicated R38 would not have had CPR which is what was expressed per R38's DNR document. NHA-A stated, it should have been addressed right away, of R38's verbalization to be a full code. NHA-A indicated that staff could have talked with R38's guardian/spouse and that R38 could have torn the DNR document up. On [DATE] at 8:30 AM, DON-B stated to Surveyor, It is all taken care of, indicating a discussion had taken place with R38 and R38's guardian/spouse and R38 was changed to a full code as that is what resident and spouse/guardian desired. DON-B indicated DON-B should have taken other measures when DON-B became aware of R38's wishes to be a full code the previous day and indicated understanding this fully now. DON-B indicated DON-B thought that only the guardian could make the decision for R38 regarding R38's code status. R38's Letters of Guardianship of the Person Due to Incompetency dated [DATE], stated the guardian of person is authorized to exercise the following specific powers in full or in part to 1.A. give informed consent to the voluntary receipt by the ward of a medical examination, medication, including an appropriate [CONDITION(S)] medication, and medical treatment that is in the ward's best interest, if the guardian has first made a good-faith attempt to discuss with the ward the voluntary receipt of the examination, medication, or treatment and if the ward does not protest. R38 did not want to be a DNR and expressed the desire to be a full code. On [DATE] at 2:29 PM, Surveyor interviewed LPN-H who indicated if LPN-H came upon a resident who was pulseless and non-breathing, LPN-H would look at the outside of the chart binder. LPN-H demonstrated by pointing to the outside binder area of the chart. LPN-H indicated if it was not an emergency, would also check inside the chart on the face sheet and under the advance directives tab in the chart. On [DATE] at 2:30 PM, another Surveyor interviewed Registered Nurse (RN)-I who was working the evening shift of duty and indicated RN-I would look at the spine of the chart. RN-I indicated that some residents would wear a DNR bracelet, but others would have it kept in front of the chart in a zip lock baggy. RN-I indicated RN-I trusted that the spine of the chart was correct and had never had an instance where it was not. On [DATE] at 2:37 PM, another Surveyor interviewed RN-J. RN-J indicated a resident's code status would be found on the chart on the outside at a quick glance, and that DNR paperwork was also right in the front of the chart. On [DATE] at 02:37 PM, another Surveyor interviewed LPN-K who indicated LPN-K would check the outside of the chart and look on the inside for a DNR form. 2. On [DATE] at 9:53 AM, Surveyor conducted a medical record review for R39 which indicated R39 was last admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's medical record indicated R39's cognition was moderately impaired. R39 had an activated Power of Attorney for Healthcare (POA-HC). R39's family member was R39's POA-HC and assisted R39 in decision making per R39's medical record. Upon admission, R39 was documented as Full Code. On [DATE] at 4:36 PM, Surveyor observed R39's paper chart had one green sticker with Full Code on the binding of the chart and one green sticker with Full Code on the cover of the chart. R39's paper chart included a document titled Interdisciplinary Care Conference Summary dated [DATE] at 1:00 PM which included Code Status: Full Code. R39's medical record included a Social Service Progress Note dated [DATE] at 3:54 PM that stated: I [SWD (Social Worker Designee)-X] spoke with [R39's POA-HC], [R39's] activated POA, in regard to [R39's] speech therapy ending. [POA-HC] was pleased to hear how well [R39] is doing. Asked that I [SWD-X] mail the ABN (Advance Beneficiary Notice of Noncoverage) notice to [POA-HC] to sign. I [SWD-X] also spoke with [R39] today about [R39's] request to become a DNR. [R39] did agree that [R39] was interested in this and I [SWD-X] asked [R39] if it was O.K. for me [SWD-X] to contact [POA-HC]. [R39] said that [R39] would like me [SWD-X] to talk to [POA-HC]. [POA-HC] agrees with [R39]. [R39] also says [R39] is interested in no further hospital stays. [POA-HC] says that [POA-HC] will talk to [POA-HC's] [R39] about this soon. R39's medical record did not contain any follow-up regarding R39's wishes and POA-HC wishes to change R39's code status to DNR. On [DATE] at 4:17 PM, Surveyor interviewed POA-HC via telephone. POA-HC stated, I thought it (R39's DNR status) was already requested. POA-HC stated that in March of 2022, after discussing DNR status with R39's family and hearing R39's wishes, POA-HC was going to honor her choice of changing R39's code status from full code to DNR. POA-HC stated the impression POA-HC had after the discussion with the facility was that R39's code status was changed because R39 had requested to be DNR. On [DATE] at 8:19 AM, Surveyor received R39's Advance Directive document dated [DATE]. R39's Advanced Directive was activated [DATE]. R39's Advanced Directive page six of nine indicated, I do not want CPR. Let me die a natural death. On [DATE] at 8:34 AM, Surveyor interviewed DON-B who stated, Yes that should have been followed up on after the Social Service Progress Note on [DATE]. On [DATE] at 2:30 PM, Surveyor interviewed SWD-X who stated R39's last care conference was ,d+[DATE]. SWD-X is sure that another care conference was performed, but did not document on the form and that form is the only place care conferences are documented. SWD-X took over as a Social Worker Designee in [DATE]. SWD-X stated R39 had wanted to be full code until March of 2022 when R39 indicated R39 wanted to be DNR. SWD-X stated SWD-X sent the DNR document via mail to POA-HC to be signed and returned Quite some time ago and Probably after the March discussion. SWD-X stated R39's POA-HC usually sends POA-HC's spouse in place of POA-HC to facility and that SWD-X requested POA-HC's spouse to call SWD-X or send the DNR paperwork back to SWD-X. SWD-X stated SWD-X called R39's POA-HC today ([DATE]) and is awaiting a return call. SWD-X stated, Like [SWD-X ] said [SWD-X] have reached out to [POA-HC] and [POA-HC and spouse] several times and at this point [SWD-X] am going to ask [R39] how [R39] feels about it before [SWD-X] reaches out to [POA-HC] again. On [DATE] at 3:22 PM, NHA-A stated R39 is now wishing to stay full code and wants CPR performed. According to a 2016 Division of Appeals Board hearing decision, It is important to not lose sight of the fact than an error in deciding whether or not to resuscitate a resident has dire implications: either someone who had a desire to live faces death without any chance for survival, or a person who desired a natural death is forced to undergo significant interventions, such as chest compressions and defibrillation, in an attempt to extend a life that he or she did not want to be unnaturally extended .If staff members are required to reconcile conflicting orders involving the question of resuscitation during a medical emergency, the resulting inconsistent action is likely to cause serious harm, injury, impairment, or death. https://www.hhs.gov/sites/default/files/static/dab/decisions/alj-decisions/2016/cr4545.pdf The failure to ensure resident's advance directives were clearly and accurately stated in the record and affirm residents received prompt emergency care consistent with their wishes if they become pulseless and non-breathing, created a reasonable likelihood for serious harm, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it had completed the following: 1. Interviewed and correctly updated the medical record regarding DNR status for R38 and R39. 2. Reviewed the charts of all residents who currently have an advanced directive to ensure accuracy and ensure compliance with facility policy and procedure. 3. Trained all facility nurses on Advanced Directive/DNR/CPR policy and procedure to include the exact locations in each resident's chart where advanced directives executed by the resident can be found. Additionally, facilty trained Social Workers on the requirements of the facility Advanced Directive/DNR/CPR policies. Training included the requirement for them to promptly comply and implement current and newly admitted resident's wishes in respect to advanced directives. 4. Reviewed and revised the DNR communication system to create easier access for staff. 3. The facility document titled [NAME] Home - Residents' Rights Regarding Treatment and Advance Directives (legal document that address your wishes with respect to future healthcare and medical treatment, also referred to and same as a POAHC document,) revised February 2020 stated: It is the resident's right to formulate an Advance Directive . Policy Explanation and Compliance Guidelines: 1. On admission, [NAME] Home will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive. On [DATE] at 8:21 AM, Surveyor reviewed R33's medical record which stated R33 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) R33 was R33's own decision maker. R33's medical record did not include a POAHC document. On [DATE] at 3:08 PM, Surveyor interviewed SW-F who stated SW-F did not see a POAHC document in R33's medical record, but the medical record indicated R33 did have a POAHC made. SW-F stated SW-F would check with Social Worker Designee (SWD)-X, who oversaw R33. On [DATE] at 3:19 PM, Surveyor interviewed SWD-X. SWD-X looked in R33's file and did not find a POAHC document. SWD-X stated SWD-X would address the POAHC document with R33. SWD-X stated POAHC documents were discussed upon admission and would assist a resident if a POAHC document needed to be created. SWD-X stated if a resident would decline to create a POAHC document, SWD-X would document that under a social services note. On [DATE] at 2:38 PM, Surveyor interviewed SWD-X who stated SWD-X talked with R33 who verified R33 did not have a POAHC document, but was interested in writing one up with the assistance of SWD-X. 4. On [DATE] at 8:46 AM, Surveyor reviewed R46's medical record which indicated R46 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R46 was their own decision maker. R46's medical record did not include a POAHC document. On [DATE] at 3:10 PM, Surveyor interviewed SWD-X who verified R46 did not have a POAHC document in R46's medical record. R46's medical record included a note that stated R46 would think about making a POAHC document, but that was when R46 was first admitted to the facility in September of 2021. SWD-X stated that was when R46 was possibly interested in creating POAHC document. R46 was then discharged in December of 2021. R46 was readmitted February of 2022 and still did not have a POAHC document.

Based on record review and staff interview, the facility did not ensure that respiratory assessments were completed as ordered for 1 Resident (R) (R1) of 3 sampled residents. R1 had a nurse practitioner's order to conduct respiratory assessments two times per shift ordered on 3/16/21. Respiratory assessments were only completed two times per day following the 3/16/21 order. R1 developed symptoms of respiratory distress on 3/19/21 that required emergency transport to hospital with a subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: On 3/29/21, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was discharged to the hospital on 3/19/21 and readmitted to the facility on [DATE]. R1's Minimum Data Set (MDS) assessment dated [DATE] stated R1's Brief Interview for Mental Status (BIMS) score was 06 of 15 which indicated R1 had severe cognitive impairment. R1's medical record contained a nursing progress note dated 3/16/21 which stated, [R1] noted to have an increase in confusion and weakness. [R1] appears red in the face and very warm to the touch, however [R1's] room is very warm. Vitals: 141/80 (blood pressure), 106 (pulse), 99.2 (temperature), 89-90% (percent) (oxygen saturation level in the blood) on 3 liters (measure of oxygen being supplied). [R1] denies any shortness of breath, but states that [R1] doesn't feel well without any elaboration on symptoms. [R1] is noted during auscultation (listening to the lungs with stethoscope) to have congestion and rhonchi (abnormal lung sounds) . Additionally, R1's medical record contained the following orders, dated 3/16/21, from R1's Nurse Practitioner (NP) in response to facility's update to NP on the above change of condition: Please place on isolation Medications to start: - [MEDICATION(S)] (used to treat congestion caused by breathing illnesses) 1200mg (milligrams) po (by mouth) BID (twice daily) for 14 (fourteen) days - [MEDICATION(S)] (used to prevent and treat wheezing and shortness of breath caused by breathing problems) 2 (two) puffs prn (as needed) tid (three times daily) and scheduled tid for 14 days. - O2 (oxygen) per NC (nasal cannula) 1-6L (liters) to keep O2 sat (oxygen saturation) above 90%, updated if required Labs to obtain: - Rapid influenza (test to detect influenza virus which can cause respiratory illness) - COVID testing (test to detect Covid-19, a mild to severe respiratory illness that is caused by a coronavirus and at the time of this situation considered pandemic, meaning worldwide spread) - CBC (Complete Blood Count, a test to check certain blood cell levels) - CMP (Comprehensive Metabolic Panel, a blood test that provides information about liver and kidneys, body sugar and protein levels, and electrolyte and fluid balance) - CRP (C-reactive Protein, a blood test used to detect inflammation) - Chest xray . (test used to view condition of organs in chest area such as lungs) Monitor X (times) 14 days - Vs (vital signs) 2x/shift (two times per shift) - Respiratory assessment 2x shift (two times per shift) On 3/29/21 at 11:15AM, Surveyor interviewed Director of Nursing (DON)-B who indicated respiratory assessments were documented in the nursing progress notes under Respiratory Findings or could be under Antibiotics if a resident was on antibiotics for a respiratory infection. On 3/29/21, Surveyor reviewed R1's medical record. R1's nursing progress notes contained the following respiratory assessments: ~3/16/21 at 12:00PM the original assessment listed above was documented. ~3/17/21 at 8:42PM: Respiratory Findings: shortness of breath or trouble breathing when sitting at rest, Respirations: regular, (on oxygen) 3L. ~3/18/21 at 9:16PM: Respiratory Findings: no problems noted. ~3/19/21 at 2:39AM: Respiratory Infection: Resident started on [MEDICATION(S)] (antibiotic used to treat infections) for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [R1] appears to be tolerating medication well. [R1] is afebrile (no fever) with temp (temperature) 98.5. No cough noted or reported. [R1] is tired and weak skin is dray and very warm to the touch. Rhonchi heard in lungs. SPO2 (oxygen saturation) 90% 3.5L. No s/sx (signs and symptoms) of adverse reaction to antibiotic therapy. Fluid intake is encouraged. Staff will continue to monitor, encourage fluid and nutritional intake, and report any changes in circulatory status while remains on antibiotic therapy. ~3/19/21 at 10:14AM: Unable to arouse [R1]. Decrease in o2 (oxygen) sats (saturation) even with increase of o2 levels, increased respirations and pulse. Resident sent out 911 (emergency). ~3/19/21 at 2:04PM: Upon checking on [R1] it was noted that [R1] had increased respirations and skin warm to the touch. [R1's] o2 was mid/high 70s on 3.5L via NC. Writer increased o2 with results of o2 sats low/mid 80s. [R1] was not responsive had tremors and was not at baseline. [R1] sent to ER (emergency room ) via 911. ER contacted facility approx. (approximately) noon and was updated on [R1's] condition, respiratory concerns/sob (shortness of breath); voice that [R1] was in poor condition and utilizing [CONDITION(S)] (a type of device that helps with breathing). [R1] was noted to have a fever of 106.0 rectally . Late Entry . On 3/29/21 at 1:22PM, Surveyor interviewed DON-B who indicated expectation of a respiratory assessment would be for nurse to listen to lung sounds, check oxygen saturation level, check for any signs of coughing or shortness of breath and check for skin color changes. When questioned regarding Surveyor not finding twice per shift respiratory assessments documented in nursing progress notes for R1, DON-B stated, Might be on treatment record, there would be initials that it (respiratory assessment) was done. On 3/29/21, Surveyor reviewed facility provided Treatment Administration Record (TAR) for R1 which included the following orders: - Assess blood pressure pulse respirations temp twice a day AM (morning) HS (bedtime) x 14 days First Date: 3/16/21 Last Date: 3/30/21 - Respiratory Assessment twice a day x 14 days AM HS First Date: 3/16/21 Last Date: 3/30/21 On 3/29/21 at 1:43PM, Surveyor interviewed DON-B who indicated the NP orders for R1 were entered into the facility's electronic medical record incorrectly. DON-B verified respiratory assessments for R1 were not completed twice per shift as ordered.

Based on staff interview and record review, the facility did not immediately consult with 1 (resident #1) of 13 sampled resident's physician when there was a significant change in the resident's physical status or a need to alter treatment significantly. Resident #1 was at risk for bleeding related to her medications, which included [MEDICATION NAME]. On 11/10/11 resident #1 experienced loose, black, tarry stools at approximately 9:00 a.m. Despite the black stool, an indicator of a potential GI (gastrointestinal) bleed, and complaints of stomach pain with decreased appetite, the resident was provided the ordered [MEDICATION NAME] dose on 11/10/11 at 7:00 p.m. without consultation with the physician. The facility did not consult with the physician after an additional black stool on 11/10/11 at approximately 8:30 p.m. The facility did not consult with the physician until resident #1's condition further deteriorated, which included additional black tarry stools and significant bruising at 3:32 a.m. on 11/11/11. An immediate jeopardy situation for resident #1 began on 11/10/11 with the facility's lack of physician notification regarding resident #1's condition when the resident experienced poor appetite, complaints of stomach pain and loose, black stools. The immediate jeopardy situation for resident #1 continued with the administration of a further [MEDICATION NAME] dose and an additional episode of black, tarry stool without physician consultation. The immediate jeopardy situation for resident #1 was identified on 11/17/11. NHA (Nursing Home Administrator)-Q was notified of the immediate jeopardy at 8:40 a.m. on 11/17/11. The immediate jeopardy was removed on 11/18/11, but non-compliance remained at a scope/severity level of E (potential for harm/pattern). The continued deficient practice had the potential to affect 15 (residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) residents residing at the facility on 11/16/11 who received [MEDICATION NAME] therapy. Findings include: The facility's "Change of Condition-Notification and Documentation" policy and procedure, dated February 2011, documented, "...The resident's physician and family will be notified of changes in the resident's physical, mental, and psychological status, and these changes will be reported to the multidisciplinary Care Plan team, so that appropriate changes in the Plan of Care can be implemented...". The procedure noted emergent changes of a resident's condition are called to the physician immediately . Follow physician's orders [REDACTED]. to the immediate emergency. On 11/16/11 surveyor # completed a record review for resident #1. The face sheet, dated 10/19/11 indicated resident #1 was admitted to the facility on [DATE]. The hospital discharge summary, dated 10/19/11, indicated resident #1 had been hospitalized from [DATE] to 10/19/11 for a left [MEDICAL CONDITION] repair. The discharge summary noted other [DIAGNOSES REDACTED]. The hospital records indicated resident #1 had been taking [MEDICATION NAME] prior to the hospitalization . The [MEDICATION NAME] was held prior to surgery and re-initiated on 10/17/11. Resident #1's last INR was documented on 10/19/11 and was 1.11. Resident #1's admitting physician orders [REDACTED]. No orders for monitoring of the INR were provided. Resident #1's physician orders [REDACTED]. The Nursing 2011 Drug Handbook by Wolters Kluwer/Lippincott, Williams & Wilkins noted the following cautions for use of Pepto-Bismol: -Drug to Drug interactions: Aspirin, oral anticoagulants...may increase the effect of these drugs...monitor patient closely. The handbook noted Pepto-Bismol, regular strength, contains 130 mg per 15 ml (milliliters) of [MEDICATION NAME]. The MAR (Medication Administration Record) for November 2011 documented resident #1 received [MEDICATION NAME] 3 mg daily from 11/1/11 to 11/10/11. The November MAR indicated [REDACTED] A. On 11/16/11 at 9:50 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-D regarding resident #1. CNA-D stated she assisted CNA-E with toileting resident #1 on 11/10/11 sometime after breakfast but before lunch (could not recall exact time). CNA-D stated resident #1 had a moderate amount of black, tarry stool. CNA-D stated she informed LPN (Licensed Practical Nurse)-F of the black stool and had LPN-F view the soiled brief. CNA-D stated the black stool was a change for resident #1. CNA-D stated, although resident #1 had ongoing issues with loose stools, the stool had not been black prior to 11/10/11. CNA-D stated she notified LPN-F because of the change in the stool color for resident #1. On 11/16/11 at 12:00 p.m. surveyor # interviewed CNA-E regarding resident #1. CNA-E verified she and CNA-D assisted resident #1 with toileting on 11/10/11 around 9:00 a.m. CNA-E stated resident #1 had been incontinent of black, tarry stool. CNA-E stated resident #1 had ongoing issues with loose stools during her stay, but the color of the stool on 11/10/11 was different from past stools. CNA-E stated 11/10/11 was the first time she had seen the stool for resident #1 to be black and tarry. CNA-E stated LPN-F was informed of the black, tarry stool, and CNA-D showed LPN-F the stool. CNA-E stated resident #1 complained of what she perceived to be stomach pain and indicated the resident refused breakfast due to not feeling well. CNA-E stated LPN-F indicated the black stools could be attributed to resident #1 taking Pepto-Bismol. Note: 3 of 4 CNAs who had cared for Resident #1 prior to 11/10/11 (CNA-M, CNA-H, and CNA-G) stated on 11/16/11 between 7:55 a.m. and 12:10 p.m. that Resident #1's stools were usually "normal" or "light brown" in color. Cross-reference F329. On 11/16/11 at 2:52 p.m. surveyor # completed a telephone interview with LPN-F regarding resident #1. LPN-F verified she cared for resident #1 on 11/10/11 during the daytime tour of duty. LPN-F stated resident #1 had one dark brown, "almost black" stool on 11/10/11. LPN-F verified the CNAs reported the stool to her. LPN-F verified CNA-D showed her "a little bit" of dark brown, almost black stool on the incontinence product. LPN-F verified she did not take resident #1's vital signs or consult with the physician. LPN-F stated MD (Medical Doctor)-L was going to be completing rounds at the facility on 11/10/11, and the stool would be reported to him when he arrived. LPN-F stated she informed RN (Registered Nurse)-N of the dark stool, and RN-N instructed her to let MD-L know when he was in the building. LPN-F indicated she passed information regarding the stool along in shift report to the oncoming nurse (LPN-J). LPN-F verified she did not review the medical record to determine if resident #1 had any recent INR levels completed, did not consult with the physician regarding the dark stool or make a determination if the next scheduled [MEDICATION NAME] dose should be administered, and did not complete any further assessment of resident #1 for signs/symptoms of bleeding. LPN-F stated at that point she did not attribute the "almost black" stool to be an indicator of a possible GI bleed. LPN-F indicated the dark stooling occurred at the end of her shift; therefore, she passed the information along to the next shift. LPN-F verified MD-L did not complete rounds in the facility on 11/10/11. LPN-F stated she could not recall what she documented in the medical record regarding resident #1's condition. (Note: The medical record did not contain any information regarding dark stool or changes in resident #1's stools on 11/10/11 during the daytime tour of duty.) Although LPN-F indicated the stool was not black, but rather "almost black", surveyor # reviewed a statement dated and signed by LPN-F on 11/14/11, documenting the following: "...How frequent, volume, color, smell of loose stools regarding (resident #1)?...", LPN-F documented, "black sticky stool (thurs.)..." (11/10/11). On 11/16/11 at 12:35 p.m. surveyor # interviewed RN-N regarding resident #1. RN-N stated she was called into resident #1's room on 11/10/11 by the resident's daughter due to the resident bleeding from the mouth. RN-N stated she examined the resident and noted no active bleeding in the mouth, but observed a bite mark with a bruise on resident #1's tongue. RN-N indicated resident #1 agreed she may have bitten her tongue. RN-N observed a very small amount of blood on the tissue, and observed no active bleeding. RN-N indicated she directed staff to monitor the tongue and added such to the treatment sheet. RN-N stated she thought she may have been notified of a darker stool on 11/10/11, but indicated it was never reported to her the stool was black. RN-N verified she had not completed an assessment of resident #1 other than to look at her mouth/tongue. RN-N had not completed vital signs or observed any stools. RN-N stated if she would have been informed of a black stool, she would have directed staff to contact the physician immediately. RN-N reviewed the progress notes in the medical record and verified no documentation regarding dark or black stools was noted in the record until 11/11/11 at 3:26 a.m. RN-N indicated any changes to resident #1's stools, including darker or black stools, should have been documented in the medical record. B. On 11/16/11 at 1:45 p.m. surveyor # completed a telephone interview with CNA-K regarding resident #1. CNA-K verified she cared for resident #1 on 11/10/11 on the 2:00 p.m. to 10:00 p.m. shift. CNA-K stated during that shift resident #1 complained of a "belly ache" and had a really, really dark stool. CNA-K stated the dark stool was reported to LPN-J immediately, and LPN-J went to resident #1's room to evaluate. CNA-K stated resident #1 had issues with loose stools in the past, but on 11/10/11 the stool was much darker than it had been in the past. That was why she reported the dark stool to the LPN. On 11/16/11 at 12:45 p.m. surveyor # completed a telephone interview with LPN-J regarding resident #1. LPN-J worked from 2:00 p.m. to 10:00 p.m. on 11/10/11 and was able to recall the events of 11/10/11 related to resident #1. LPN-J stated no information regarding any black stool or changes in resident #1's stool was reported to her at the beginning of her shift on 11/10/11. LPN-J stated she was not aware of any concern related to dark or changed stools for resident #1 at the start of her shift, and verified MD-L was not at the facility during her shift. LPN-J stated she administered resident #1's [MEDICATION NAME] 3 mg on 11/10/11 at approximately 7:00 p.m. LPN-J stated at approximately 8:30 p.m. she was called to resident #1's room due to resident #1 having a large, black stool. LPN-J stated she observed resident #1 to have expelled a black stool and noted that was a change from the resident's past stools. LPN-J stated she was concerned about the black stool and reviewed the resident's medications to see what may have caused the black stool. LPN-J stated after reviewing the medications she did not note any medications she could attribute to the black stool. When surveyor # questioned if she was aware resident #1 was taking [MEDICATION NAME] 3 mg, LPN-J responded she was aware; as she provided resident #1 the [MEDICATION NAME] on that evening and on previous evenings. LPN-J stated she did not feel the [MEDICATION NAME] was contributing to the black stool. LPN-J stated she was not sure if, perhaps, the stools being black was a result of something resident #1 had eaten. LPN-J stated she did not take vital signs, did not notify the RN, did not consult with the physician, but rather passed along the information regarding the black stools to the oncoming nurse for the next shift. Although LPN-J verified she recognized the black stool had been a change for resident #1, she did not consider the [MEDICATION NAME] to be a contributing factor. LPN-J indicated as far as she was aware, the black stool at 8:30 p.m. on 11/10/11 was the first black stool for resident #1. Although LPN-J verified she was aware resident #1 was taking [MEDICATION NAME], she did not review the medical record to determine if a recent INR had been monitored. (Note: the medical record did not document any black stools during LPN-J's shift on 11/10/11). The only vital signs recorded for resident #1 on 11/10/11 was a routine blood pressure documented at 7:35 p.m. No other vital signs or documentation of resident #1's condition were noted within the medical record. C. On 11/16/11 at 9:17 a.m. surveyor # completed a telephone interview with CNA-O regarding resident #1. CNA-O stated she worked the night shift from 11/10/11 to 11/11/11. CNA-O stated she and CNA-P entered resident #1's room on 11/11/11 around 3:00 a.m. CNA-O stated she and CNA-P rolled resident #1 onto her side and noted bruising around resident #1's rectum. CNA-O stated they had LPN-C come to the room to evaluate resident #1. CNA-O stated when they rolled resident #1 onto her side, so LPN-C could evaluate the rectal area, resident #1 expelled a moderate amount of "grape jelly" appearing stool. CNA-O stated RN-B also came to the room to assess resident #1. CNA-O stated she and CNA-P cleaned resident #1 up prior to transport to the hospital. CNA-O indicated resident #1 had an additional [MEDICAL CONDITION] stool that had visible blood in it prior to the hospital transfer. CNA-O noted bruises to resident #1's left upper arm and right inner thigh in addition to the rectal bruising. CNA-O indicated she had not cared for resident #1 during her 11/10/11 to 11/11/11 shift until 3:00 a.m.; and therefore, had not seen the bruising prior to that time. On 11/16/11 at 10:10 a.m. surveyor # completed a telephone interview with LPN-C regarding resident #1. LPN-C verified she cared for resident #1 on the night shift from 11/10/11 to 11/11/11. LPN-C stated she received report at the start of her shift that resident #1 had experienced a black stool during the prior shift. LPN-C indicated she was informed the black stool may have been from resident #1 taking Pepto-Bismol. LPN-C verified she had not completed monitoring of resident #1 prior to the notification of the rectal bruising on 11/11/11 at approximately 3:15-3:30 a.m. LPN-C stated she was informed resident #1 had rectal bruising and went to evaluate. LPN-C noted the black, tarry stool and rectal bruising. LPN-C further observed bruising to resident #1's upper arm and leg. LPN-C called RN-B for an assessment, and resident #1 was subsequently transferred to the hospital for evaluation. LPN-C indicated when she saw the black stool, she immediately felt it was a result of a GI bleed and could be related to the [MEDICATION NAME] use. On 11/16/11 at 7:07 a.m. surveyor # interviewed RN-B regarding resident #1. RN-B stated she was called to resident #1's room in the early morning of 11/11/11, at approximately 3:15 to 3:30 a.m. RN-B stated she was informed resident #1 was having black, tarry stools. RN-B observed the black, tarry stool and noted a dark red area around resident #1's anus. RN-B stated the area around the anus appeared to be bruising from pushing when expelling stool. RN-B stated she noted bruising on resident #1's arm, which appeared to be yellowing, and a bruise on the resident's leg. RN-B instructed LPN-C to contact the physician and have resident #1 sent to the hospital. RN-B indicated vitals were obtained prior to the hospital transport and were within normal limits for resident #1. RN-B stated she was concerned resident #1 may have a GI bleed due to the new bruising noted and the symptom of black, tarry stool. The resident progress notes for resident #1 on 11/11/11 at 3:26 a.m. documented, "Stool: tarry, one time this shift...Dr. notified...resident has had large amount of black tarry stool one time. Has significant bruising around anus, on upper arms, left wrist, and right inner thigh. Dr. (name) updated. Orders received to send to ER (emergency room ) for evaluation...3:40 AM sent to hospital ER...". A late entry was noted for 3:00 a.m., which documented resident #1's vital signs as blood pressure 109/46, pulse 90 and respirations of 14. The emergency room report, dated 11/11/11, documented resident #1 was evaluated and noted to have an elevated INR (International Normalized Ratio) of 10.55 (therapeutic range 2-3), hemoglobin of 8.6 (normal range 11.7-15.7) and hematocrit of 24.1 (normal range 34.9-46.9). Resident #1 was provided 5 mg of Vitamin K, two units of fresh frozen plasma, and one unit of packed cells. Resident #1 was transferred to another hospital for further evaluation of a GI bleed. According to the hospital records from the receiving hospital, dated 11/11/11, resident #1 was admitted to the ICU for further management. The hospital records indicated resident #1 had bruising, which included a 1.5 inch, dark red/purple area surrounding the rectum, purple/swollen labia, a 4 cm (centimeter) by 3 cm red/purple circular discoloration to the left posterior thigh, a 3 cm . by 1.5 cm purple area to the right inner leg, 3 cm and 2 cm green discoloration to the upper right thigh, and a purple/green oval shaped area to the left wrist measuring 5 cm by 3.5 cm. D. On 11/16/11 at 2:05 p.m. surveyor # completed a telephone interview with MD-L regarding resident #1. MD-L stated he would expect the facility to notify him immediately of any sign/symptoms of bleeding. MD-L verified an indication of bleeding would be black, tarry stools. MD-L stated with the onset of any indication of bleeding, the INR would have to be evaluated. MD-L stated he was not notified of resident #1 having black, tarry stools until 11/11/11 around 3:15 a.m. to 3:30 a.m. MD-L stated he had been on-call all day on 11/10/11 and had not received any notification from the facility of earlier onset of black stools. MD-L stated had he been notified earlier, he would have had resident #1 evaluated at the ER; as he did when he was notified, and the resident was subsequently transferred. On 11/16/11 at 1:15 p.m. surveyor # interviewed DON (Director of Nursing)-A regarding physician notification related to change of condition. DON-A verified a black and/or tarry stool could be an indication of GI bleeding, and the physician should be notified immediately of such. DON-A verified the physician should be consulted regarding black stools for any resident, including those taking [MEDICATION NAME], and the physician should be consulted prior to administration of the next scheduled [MEDICATION NAME] dose. On 11/16/11 at 3:28 p.m. DON-A verified to surveyor # residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16 currently resided in the facility and utilized [MEDICATION NAME]. The immediate jeopardy for resident #1 that began on 11/10/11 was removed on 11/18/11 when the facility initiated training for all staff prior to their taking the floor. The training addressed anticoagulant medications and included knowledge of purpose, risks and benefits of the medication including recognition of signs and symptoms of bleeding which need to be reported. The training addressed knowledge of lab values related to anticoagulant medications and when to consult the physician when lab values are outside parameters. The training addressed assessment for signs and symptoms of bleeding, testing for dark, tarry stools and documentation of findings. The training addressed scheduling of PT/INR testing for residents admitted on anticoagulation therapy and a method to follow the results of that testing. The training addressed monitoring of any drug with a potential for drug interaction with an anticoagulant medication and reporting any altered level to the physician. The training addressed the pharmacist's monthly review of medications and review of any interactions with the physician for special monitoring or alteration. The training also addressed the physician's responsibility for the INR goal, laboratory monitoring and review for possible complications. The non-compliance remains at the lower scope and severity of E (potential for harm/pattern) until all portions of the facility's removal plan are fully implemented and tested .

Based on staff interview and record review, the facility did not ensure services provided by an RN (Registered Nurse) and LPN (Licensed Practical Nurse) met professional standards of quality for 1 (resident #1) of 13 sampled residents. Resident #1 was at risk for bleeding related to her medications, which included [MEDICATION NAME]. On 11/10/11 resident #1 experienced loose, black, tarry stools at approximately 9:00 a.m. Despite the black stool, an indicator of a potential GI (gastrointestinal) bleed and complaints of stomach pain with decreased appetite, the facility did not implement close monitoring of resident #1's condition; and the resident was provided the scheduled [MEDICATION NAME] dose on 11/10/11 at 7:00 p.m. without consultation with the physician. The resident experienced an additional black stool on 11/10/11 at approximately 8:30 p.m. The LPN who observed the black stool on 11/10/11 at 8:30 p.m. did not recognize that bleeding could be occurring from [MEDICATION NAME] usage, did not inform the RN of the resident's condition, and did not provide further monitoring of resident #1, including vital signs. The facility did not consult with the physician until resident #1's condition further deteriorated, which included additional black tarry stools and significant bruising at 3:32 a.m. on 11/11/11. An immediate jeopardy situation for resident #1 began on 11/10/11 when the facility nurses failed to adequately monitor [MEDICATION NAME] use for resident #1, continued administration of [MEDICATION NAME] when an adverse reaction to [MEDICATION NAME] was noted (loose, black, tarry stool) and did not notify the physician of the resident's condition change. The immediate jeopardy situation for resident #1 was identified on 11/17/11. NHA (Nursing Home Administrator)-Q was notified of the immediate jeopardy at 8:40 a.m. on 11/17/11. The immediate jeopardy was removed on 11/18/11, but non-compliance remained at a scope/severity level of E (potential for harm/pattern). The continued deficient practice had the potential to affect 15 (residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) residents residing at the facility on 11/16/11 who received [MEDICATION NAME] therapy. Findings include: N 6.03(1), Standards of practice for registered nurses indicates, "An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis." N 6.04 Standards or practice for licensed practical nurses indicates, "In the performance of acts in basic patient situations, the LPN shall, under the general supervision of an R.N. or the direction of a physician, podiatrist, dentist or optometrist: (a) Accept only patient care assignments which the L.P.N. is competent to perform; (b) Provide basic nursing care; (c) Record nursing care given and report to the appropriate person changes in the condition of a patient; (d) Consult with an R.N., physician, podiatrist, dentist or optometrist in cases where an L.P.N. knows or should know a delegated nursing or medical act may harm a patient; and, (e) Perform the following other acts when applicable: 1. Assist with the collection of data; 2. Assist with the development and revision of a nursing care plan; 3. Reinforce the teaching provided by an R.N., physician, podiatrist, dentist or optometrist and provide basic health care instruction; or, 4. Participate with other health team members in meeting basic patient needs. (2) PERFORMANCE OF ACTS IN COMPLEX PATIENT SITUATIONS. In the performance of acts in complex patient situations the L.P.N. shall: (a) Meet standards under sub. (1) under the general supervision of an R.N., physician, podiatrist, dentist or optometrist. (b) Perform delegated nursing or medical acts beyond basic nursing care under the direct supervision of an R.N., physician, podiatrist, dentist or optometrist. An L.P.N. shall, upon request of the board, provide documentation of his or her nursing education, training or experience which prepare the L.P.N. to competently perform these assignments. N 7.03(1) of the Nurse Practice Act defines "negligence" as "a substantial departure from the standard of care ordinarily exercised by a competent licensee. " Negligence" includes but is not limited to the following conduct: ... (c) Failing to observe the conditions, signs and symptoms of a patient, record them, or report significant changes to the appropriate person ..." In Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; ?1990. Chapter 85., HK Walker, WD Hall and JW Hurst note the following: Hematemesis is the vomiting of blood, which may be obviously red or have an appearance similar to coffee grounds. Melena is the passage of black, tarry stools. Hematochezia is the passage of fresh blood per anus, usually in or with stools. Hematemesis, melena, and hematochezia are symptoms of acute [MEDICAL CONDITION]. Bleeding that brings the patient to the physician is a potential emergency and must be considered as such until its seriousness can be evaluated. Melena, hematemesis, or hematochezia indicates that a potentially lethal situation may be developing. A convincing description of hematemesis, melena, or substantial amounts of hematochezia indicates bleeding that is a potential emergency and should be handled as such until the situation can be assessed. http://www.ncbi.nlm.nih.gov/books/NBK411/. On 11/16/11 surveyor # completed a record review for resident #1. The face sheet, dated 10/19/11 indicated resident #1 was admitted to the facility on [DATE]. The hospital discharge summary, dated 10/19/11, indicated resident #1 had been hospitalized from [DATE] to 10/19/11 for a left [MEDICAL CONDITION] repair. The discharge summary noted other [DIAGNOSES REDACTED]. The hospital records indicated resident #1 had been taking [MEDICATION NAME] prior to the hospitalization . The [MEDICATION NAME] was held prior to surgery and re-initiated on 10/17/11. Resident #1's last INR was documented on 10/19/11 and was 1.11. Resident #1's admitting physician orders [REDACTED]. No orders for monitoring of the INR were provided. The medical record did not contain any documentation indicating consultation with the physician regarding INR monitoring. During an interview with surveyor # on 11/16/11 at 8:20 a.m. DON (Director of Nursing)-A verified resident #1 did not have orders to monitor her INR. DON-A stated the physician had been sent resident #1's medical history and medication list, which included the order for [MEDICATION NAME] 3 mg daily; and the physician did not order an INR to be completed. DON-A verified no specific request/consultation with the physician regarding the INR level had been completed. The Nursing 2011 Drug Handbook by Wolters Kluwer/Lippincott, Williams & Wilkins indicated the following cautions for [MEDICATION NAME] use included, but were not limited to: -Black Box Warning-[MEDICATION NAME] can cause major bleeding or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients. Consider more frequent INR monitoring in those at high risk for bleeding. -Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae (red spots on the skin caused by a small amount of escaping blood), nosebleeds, melena (black tarry color stool), tarry stools, hematuria and hematemesis. The drug handbook further noted to warn patients to avoid OTC (over the counter) products containing aspirin, other [MEDICATION NAME] or drugs that interact with [MEDICATION NAME]. Resident #1's physician orders [REDACTED]. The Nursing 2011 Drug Handbook by Wolters Kluwer/Lippincott, Williams & Wilkins noted the following cautions for use of Pepto-Bismol: -Drug to Drug interactions: Aspirin, oral anticoagulants...may increase the effect of these drugs...monitor patient closely. The handbook noted Pepto-Bismol, regular strength, contains 130 mg per 15 ml (milliliters) of [MEDICATION NAME]. The MAR (Medication Administration Record) for November 2011 documented resident #1 received [MEDICATION NAME] 3 mg daily from 11/1/11 to 11/10/11. The November MAR indicated [REDACTED] A. On 11/16/11 at 9:50 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-D regarding resident #1. CNA-D stated she assisted CNA-E with toileting resident #1 on 11/10/11 sometime after breakfast but before lunch (could not recall exact time). CNA-D stated resident #1 had a moderate amount of black, tarry stool. CNA-D stated she informed LPN (Licensed Practical Nurse)-F of the black stool and had LPN-F view the soiled brief. CNA-D stated the black stool was a change for resident #1. CNA-D stated, although resident #1 had ongoing issues with loose stools, the stool had not been black prior to 11/10/11. CNA-D stated she notified LPN-F because of the change in the stool color for resident #1. On 11/16/11 at 12:00 p.m. surveyor # interviewed CNA-E regarding resident #1. CNA-E verified she and CNA-D assisted resident #1 with toileting on 11/10/11 around 9:00 a.m. CNA-E stated resident #1 had been incontinent of black, tarry stool. CNA-E stated resident #1 had ongoing issues with loose stools during her stay, but the color of the stool on 11/10/11 was different from past stools. CNA-E stated 11/10/11 was the first time she had seen the stool for resident #1 to be black and tarry. CNA-E stated LPN-F was informed of the black, tarry stool, and CNA-D showed LPN-F the stool. CNA-E stated resident #1 complained of what she perceived to be stomach pain and indicated the resident refused breakfast due to not feeling well. CNA-E stated LPN-F indicated the black stools could be attributed to resident #1 taking Pepto-Bismol. On 11/16/11 at 2:52 p.m. surveyor # completed a telephone interview with LPN-F regarding resident #1. LPN-F verified she cared for resident #1 on 11/10/11 during the daytime tour of duty. LPN-F stated resident #1 had one dark brown, "almost black" stool on 11/10/11. LPN-F verified the CNAs reported the stool to her. LPN-F verified CNA-D showed her "a little bit" of dark brown, almost black stool on the incontinence product. LPN-F verified she did not take resident #1's vital signs or consult with the physician. LPN-F stated MD (Medical Doctor)-L was going to be completing rounds at the facility on 11/10/11, and the stool would be reported to him when he arrived. LPN-F stated she informed RN (Registered Nurse)-N of the dark stool, and RN-N instructed her to let MD-L know when he was in the building. LPN-F indicated she passed information regarding the stool along in shift report to the oncoming nurse (LPN-J). LPN-F verified she did not review the medical record to determine if resident #1 had any recent INR levels completed, did not consult with the physician regarding the dark stool or make a determination if the next scheduled [MEDICATION NAME] dose should be administered, and did not complete any further assessment of resident #1 for signs/symptoms of bleeding. LPN-F stated at that point she did not attribute the "almost black" stool to be an indicator of a possible GI bleed. LPN-F indicated the dark stooling occurred at the end of her shift; therefore, she passed the information along to the next shift. LPN-F verified MD-L did not complete rounds in the facility on 11/10/11. LPN-F stated she could not recall what she documented in the medical record regarding resident #1's condition. (Note: The medical record did not contain any information regarding dark stool or changes in resident #1's stools on 11/10/11 during the daytime tour of duty.) Although LPN-F indicated the stool was not black, but rather "almost black", surveyor # reviewed a statement dated and signed by LPN-F on 11/14/11, documenting the following: "...How frequent, volume, color, smell of loose stools regarding (resident #1)?...", LPN-F documented, "black sticky stool (thurs.)..." (11/10/11). On 11/16/11 at 12:35 p.m. surveyor # interviewed RN-N regarding resident #1. RN-N stated she was called into resident #1's room on 11/10/11 by the resident's daughter due to the resident bleeding from the mouth. RN-N stated she examined the resident and noted no active bleeding in the mouth, but observed a bite mark with a bruise on resident #1's tongue. RN-N indicated resident #1 agreed she may have bitten her tongue. RN-N observed a very small amount of blood on the tissue, and observed no active bleeding. RN-N indicated she directed staff to monitor the tongue and added such to the treatment sheet. RN-N stated she thought she may have been notified of a darker stool on 11/10/11, but indicated it was never reported to her the stool was black. RN-N verified she had not completed an assessment of resident #1 other than to look at her mouth/tongue. RN-N had not completed vital signs or observed any stools. RN-N stated if she would have been informed of a black stool, she would have directed staff to contact the physician immediately. RN-N reviewed the progress notes in the medical record and verified no documentation regarding dark or black stools was noted in the record until 11/11/11 at 3:26 a.m. RN-N indicated any changes to resident #1's stools, including darker or black stools, should have been documented in the medical record. B. On 11/16/11 at 1:45 p.m. surveyor # completed a telephone interview with CNA-K regarding resident #1. CNA-K verified she cared for resident #1 on 11/10/11 on the 2:00 p.m. to 10:00 p.m. shift. CNA-K stated during that shift resident #1 complained of a "belly ache" and had a really, really dark stool. CNA-K stated the dark stool was reported to LPN-J immediately, and LPN-J went to resident #1's room to evaluate. CNA-K stated resident #1 had issues with loose stools in the past, but on 11/10/11 the stool was much darker than it had been in the past. That was why she reported the dark stool to the LPN. On 11/16/11 at 12:45 p.m. surveyor # completed a telephone interview with LPN-J regarding resident #1. LPN-J worked from 2:00 p.m. to 10:00 p.m. on 11/10/11 and was able to recall the events of 11/10/11 related to resident #1. LPN-J stated no information regarding any black stool or changes in resident #1's stool was reported to her at the beginning of her shift on 11/10/11. LPN-J stated she was not aware of any concern related to dark or changed stools for resident #1 at the start of her shift, and verified MD-L was not at the facility during her shift. LPN-J stated she administered resident #1's [MEDICATION NAME] 3 mg on 11/10/11 at approximately 7:00 p.m. LPN-J stated at approximately 8:30 p.m. she was called to resident #1's room due to resident #1 having a large, black stool. LPN-J stated she observed resident #1 to have expelled a black stool and noted that was a change from the resident's past stools. LPN-J stated she was concerned about the black stool and reviewed the resident's medications to see what may have caused the black stool. LPN-J stated after reviewing the medications she did not note any medications she could attribute to the black stool. When surveyor # questioned if she was aware resident #1 was taking [MEDICATION NAME] 3 mg, LPN-J responded she was aware; as she provided resident #1 the [MEDICATION NAME] on that evening and on previous evenings. LPN-J stated she did not feel the [MEDICATION NAME] was contributing to the black stool. LPN-J stated she was not sure if, perhaps, the stools being black was a result of something resident #1 had eaten. LPN-J stated she did not take vital signs, did not notify the RN, did not consult with the physician, but rather passed along the information regarding the black stools to the oncoming nurse for the next shift. Although LPN-J verified she recognized the black stool had been a change for resident #1, she did not consider the [MEDICATION NAME] to be a contributing factor. LPN-J indicated as far as she was aware, the black stool at 8:30 p.m. on 11/10/11 was the first black stool for resident #1. Although LPN-J verified she was aware resident #1 was taking [MEDICATION NAME], she did not review the medical record to determine if a recent INR had been monitored. (Note: the medical record did not document any black stools during LPN-J's shift on 11/10/11). The only vital signs recorded for resident #1 on 11/10/11 was a routine blood pressure documented at 7:35 p.m. No other vital signs or documentation of resident #1's condition were noted within the medical record. C. On 11/16/11 at 9:17 a.m. surveyor # completed a telephone interview with CNA-O regarding resident #1. CNA-O stated she worked the night shift from 11/10/11 to 11/11/11. CNA-O stated she and CNA-P entered resident #1's room on 11/11/11 around 3:00 a.m. CNA-O stated she and CNA-P rolled resident #1 onto her side and noted bruising around resident #1's rectum. CNA-O stated they had LPN-C come to the room to evaluate resident #1. CNA-O stated when they rolled resident #1 onto her side, so LPN-C could evaluate the rectal area, resident #1 expelled a moderate amount of "grape jelly" appearing stool. CNA-O stated RN-B also came to the room to assess resident #1. CNA-O stated she and CNA-P cleaned resident #1 up prior to transport to the hospital. CNA-O indicated resident #1 had an additional [MEDICAL CONDITION] stool that had visible blood in it prior to the hospital transfer. CNA-O noted bruises to resident #1's left upper arm and right inner thigh in addition to the rectal bruising. CNA-O indicated she had not cared for resident #1 during her 11/10/11 to 11/11/11 shift until 3:00 a.m.; and therefore, had not seen the bruising prior to that time. On 11/16/11 at 10:10 a.m. surveyor # completed a telephone interview with LPN-C regarding resident #1. LPN-C verified she cared for resident #1 on the night shift from 11/10/11 to 11/11/11. LPN-C stated she received report at the start of her shift that resident #1 had experienced a black stool during the prior shift. LPN-C indicated she was informed the black stool may have been from resident #1 taking Pepto-Bismol. LPN-C verified she had not completed monitoring of resident #1 prior to the notification of the rectal bruising on 11/11/11 at approximately 3:15-3:30 a.m. LPN-C stated she was informed resident #1 had rectal bruising and went to evaluate. LPN-C noted the black, tarry stool and rectal bruising. LPN-C further observed bruising to resident #1's upper arm and leg. LPN-C called RN-B for an assessment, and resident #1 was subsequently transferred to the hospital for evaluation. LPN-C indicated when she saw the black stool, she immediately felt it was a result of a GI bleed and could be related to the [MEDICATION NAME] use. On 11/16/11 at 7:07 a.m. surveyor # interviewed RN-B regarding resident #1. RN-B stated she was called to resident #1's room in the early morning of 11/11/11, at approximately 3:15 to 3:30 a.m. RN-B stated she was informed resident #1 was having black, tarry stools. RN-B observed the black, tarry stool and noted a dark red area around resident #1's anus. RN-B stated the area around the anus appeared to be bruising from pushing when expelling stool. RN-B stated she noted bruising on resident #1's arm, which appeared to be yellowing, and a bruise on the resident's leg. RN-B instructed LPN-C to contact the physician and have resident #1 sent to the hospital. RN-B indicated vitals were obtained prior to the hospital transport and were within normal limits for resident #1. RN-B stated she was concerned resident #1 may have a GI bleed due to the new bruising noted and the symptom of black, tarry stool. The resident progress notes for resident #1 on 11/11/11 at 3:26 a.m. documented, "Stool: tarry, one time this shift...Dr. notified...resident has had large amount of black tarry stool one time. Has significant bruising around anus, on upper arms, left wrist, and right inner thigh. Dr. (name) updated. Orders received to send to ER (emergency room ) for evaluation...3:40 AM sent to hospital ER...". A late entry was noted for 3:00 a.m., which documented resident #1's vital signs as blood pressure 109/46, pulse 90 and respirations of 14. The emergency room report, dated 11/11/11, documented resident #1 was evaluated and noted to have an elevated INR (International Normalized Ratio) of 10.55 (therapeutic range 2-3), hemoglobin of 8.6 (normal range 11.7-15.7) and hematocrit of 24.1 (normal range 34.9-46.9). Resident #1 was provided 5 mg of Vitamin K, two units of fresh frozen plasma, and one unit of packed cells. Resident #1 was transferred to another hospital for further evaluation of a GI bleed. According to the hospital records from the receiving hospital, dated 11/11/11, resident #1 was admitted to the ICU for further management. The hospital records indicated resident #1 had bruising, which included a 1.5 inch, dark red/purple area surrounding the rectum, purple/swollen labia, a 4 cm (centimeter) by 3 cm red/purple circular discoloration to the left posterior thigh, a 3 cm . by 1.5 cm purple area to the right inner leg, 3 cm and 2 cm green discoloration to the upper right thigh, and a purple/green oval shaped area to the left wrist measuring 5 cm by 3.5 cm. Resident #1 was at high risk for bleeding related to [MEDICATION NAME] use. When the resident experienced a change in her condition manifested by refusing breakfast due to not feeling well, stomach pain and new onset of black stool, the facility nurses did not meet professional standards of practice by failing to recognize the significance of the change and its possible relation to [MEDICATION NAME] usage, by failing to adequately monitor vital signs and the resident's overall condition, by failing to promptly inform the charge RN or the physician of the resident's changed condition, and by administering the next scheduled [MEDICATION NAME] dose in the presence of an adverse reaction. On 11/16/11 at 3:28 p.m. DON-A verified to surveyor # residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16 currently resided in the facility and utilized [MEDICATION NAME]. The immediate jeopardy for resident #1 that began on 11/10/11 was removed on 11/18/11 when the facility initiated training for all nursing staff prior to their taking the floor. The training addressed anticoagulant medications and included knowledge of purpose, risks and benefits of the medication including recognition of signs and symptoms of bleeding which need to be reported. The training addressed knowledge of lab values related to anticoagulant medications and when to consult the physician when lab values are outside parameters. The training addressed assessment for signs and symptoms of bleeding, testing for dark, tarry stools and documentation of findings. The training addressed scheduling of PT ([MEDICATION NAME])/INR testing for residents admitted on anticoagulation therapy and a method to follow the results of that testing. The training addressed monitoring of any drug with a potential for drug interaction with an anticoagulant medication and reporting any altered level to the physician. The non-compliance remains at the lower scope and severity of E (potential for harm/pattern) until all portions of the facility's removal plan are fully implemented and tested .

Based on staff interview and record review, the facility did not provide adequate monitoring for [MEDICATION NAME] use and continued to provide the medication in the presence of adverse consequences that indicated the dose should be reduced or discontinued; this resulted in serious harm for 1 (resident #1) of 5 residents reviewed for [MEDICATION NAME] therapy in a total sample of 13 residents. Resident #1 was at risk for bleeding related to her medications, which included [MEDICATION NAME]. The facility did not adequately monitor resident #1 for signs and symptoms of bleeding; and when the resident was noted to have a black stool, which may be an indication of bleeding, the facility continued to provide the medication ([MEDICATION NAME]). On 11/10/11 at approximately 9:00 a.m. resident #1 had a black, foul smelling stool. The facility did not complete a comprehensive assessment, complete routine monitoring of the resident's condition, including vital signs, or consult with the physician. Despite a black stool on 11/10/11, facility staff administered the resident's [MEDICATION NAME] 3 mg (milligram) dose on 11/10/11 at approximately 7:00 p.m. At approximately 8:30 p.m. on 11/10/11 resident #1 had a second black stool. The facility did not complete a comprehensive assessment, complete routine monitoring of the resident's condition, including vital signs, or consult with the physician. On 11/11/11 at approximately 3:15 to 3:30 a.m. resident #1 had a large, black, tarry stool; had significant rectal bruising and had bruising on the upper arms, left wrist and right inner thigh. Resident #1 was transferred to the local hospital at 3:40 a.m., where she was diagnosed with [REDACTED]. Resident #1 was provided Vitamin K due to the critical INR level and was transfused with a unit of blood and two units of plasma. Resident #1 was transferred to another hospital for further evaluation of a GI (gastrointestinal) bleed and was admitted to the ICU (Intensive Care Unit). Resident #1 remains hospitalized . An immediate jeopardy situation for resident #1 began on 11/10/11 with the facility's lack of adequate monitoring of [MEDICATION NAME] use for resident #1 and continued administration of [MEDICATION NAME] when an adverse reaction to [MEDICATION NAME] was noted (loose, black, tarry stool). The immediate jeopardy situation for resident #1 was identified on 11/17/11. NHA (Nursing Home Administrator)-Q was notified of the immediate jeopardy at 8:40 a.m. on 11/17/11. The immediate jeopardy was removed on 11/18/11, but non-compliance remained at a scope/severity level of E (potential for harm/pattern) because all training has not yet been completed. The continued deficient practice had the potential to affect 15 (residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) residents residing at the facility on 11/16/11 who receive [MEDICATION NAME] therapy. Findings include: Information at www.mayoclinic.com indicates [MEDICATION NAME] ([MEDICATION NAME]) side effects that require immediate medical attention include black stool or bleeding from the rectum. Complications from uncontrolled bleeding can progress rapidly, and immediate intervention is needed to prevent serious harm from occurring. The facility's "Oral Anticoagulant Therapy" policy and procedure, revised October 2003, included the following regarding [MEDICATION NAME] therapy: 1. Administer oral anticoagulant as ordered by physician. 2. Be aware of normal and therapeutic range for [MEDICATION NAME] and check therapeutic level on lab forms. 3. Know potential disadvantages or {sic} oral anticoagulant therapy: a. Effect may be unpredictable, b) PT ([MEDICATION NAME]) must be checked regularly. Follow physician protocol or orders. c) May be cumulative [MEDICATION NAME] onset with 12-24 hours, Cumulative effect may last up to 7 days. 4. Observe resident on anticoagulants for adverse reactions: a) Skin discolorations or bruises b) Excessive oozing from small skin tear c) Nosebleeds d) S/S (signs/symptoms) of GI bleeding: tarry stools, stomach pain, hematemesis (bloody vomit) e) Hematuria (bloody urine). 5. Report s/s bleeding changes or lab values to MD (medical doctor). 6. Be aware of medication interactions: a) antibiotic use, anticoagulant dose may need to increase b) Aspirin and slicylates {sic} interfere with clotting mechanism c) [MEDICATION NAME] may increase bleeding with prolonged use d) Resident should avoid alcoholic beverages. On 11/16/11 surveyor # completed a record review for resident #1. The face sheet, dated 10/19/11 indicated resident #1 was admitted to the facility on [DATE]. The hospital discharge summary, dated 10/19/11, indicated resident #1 had been hospitalized from [DATE] to 10/19/11 for a left [MEDICAL CONDITION] repair. The discharge summary noted other [DIAGNOSES REDACTED]. The hospital records indicated resident #1 had been taking [MEDICATION NAME] prior to the hospitalization . The [MEDICATION NAME] was held prior to surgery and re-initiated on 10/17/11. Resident #1's last INR was documented on 10/19/11 and was 1.11. Resident #1's admitting physician orders [REDACTED]. No orders for monitoring of the INR were provided. The medical record did not contain any documentation indicating consultation with the physician regarding INR monitoring. During an interview with surveyor # on 11/16/11 at 8:20 a.m. DON (Director of Nursing)-A verified resident #1 did not have orders to monitor her INR. DON-A stated the physician had been sent resident #1's medical history and medication list, which included the order for [MEDICATION NAME] 3 mg daily; and the physician did not order an INR to be completed. DON-A verified no specific request/consultation with the physician regarding the INR level had been completed. The Nursing 2011 Drug Handbook by Wolters Kluwer/Lippincott, Williams & Wilkins indicated the following cautions for [MEDICATION NAME] use included, but were not limited to: -Black Box Warning-[MEDICATION NAME] can cause major bleeding or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients. Consider more frequent INR monitoring in those at high risk for bleeding. -Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae (red spots on the skin caused by a small amount of escaping blood), nosebleeds, melena (black tarry color stool), tarry stools, hematuria and hematemesis. The drug handbook further noted to warn patients to avoid OTC (over the counter) products containing aspirin, other [MEDICATION NAME] or drugs that interact with [MEDICATION NAME]. The plan of care for resident #1, dated 10/19/11, documented a problem of "Potential for Alteration in Cardiac Output" related to [MEDICAL CONDITION], hypertension with use of anticoagulants. The interventions included the following: -Teach resident to express chest pain, weakness, or dizziness. Teach importance of: Avoid overexertion, Monitor consciousness, Monitor labs and Vitals as appropriate. Report any changes to physician. Administer medications as ordered. Vital signs as ordered, report to nurse. Observe for any c/o (complaints of) chest pain, dizziness, weakness and report to nurse for assessment. Allow adequate time for tasks, allow for rest periods. Although the plan of care indicated resident #1 utilized an anticoagulant, the plan of care did not direct staff to monitor for bleeding. Resident #1's physician orders [REDACTED]. The Nursing 2011 Drug Handbook by Wolters Kluwer/Lippincott, Williams & Wilkins noted the following cautions for use of Pepto-Bismol: -Drug to Drug interactions: Aspirin, oral anticoagulants...may increase the effect of these drugs...monitor patient closely. The handbook noted Pepto-Bismol, regular strength, contains 130 mg per 15 ml (milliliters) of [MEDICATION NAME]. The MAR (Medication Administration Record) for November 2011 documented resident #1 received [MEDICATION NAME] 3 mg daily from 11/1/11 to 11/10/11. The November MAR indicated [REDACTED] The resident progress notes dated 11/10/11 at 1:43 p.m. documented , "...Incident type: Bit her own tongue...Date of occurrence: 11/9/11 Time: 1:37 p.m...." The note documented, "...writer was called to res (resident) room by daughter who stated she had blood coming out of her mouth, writer inspected mouth with flashlight and found that she had bitten her tongue...bruise noted with teeth marks around it...". Progress notes on 11/10/11 at 9:15 p.m. noted "...bruising with dark red in color under right side of tongue...staff will continue to monitor." A. On 11/16/11 at 9:50 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-D regarding resident #1. CNA-D stated she assisted CNA-E with toileting resident #1 on 11/10/11 sometime after breakfast but before lunch (could not recall exact time). CNA-D stated resident #1 had a moderate amount of black, tarry stool. CNA-D stated she informed LPN (Licensed Practical Nurse)-F of the black stool and had LPN-F view the soiled brief. CNA-D stated the black stool was a change for resident #1. CNA-D stated, although resident #1 had ongoing issues with loose stools, the stool had not been black prior to 11/10/11. CNA-D stated she notified LPN-F because of the change in the stool color for resident #1. On 11/16/11 at 12:00 p.m. surveyor # interviewed CNA-E regarding resident #1. CNA-E verified she and CNA-D assisted resident #1 with toileting on 11/10/11 around 9:00 a.m. CNA-E stated resident #1 had been incontinent of black, tarry stool. CNA-E stated resident #1 had ongoing issues with loose stools during her stay, but the color of the stool on 11/10/11 was different from past stools. CNA-E stated 11/10/11 was the first time she had seen the stool for resident #1 to be black and tarry. CNA-E stated LPN-F was informed of the black, tarry stool, and CNA-D showed LPN-F the stool. CNA-E stated resident #1 complained of what she perceived to be stomach pain and indicated the resident refused breakfast due to not feeling well. CNA-E stated LPN-F indicated the black stools could be attributed to resident #1 taking Pepto-Bismol. On 11/16/11 at 2:52 p.m. surveyor # completed a telephone interview with LPN-F regarding resident #1. LPN-F verified she cared for resident #1 on 11/10/11 during the daytime tour of duty. LPN-F stated resident #1 had one dark brown, "almost black" stool on 11/10/11. LPN-F verified the CNAs reported the stool to her. LPN-F verified CNA-D showed her "a little bit" of dark brown, almost black stool on the incontinence product. LPN-F verified she did not take resident #1's vital signs or consult with the physician. LPN-F stated MD (Medical Doctor)-L was going to be completing rounds at the facility on 11/10/11, and the stool would be reported to him when he arrived. LPN-F stated she informed RN (Registered Nurse)-N of the dark stool, and RN-N instructed her to let MD-L know when he was in the building. LPN-F indicated she passed information regarding the stool along in shift report to the oncoming nurse (LPN-J). LPN-F verified she did not review the medical record to determine if resident #1 had any recent INR levels completed, did not consult with the physician regarding the dark stool or make a determination if the next scheduled [MEDICATION NAME] dose should be administered, and did not complete any further assessment of resident #1 for signs/symptoms of bleeding. LPN-F stated at that point she did not attribute the "almost black" stool to be an indicator of a possible GI bleed. LPN-F indicated the dark stooling occurred at the end of her shift; therefore, she passed the information along to the next shift. LPN-F verified MD-L did not complete rounds in the facility on 11/10/11. LPN-F stated she could not recall what she documented in the medical record regarding resident #1's condition. (Note: The medical record did not contain any information regarding dark stool or changes in resident #1's stools on 11/10/11 during the daytime tour of duty.) Although LPN-F indicated the stool was not black, but rather "almost black", surveyor # reviewed a statement dated and signed by LPN-F on 11/14/11, documenting the following: "...How frequent, volume, color, smell of loose stools regarding (resident #1)?...", LPN-F documented, "black sticky stool (thurs.)..." (11/10/11). On 11/16/11 at 12:35 p.m. surveyor # interviewed RN-N regarding resident #1. RN-N stated she was called into resident #1's room on 11/10/11 by the resident's daughter due to the resident bleeding from the mouth. RN-N stated she examined the resident and noted no active bleeding in the mouth, but observed a bite mark with a bruise on resident #1's tongue. RN-N indicated resident #1 agreed she may have bitten her tongue. RN-N observed a very small amount of blood on the tissue, and observed no active bleeding. RN-N indicated she directed staff to monitor the tongue and added such to the treatment sheet. RN-N stated she thought she may have been notified of a darker stool on 11/10/11, but indicated it was never reported to her the stool was black. RN-N verified she had not completed an assessment of resident #1 other than to look at her mouth/tongue. RN-N had not completed vital signs or observed any stools. RN-N stated if she would have been informed of a black stool, she would have directed staff to contact the physician immediately. RN-N reviewed the progress notes in the medical record and verified no documentation regarding dark or black stools was noted in the record until 11/11/11 at 3:26 a.m. RN-N indicated any changes to resident #1's stools, including darker or black stools, should have been documented in the medical record. B. On 11/16/11 at 1:45 p.m. surveyor # completed a telephone interview with CNA-K regarding resident #1. CNA-K verified she cared for resident #1 on 11/10/11 on the 2:00 p.m. to 10:00 p.m. shift. CNA-K stated during that shift resident #1 complained of a "belly ache" and had a really, really dark stool. CNA-K stated the dark stool was reported to LPN-J immediately, and LPN-J went to resident #1's room to evaluate. CNA-K stated resident #1 had issues with loose stools in the past, but on 11/10/11 the stool was much darker than it had been in the past. That was why she reported the dark stool to the LPN. On 11/16/11 at 12:45 p.m. surveyor # completed a telephone interview with LPN-J regarding resident #1. LPN-J worked from 2:00 p.m. to 10:00 p.m. on 11/10/11 and was able to recall the events of 11/10/11 related to resident #1. LPN-J stated no information regarding any black stool or changes in resident #1's stool was reported to her at the beginning of her shift on 11/10/11. LPN-J stated she was not aware of any concern related to dark or changed stools for resident #1 at the start of her shift, and verified MD-L was not at the facility during her shift. LPN-J stated she administered resident #1's [MEDICATION NAME] 3 mg on 11/10/11 at approximately 7:00 p.m. LPN-J stated at approximately 8:30 p.m. she was called to resident #1's room due to resident #1 having a large, black stool. LPN-J stated she observed resident #1 to have expelled a black stool and noted that was a change from the resident's past stools. LPN-J stated she was concerned about the black stool and reviewed the resident's medications to see what may have caused the black stool. LPN-J stated after reviewing the medications she did not note any medications she could attribute to the black stool. When surveyor # questioned if she was aware resident #1 was taking [MEDICATION NAME] 3 mg, LPN-J responded she was aware; as she provided resident #1 the [MEDICATION NAME] on that evening and on previous evenings. LPN-J stated she did not feel the [MEDICATION NAME] was contributing to the black stool. LPN-J stated she was not sure if, perhaps, the stools being black was a result of something resident #1 had eaten. LPN-J stated she did not take vital signs, did not notify the RN, did not consult with the physician, but rather passed along the information regarding the black stools to the oncoming nurse for the next shift. Although LPN-J verified she recognized the black stool had been a change for resident #1, she did not consider the [MEDICATION NAME] to be a contributing factor. LPN-J indicated as far as she was aware, the black stool at 8:30 p.m. on 11/10/11 was the first black stool for resident #1. Although LPN-J verified she was aware resident #1 was taking [MEDICATION NAME], she did not review the medical record to determine if a recent INR had been monitored. (Note: the medical record did not document any black stools during LPN-J's shift on 11/10/11). The only vital signs recorded for resident #1 on 11/10/11 was a routine blood pressure documented at 7:35 p.m. No other vital signs or documentation of resident #1's condition were noted within the medical record. C. On 11/16/11 at 9:17 a.m. surveyor # completed a telephone interview with CNA-O regarding resident #1. CNA-O stated she worked the night shift from 11/10/11 to 11/11/11. CNA-O stated she and CNA-P entered resident #1's room on 11/11/11 around 3:00 a.m. CNA-O stated she and CNA-P rolled resident #1 onto her side and noted bruising around resident #1's rectum. CNA-O stated they had LPN-C come to the room to evaluate resident #1. CNA-O stated when they rolled resident #1 onto her side, so LPN-C could evaluate the rectal area, resident #1 expelled a moderate amount of "grape jelly" appearing stool. CNA-O stated RN-B also came to the room to assess resident #1. CNA-O stated she and CNA-P cleaned resident #1 up prior to transport to the hospital. CNA-O indicated resident #1 had an additional [MEDICAL CONDITION] stool that had visible blood in it prior to the hospital transfer. CNA-O noted bruises to resident #1's left upper arm and right inner thigh in addition to the rectal bruising. CNA-O indicated she had not cared for resident #1 during her 11/10/11 to 11/11/11 shift until 3:00 a.m.; and therefore, had not seen the bruising prior to that time. On 11/16/11 at 10:10 a.m. surveyor # completed a telephone interview with LPN-C regarding resident #1. LPN-C verified she cared for resident #1 on the night shift from 11/10/11 to 11/11/11. LPN-C stated she received report at the start of her shift that resident #1 had experienced a black stool during the prior shift. LPN-C indicated she was informed the black stool may have been from resident #1 taking Pepto-Bismol. LPN-C verified she had not completed monitoring of resident #1 prior to the notification of the rectal bruising on 11/11/11 at approximately 3:15-3:30 a.m. LPN-C stated she was informed resident #1 had rectal bruising and went to evaluate. LPN-C noted the black, tarry stool and rectal bruising. LPN-C further observed bruising to resident #1's upper arm and leg. LPN-C called RN-B for an assessment, and resident #1 was subsequently transferred to the hospital for evaluation. LPN-C indicated when she saw the black stool, she immediately felt it was a result of a GI bleed and could be related to the [MEDICATION NAME] use. On 11/16/11 at 7:07 a.m. surveyor # interviewed RN-B regarding resident #1. RN-B stated she was called to resident #1's room in the early morning of 11/11/11, at approximately 3:15 to 3:30 a.m. RN-B stated she was informed resident #1 was having black, tarry stools. RN-B observed the black, tarry stool and noted a dark red area around resident #1's anus. RN-B stated the area around the anus appeared to be bruising from pushing when expelling stool. RN-B stated she noted bruising on resident #1's arm, which appeared to be yellowing, and a bruise on the resident's leg. RN-B instructed LPN-C to contact the physician and have resident #1 sent to the hospital. RN-B indicated vitals were obtained prior to the hospital transport and were within normal limits for resident #1. RN-B stated she was concerned resident #1 may have a GI bleed due to the new bruising noted and the symptom of black, tarry stool. The resident progress notes for resident #1 on 11/11/11 at 3:26 a.m. documented, "Stool: tarry, one time this shift...Dr. notified...resident has had large amount of black tarry stool one time. Has significant bruising around anus, on upper arms, left wrist, and right inner thigh. Dr. (name) updated. Orders received to send to ER (emergency room ) for evaluation...3:40 AM sent to hospital ER...". A late entry was noted for 3:00 a.m., which documented resident #1's vital signs as blood pressure 109/46, pulse 90 and respirations of 14. The emergency room report, dated 11/11/11, documented resident #1 was evaluated and noted to have an elevated INR (International Normalized Ratio) of 10.55 (therapeutic range 2-3), hemoglobin of 8.6 (normal range 11.7-15.7) and hematocrit of 24.1 (normal range 34.9-46.9). Resident #1 was provided 5 mg of Vitamin K, two units of fresh frozen plasma, and one unit of packed cells. Resident #1 was transferred to another hospital for further evaluation of a GI bleed. According to the hospital records from the receiving hospital, dated 11/11/11, resident #1 was admitted to the ICU for further management. The hospital records indicated resident #1 had bruising, which included a 1.5 inch, dark red/purple area surrounding the rectum, purple/swollen labia, a 4 cm (centimeter) by 3 cm red/purple circular discoloration to the left posterior thigh, a 3 cm . by 1.5 cm purple area to the right inner leg, 3 cm and 2 cm green discoloration to the upper right thigh, and a purple/green oval shaped area to the left wrist measuring 5 cm by 3.5 cm. D. On 11/16/11 at 12:19 p.m. surveyor # interviewed CNA-I regarding resident #1. CNA-I indicated resident #1 had ongoing issues with loose stools throughout her stay. CNA-I indicated the stools were usually very foul smelling and black in color. CNA-I indicated on 11/10/11 she assisted resident #1 with toileting in the morning and thought the stool seemed more formed than it had in the past. CNA-I indicated the stool did not appear darker to her, as she stated the resident's stools had always been black in color. On 11/16/11 at 7:55 a.m. surveyor # interviewed CNA-M regarding resident #1. CNA-M stated she did not care for resident #1 from 11/10/11 to 11/11/11. CNA-M stated resident #1 did have loose stools at times; but the stools were never dark, but rather a "normal color." CNA-M stated she would report any dark or black stools to the charge nurse. On 11/16/11 at 9:40 a.m. surveyor # interviewed CNA-H regarding resident #1. CNA-H stated resident #1 had issues with loose stools throughout her stay, but the stools CNA-H observed were tan/light brown in color. CNA-H stated she had not observed any black stools for resident #1. On 11/16/11 at 9:55 a.m. surveyor # interviewed CNA-G regarding resident #1. CNA-G stated resident #1 had issues with loose stools throughout her stay, but the stools the CNA observed for resident #1 were light brown in color. CNA-G stated she had not observed any black stools for the resident. On 11/16/11 at 2:05 p.m. surveyor # completed a telephone interview with MD-L regarding resident #1. MD-L stated the facility did not have any standard protocol for INR monitoring. MD-L stated he would have ordered the first INR check to be completed four weeks after admission, as resident #1 had taken [MEDICATION NAME] prior to her hip surgery. MD-L verified the facility had not requested orders for a check of the INR. MD-L stated he would expect the facility to notify him immediately of any sign/symptoms of bleeding. MD-L verified an indication of bleeding would be black, tarry stools. MD-L stated with the onset of any indication of bleeding, the INR would have to be evaluated. MD-L stated he was not notified of resident #1 having black, tarry stools until 11/11/11 around 3:15 a.m. to 3:30 a.m. MD-L stated he had been on-call all day on 11/10/11 and had not received any notification from the facility of earlier onset of black stools. MD-L stated had he been notified earlier, he would have had resident #1 evaluated at the ER; as he did when he was notified, and the resident was subsequently transferred. On 11/16/11 at 1:15 p.m. surveyor # interviewed DON-A. DON-A stated on 11/14/11 the facility completed an audit of all residents taking [MEDICATION NAME] to ensure INR orders had been obtained, and the physician was aware of the results. DON-A stated the facility audited to ensure each resident taking [MEDICATION NAME] had a care plan in place to monitor for signs or symptoms of bleeding. DON-A stated she was in the process of revising the facility policy/procedure for anticoagulant use, and needed Medical Director approval prior to implementation. DON-A verified the facility had not completed any training with staff as of 11/16/11 regarding the new policy or potential signs/symptoms of bleeding or assessment thereof. DON-A verified a black and/or tarry stool could be an indication of GI bleeding, and the physician should be notified immediately of such. DON-A verified the physician should be consulted regarding black stools for any resident, including those taking [MEDICATION NAME]; and the physician should be consulted prior to administration of the next scheduled [MEDICATION NAME] dose. On 11/16/11 at 3:28 p.m. DON-A verified to surveyor # residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16 currently resided in the facility and utilized [MEDICATION NAME]. The immediate jeopardy situation that began for resident #1 on 11/10/11 was removed on 11/18/11 when the facility initiated training for all nursing staff prior to their taking the floor. The training addressed anticoagulant medications and included knowledge of purpose, risks and benefits of the medication including recognition of signs and symptoms of bleeding which need to be reported. The training addressed knowledge of lab values related to anticoagulant medications and when to consult the physician when lab values are outside parameters. The training addressed assessment for signs and symptoms of bleeding, testing for dark, tarry stools and documentation of findings. The training addressed scheduling of PT/INR testing for residents admitted on anticoagulation therapy and a method to follow the results of that testing. The training addressed monitoring of any drug with a potential for drug interaction with an anticoagulant medication and reporting any altered level to the physician. The training addressed the pharmacist's monthly review of medications and review of any interactions with the physician for special monitoring or alteration. The training also addressed the physician's responsibility for the INR goal, laboratory monitoring and review for possible complications. The non-compliance remains at the lower scope and severity of E (potential for harm/pattern) until all portions of the facility's removal plan are fully implemented and tested .