Every finding on record at Manawa Com Nur CTR

Based on observation, interview, and record review, the facility did not ensure food was not stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 20 residents residing in the facility.Food was not dated when opened.The temperature of the ice cream freezer was not monitored.Quaternary (Quat) sanitizing solution was not tested at the correct temperature to ensure the solution reached the correct parts per million (PPM) for effectiveness.Findings include:Undated/Expired Food:The facility's Food Storage policy, dated 12/19/17, indicates: Dry storage: .Label and date all storage containers as follows: 1. The received date should already be on it. 2. Date opened. 3. Date the item expires.On 7/20/26 at 8:15 AM, Surveyor toured the kitchen and pantry with Dietary Manager (DM)-D. Surveyor and DM-D observed the following items that were open and undated and/or expired:~ An open and undated bag of brown sugar ~ Sweet potatoes with a received date of 4/30/26~ An open and undated container of Smokehouse BBQ sauce~ A container of Carolina tangy gold sauce opened on 3/1/26~ An open and undated bag of dry gravy ~ An open and undated bag of instant mashed potatoes~ An open baking mix dated 6/20/25Surveyor interviewed DM-D who stated the brown sugar, BBQ sauce, dry gravy, and instant mashed potatoes should have been dated. DM-D disposed of the items. DM-D stated the Carolina tangy gold sauce was good for 1 month after opening and disposed of the sauce. DM-D stated the sweet potatoes were good for 2-4 weeks after receipt and should be disposed of. DM-D stated the baking mix was good for 8-12 months after opening and should be disposed of. Temperature Monitoring:The 2022 Food and Drug Administration (FDA) Food Code documents at 3 202.11 Temperature: .Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. Refrigerators should be set below 41 Fahrenheit (F) (5 Celsisus (C)) and freezers at or below 0 F (-18 C).On 7/20/26 at approximately 8:30 AM, Surveyor observed the thermometer for the ice cream freezer outside of the freezer. DM-D put the thermometer back in the freezer and stated staff did not monitor the temperature of the freezer. DM-D stated they just added ice cream to the freezer and accidentally left the thermometer outside. DM-D verified the thermometer should be in the freezer and stated they planned to start monitoring freezer temperatures by instituting a temperature log.Sanitizing Solution:The facility's Sanitizing Food Contact Solutions Policy and Procedure, dated 2/15/25, indicates: All food-contact surfaces, utensils, and equipment must be cleaned and sanitized using an approved Quaternary ammonium (QUAT) sanitizer according to the manufacturer's instructions and applicable food safety regulations .The ideal temperature for sanitizer testing typically falls between 75 degrees Fahrenheit (F) and 120 degrees F. This range ensures proper chemical activity and accurate testing results for most sanitizers.On 7/20/26 at approximately 9:15 AM, Surveyor interviewed DM-D who stated staff fill buckets with water/sanitizing solution and test the solution with testing strips. DM-D stated the water is hot when it comes out of the faucet and staff do not let it cool to room temperature before testing PPM of the sanitizing solution. DM-D verified instructions posted on the wall where the buckets are filled indicate the water should be between 65 and 75 degrees F. DM-D stated the system is automatically set to add the correct amount of sanitizing solution to the water and the PPM remain between the expected 200-400 when tested after filling the bucket without cooling the water.On 7/20/26 at 4:10 PM, Surveyor interviewed Ecolab Representative (ER)-E who provided Quaternary sanitizing solution for the facility and indicated the water should be at room temperature when testing PPM of the sanitizing solution.

Based on observation, interview, and record review, the facility did not properly dispose of medication for 1 resident (R) (R10) of 5 residents from a total sample of 12 residents.R10 had orders for senna and vitamin B12 to be administered in the AM. Registered Nurse (RN)-C threw away 2 tablets of medication in the trash can on the medication cart which was not in accordance with the facility's policy.Findings include:The facility's Disposal/Destruction of Medications Including Narcotics policy/procedure, revised 6/2026, indicates: Non-controlled oral medications that are: opened, expired, refused/dropped, and/or discontinued must be disposed of using: the Drug Buster bottle. DO NOT flush medications and DO NOT place medications in regular trash.R10's medical record contained orders for Senna 8.6 milligrams (mg) 1 tablet daily and Vitamin B12 500 micrograms (mcg) 1 tablet daily. R10 preferred that staff administer their medications.On [DATE] at approximately 8:25 AM, Surveyor observed RN-C prepare to administer R10's AM medications. RN-C poured 2 tablets of senna 8.6 mg into the cap of a bulk supply bottle. RN-C threw 1 of the tablets in the trash can on the medication cart and put the other tablet in a medication cup. RN-C then poured 2 tablets of vitamin B12 500 mcg into a the cap of a bulk supply bottle. RN-C threw 1 of the tablets in the trash can on the medication cart and put the other tablet in a medication cup.On [DATE] at 8:34 AM, Surveyor interviewed RN-C who stated they did not usually throw pills in the garbage and should have used the Drug Buster to dispose of the medication.On [DATE] at 8:37 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-F who stated medication should be disposed of in the Drug Buster. Surveyor observed ADON-F and RN-C remove the tablets from the trash and put them in the Drug Buster.On [DATE] at 8:39 AM, Surveyor interviewed Director of Nursing (DON)-B who stated staff should use the Drug Buster to dispose of medication.

Based on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This practice had the potential to affect all 23 residents residing in the facility. Dietary Manager (DM)-H did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: On 4/28/25 at 8:42 AM, Surveyor began an initial kitchen tour with DM-H who indicated DM-H was enrolled in a certified dietary manager (CDM) course. DM-H indicated DM-H started the course approximately one month ago. On 4/30/25 at 10:30 AM, Surveyor interviewed DM-H who indicated DM-H was hired in March of 2024. DM-H indicated DM-H had signed up for a CDM course in August (2024) but had just started the course a month ago and planned to complete the course in August of 2025. DM-H indicated DM-H had one year to complete the course, however, due to personal reasons and staffing-related issues, DM-H just started the course a month ago. On 4/30/25 at 10:35 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility thought DM-H just needed to be enrolled in a course.

Based on observation, staff and resident interview, and record review, the facility did not ensure menus met the nutritional needs of residents in accordance with established national guidelines. This practice had the potential to affect all 23 residents residing in the facility. The facility did not implement an extended menu that delineated the differences between diet types and portion sizes for residents. Findings include: The facility's Standard Portions policy, dated 12/19/17, indicates: Uniform food portions shall be established for each diet and served to all patients .Recipes and menus will have appropriate portions noted. On 4/29/25 at 12:12 PM, Surveyor began an observation of lunch service and interviewed Dietary Staff (DS)-J who indicated the facility did not have a menu that indicated how much of each item or what diet type residents should receive. Surveyor observed a menu on the refrigerator that indicated the lunch meal was Polish sausage and cabbage, hot German potato salad, and bread and butter. The alternative was a turkey sandwich. Dessert was a pumpkin bar. The menu did not indicate those on No Added Salt (NAS) or No Concentrated Sweets (NCS) diets should receive anything other than the main meal. When Surveyor asked about portion sizes, DS-J indicated there were no portion sizes indicated on the menu. DS-J indicated DS-J and other staff know to use a green scoop for sides (2 ounces) and a gray scoop (4-5 ounces) for the main course. On 4/29/25 at 12:38 PM, Surveyor reviewed residents' meal cards and noted residents had either a regular, NAS, or NCS diet. The diet cards did not contain portion sizes and there were no changes listed between the diets. The diet cards were hand marked to indicate what items residents wanted or did not want for lunch. On 4/29/25 at 12:55 PM, Surveyor observed DS-J puree sausage and cabbage in a blender for 4 residents on pureed diets who were eating in the dining room. After DS-J finished pureeing, DS-J divided the food evenly onto each plate with a spatula. DS-J indicated DS-J evenly divides the food between residents and if there is any left, DS-J puts the remainder on the plate of a resident who is known to eat more. Surveyor noted DS-J did not use a scoop for proper portion sizes. On 4/30/25 at 9:41 AM, Surveyor interviewed Dietary Manager (DM)-H who indicated the facility uses one menu that is created by DM-H and is approved by the dietitian. DM-H indicated there are no portion sizes or diet types on the menu. There is also no delineation between NAS and NCS diets and if residents should receive different items with their meals. DM-H indicated residents choose what they want and staff know to use certain scoops for certain items. DM-H indicated the facility has an upcoming meeting with a menu company to standardize things. DM-H indicated Registered Dietitian (RD)-I just started a couple of weeks ago. On 4/30/25 at 10:03 AM, Surveyor interviewed RD-I who verified RD-I started employment a couple of weeks ago. RD-I indicated RD-I met with kitchen staff and recommended menu systems for the facility to purchase. RD-I verified portion sizes and menus should be standardized for all diets which includes moving from an NCS diet for residents who are diabetic to more of a Consistent Carbohydrate (CCH) diet. RD-I indicated the menu should state what a CCH diet would receive for that particular meal to stay within nutritional guidelines.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 23 residents residing in the facility. Infection control line lists for residents and staff did not contain last symptom dates, times, and/or return to work dates in accordance with the facility's policy. Staff did not ensure infection control procedures were maintained during the provision of care and handling of linens for R18 and R17. Findings include: The facility's Infection Prevention and Control policy, dated 1/12/19, indicates: The facility establishes a program under which it: Provides a system of surveillance to identify possible communicable disease or infection before they can be spread in the facility; Provides standard and transmission-based precautions to be followed to prevent the spread of infection; Maintains a record of incidents and corrective actions related to infections .Institutional Factors: Provide other resources needed to contain infections such as disposable items, laundry facilities and staff trained in infection control; Document employee health . The facility's Coronavirus COVID-19 policy, dated 3/20/20, indicates: Manawa Community Living Center (MCLC) will actively monitor staff, residents, and visitors for the following symptoms. MCLC will continue to follow guidance provided from local heal department agencies, the WI Department of Health Services (DHS), the Centers for Medicare and Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC) .MCLC will follow guidance pertaining to COVID-19 as updates are provided from local departments, the CDC, WI DHS, and CMS. MCLC nursing staff will be monitored for signs and symptoms of COVID-19 at the beginning of their shifts . The facility's Guidance Regarding Return to Work of Healthcare Personnel Following COVID-19 Exposure policy, updated 2/15/21, indicates: It is the policy of MCLC to comply with DHS, CMS and CDC guidance pertaining to healthcare professionals return to work criteria. Update 12/4/20 indicates: Quarantine can end after day 10 without testing if no symptoms have been reported during daily monitoring .When diagnostic testing resources are sufficient and available then quarantine can end after day 7 if a diagnostic specimen tests negative and if no symptoms were reported during daily monitoring. The specimen may be collected and tested within 48 hours before the time of planned discontinuation, but quarantine cannot be discontinued earlier than after day 7. CDC (dated 3/21/24), 42a. category IB recommends healthcare personnel with gastrointestinal (GI) illnesses, particularly those with symptoms like vomiting or diarrhea, be excluded from work for a minimum of 48 hours after their symptoms have resolved. The facility's Perineal Care (Peri-Care) policy and procedure, dated 4/20/21, indicates: Females: .Wash downward front to back repeating the motion as needed using a different part of the washcloth or disposable wipe product for each stroke. Rinse and dry using the same technique .Assist the resident into a side lying position. Cleanse the rectal area, wiping from front to back, repeating as needed. Use more than one disposable wipe if necessary, rinse and dry using the same technique. After completion of peri-care, remove gloves and wash hands before assisting the resident with dressing and grooming. All soiled washcloths, towels, and clothing should be placed in a plastic bag before leaving the resident's room. Certified Nursing Assistant (CNA) training material provided by facility indicates: .Linen Handling the Basics: Never place linen in these areas: .On the floor. This includes clean or soiled linen. Once on the floor, it is considered contaminated; In sinks. Sinks are not for linen storage or disposal. They are for hand washing and medical cleaning only Clean linen handling: If clean linen touches the floor or any unclean surface, it must be considered soiled. Floor Policy: No dirty or clean linen, supplies, or equipment should ever be placed on the floor. The floor is considered a contaminated surface at all times .Peri-care: .Use clean clothes for each area. On 4/28/25, Surveyor reviewed the facility's infection control staffing line list and noted the following: April 2025: ~ Hospitality Aide (HA)-L had emesis with an onset date of 4/10/25, a last symptom date of 4/11/25, and a return to work date of 4/13/25. The line list did not indicate the time of HA-L's last symptom on 4/11/25. February 2025: ~ Licensed Practical Nurse (LPN)-Q had a fever and cough with an onset date of 2/9/25, a last symptom date of 2/11/25, and a return to work date of 2/13/25. The line list did not indicate the time of LPN-Q's last symptom on 2/11/25. ~ Certified Nursing Assistant (CNA)-N was COVID-19 positive on 2/10/25 and had a return to work date of 2/17/25. The date and time of CNA-N's last symptom was unknown. ~ CNA-O was COVID-19 positive on 2/17/25 and had a return to work date of 2/28/25. The date and time of CNA-O's last symptom was unknown. ~ Dietary Manager (DM)-H was COVID-19 positive on 2/18/25 and had a return to work date of 2/24/25. The date and time of DM-H's last symptom was unknown. ~ Kitchen Lead (KL)-P was COVID-19 positive on 2/10/25 and had a return to work date of 2/17/25. The date and time of KL-P's last symptom was unknown. Surveyor requested tracking of COVID-19 testing on day 5 and day 7. The facility did not provide test results before the survey ended on 4/30/25. (Of note: The line list contained 4 COVID-19 positive staff.) January 2025: ~ CNA-R had vomiting and diarrhea with an onset date of 1/7/25, a last symptoms date of 1/9/25, and a return to work date of 1/11/25. The line list did not indicate the time of CNA-R's last symptom on 1/9/25. ~ Registered Nurse (RN)-T had vomiting and diarrhea with an onset date of 1/8/25, a last symptom date of 1/11/25, and a return to work date of 1/13/25. The line list did not indicate the time of RN-T's last symptom on 1/11/25. ~ RN-Y had a fever on 1/9/25 and a return to work date of 1/15/25. The line list did not indicate the date and time of RN-Y's last symptom. ~ RN-Y had vomiting and diarrhea with an onset date of 1/11/25, a last symptom date of 1/13/25, and a return to work date of 1/15/25. The line list did not indicate the time of RN-Y's last symptom on 1/13/25. ~ CNA-X had vomiting with an onset date of 1/11/25, a last symptom date of 1/12/25, and a return to work date of 1/14/25. The line list did not indicate the time of CNA-X's last symptom on 1/12/25. ~ CNA-W had vomiting and diarrhea with an onset date of 1/11/25, a last symptom date of 1/15/25, and a return to work date of 1/17/25. The line list did not indicate the time of CNA-W's last symptom on 1/15/25. ~ CNA-U had vomiting and diarrhea with an onset date of 1/9/25, a last symptom date of 1/12/25, and a return to work date of 1/14/25. The line list did not indicate the time of CNA-U's last symptom on 1/12/25. ~ Director of Nursing (DON)-B was COVID-19 positive on 1/19/25, had a last symptom date of 1/20/25, and a return to work date of 1/27/25. The line list did not indicate the time of DON-B's last symptom on 1/20/25. ~ Dietary Aide (DA)-V was COVID-19 positive on 1/7/25 and returned to work on 1/15/25. The date and time of DA-V's last symptom was unknown. Surveyor requested tracking of COVID-19 testing on day 5 and day 7. The facility did not provide test results before the survey ended on 4/30/25. (Of note: The line list contained 2 positive COVID-19 staff.) On 4/28/25, Surveyor reviewed the facility's resident line list and noted the following: March 2025: ~ R15 was COVID-19 positive from 2/18/25 to 2/25/25. On 3/4/25, R15 had a temperature of 100 degrees Fahrenheit (F). A chest X-ray indicated R15 had pneumonia. R15 was placed on precautions on 3/4/25 and removed the same day. February 2025: ~ R15 had a temperature of 99.9 degrees F on 2/17/25 and a negative COVID-19 test. On 2/18/25, R15 tested positive for COVID-19 and was placed on isolation precautions which ended on 2/25/25. ~ Routine testing indicated R6 was COVID-19 positive on 2/19/25. R6 was placed on isolation precautions which ended on 2/26/25. January 2025:. ~ R15 had cold symptoms on 1/21/25. R15 tested negative for COVID-19 on 1/21/25 and 1/22/25. Testing information on 1/24/25 did not contain results. R15 was on isolation precautions from 1/21/25 to 1/24/25. ~ R21 was added to line list on 1/4/25 and 1/20/25. No data was completed. ~ R18 was added to line list on 1/4/25. No data was completed. ~ R21 was added to the GI line list on 1/8/25 and put on precautions. The line list did not contain a last symptom date or indicate when R21 was removed from precautions. ~ R11 was added to the GI line list on 1/9/25 with a last bowel movement date of 1/9/25. R11 was removed from precautions on 1/11/25. The line list did not indicate the time of R11's last symptom. ~ R2 was added to the GI line list on 1/12/25 with a last bowel movement date of 1/17/25. R2 was removed from precautions on 1/19/25. The line list did not indicate the time of R2's last symptom. On 4/30/25 at 11:01 AM, Surveyor interviewed and reviewed the above line lists with DON-B who verified the line lists were not completed correctly and were missing information. DON-B also confirmed the facility used residents' and staffs' test date/COVID-19 positive date as day one and not day zero. On 4/30/25 at 12:03 PM, Surveyor interviewed County Health Nurse (CHN)-BB who indicated CHN-BB does not advise facilities on what they should do for infection control and indicated each facility should have their own policies and procedures. CHN-BB indicated CHN-BB gives guidance if a facility needs help and directs the facility to the Department of Health Services (DHS) or the CDC for the current regulations and updates. 2. From 4/28/25 to 4/3025, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, complete traumatic amputation at knee level left lower leg, and unspecified chronic kidney disease. R18's Minimum Data Set (MDS) assessment, dated 2/7/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R18 had little to no cognitive impairment. On 4/29/25 at 7:27 AM, Surveyor observed Assistant Director of Nursing (ADON)-C in R18's room and noted R18's top sheet was on the floor. ADON-C picked the top sheet off the floor and put it back on R18's bed. A short time later, ADON-C covered R18 with the top sheet. R18 refused to be covered and indicated the sheet was saturated with urine. ADON-C then put the top sheet in a dirty laundry basket. On 4/29/25 at 8:03 AM, Surveyor observed CNA-Z complete peri-care for R18 who was incontinent. Surveyor noted CNA-Z had only two washcloths, one with soap and one to rinse. CNA-Z completed frontal peri-care and put the soiled washcloth on R18's bed without a barrier. CNA-Z completed peri-care with the rinse washcloth which CNA-Z also put on R18's bed without a barrier. With the help of ADON-C, CNA-Z rolled R18 on the right side and used the same two washcloths to wash and rinse R18's buttock. CNA-Z then put both soiled washcloths on R18's bed. Without changing gloves or cleansing hands, CNA-Z then put a clean brief on R18. CNA-Z then used the same soiled gloves to situate R18 in a lift. On 4/29/25 at 12:50 PM, Surveyor interviewed CNA-Z who confirmed CNA-Z used the same 2 washcloths during peri-care for R18. CNA-Z also confirmed dirty linens should be placed on a barrier or in the laundry basket. CNA-Z indicated hand hygiene and a glove change should take place between dirty and clean items. On 4/29/25 at 12:55 PM, Surveyor interviewed DON-B who indicated staff use 2 blue washcloths for peri-care and instructed Surveyor to speak to RN-D who is the facility's staff development person. DON-B confirmed the same 2 washcloths are used to clean residents' front and back peri areas. DON-B also confirmed dirty items should not be put on a resident's bed without a barrier . On 4/29/25 at 1:02 PM, Surveyor interview RN-D who confirmed staff use 2 washcloths with the 4 square method to ensure a clean surface with each stroke. When asked how the facility ensures when staff complete backside peri-care they use a clean area of the washcloth that was not used on the front, RN-D indicated staff should use wipes first if a resident is incontinent and then use washcloths. RN-D provided Surveyor with CNA Training for peri-care that is posted at each CNA station. 3. On 4/30/25 at 7:46 AM, Surveyor observed CNA-AA prepare to complete catheter care for R17. CNA-AA turned on the water and put washcloths in R17's sink. CNA-AA did not sanitize the sink prior to placing washcloths in the sink. On 4/30/25 at 7:52 AM, Surveyor interviewed CNA-AA and asked if washcloths should have been placed in the sink. CNA-AA confirmed CNA-AA should not have put the washcloths in the sink and should have used a basin instead. On 4/30/25 at 1:52 PM, Surveyor interviewed RN-D who indicated washcloths should not be put in sinks and staff should use a basin for cares. RN-D referred to the CNA Training sheets for reference.

Based on observation, staff interview, and record review, the facility did not ensure medication was secured and stored appropriately. This practice had the potential to affect more than 4 of the 23 residents residing in the facility. On 4/29/25, a bottle of aspirin 81 milligrams (mg) and a bottle of Lactobacillus 100 mg for R20 were left on top of the medication cart. The medication cart was left unlocked and unattended by a licensed nurse. Findings include: The facility's Medication Storage Policy, dated 3/1/05, indicates: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medication (medication aides) are allowed access to medication. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. The facility's Medication Administration Policy, dated 4/4/17, indicates: .13. Lock medication cart before entering resident room to prevent accidental ingestion of medication and diversion of medication. Note: Never leave the medication cart open and unattended. On 4/29/25, Surveyor observed a medication cart unlocked from the start of medication pass at 7:52 AM until 8:32 AM when Registered Nurse (RN)-K obtained water for a resident. The medication cart was unattended in the hallway while RN-K administered medication in residents' rooms. Surveyor observed staff and residents pass by in the hallway. At one point during the observation, RN-K was in a resident's room with the door closed. On 4/29/25 from 8:12 AM to 8:19 AM, Surveyor observed a bottle of aspirin 81 mg and a bottle of Lactobacillus (a probiotic) 100 mg for R20 on top of the medication cart. On 4/29/25 AM at 8:19 AM, Surveyor interviewed RN-K who verified the medications should have been put back in the medication cart. On 4/29/25 at 10:16 AM, Surveyor interviewed RN-K who indicated RN-K remembered to lock the medication cart at least once prior to 8:32 AM, however, Surveyor did not observe that. RN-K indicated at other facilities where RN-K worked, the medication cart could be kept unlocked if within eyesight. RN-K verified RN-K could not see the medication cart when RN-K administered medication to a resident in the dining room. On 4/30/25 at 10:24 AM, Surveyor interviewed Director of Nursing (DON)-B who was aware RN-K left medications on top of the medication cart and left the medication cart unlocked and unattended. DON-B verified medications should not be on top of medication cart and the medication cart should be locked when unattended.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R8) of 3 sampled residents who was unable to carry out activities of daily living (ADLs) was provided assistance with nail care. R8 was not provided routine nail care. Findings include: The facility's Activities of Daily Living (ADL) policy, dated 2/15/12, indicates: It is the policy of the facility that residents' ADL needs will be met .It is the goal of the facility to provide necessary care and services. From 4/28/25 to 4/30/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including Marfan syndrome (an inherited disorder that affects connective tissue), dementia, and cerebrovascular accident (CVA) (stroke). R8's Minimum Data Set (MDS) assessment, dated 3/27/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R8 had severe cognitive impairment. The MDS assessment also indicated R8 required substantial/maximal assistance of staff for bathing. R8 had an activated Power or Attorney for Healthcare (POAHC). A care plan, dated 5/4/23, indicated R8 had an ADL self-care performance deficit related to a stroke. The care plan contained an intervention for bathing/showering: check nail length and trim and clean on bath day and as necessary. An activity participation note, dated 3/18/25, indicated R8 participated in 15 minutes of activity during which R8's nails were trimmed, filed, and cleaned. On 4/28/25 at 10:02 AM, Surveyor observed R8's fingernails and noted they were clean but approximately ¼ inch long. Surveyor attempted to interview R8 but R8 was unable to answer Surveyor's questions. On 4/29/25 at 12:08 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated R8 received showers on the Saturday AM shift. CNA-F was not assigned to R8 the previous Saturday but was aware R8 did not receive a shower because the key to the shower room was missing. CNA-F indicated R8's nails should have been trimmed even though R8 did not receive a shower. Surveyor reviewed a shower sheet that indicated R8 was scheduled to receive a shower on the Saturday AM shift including a skin check, nails/toes, ears, and vital signs. On Saturday 4/26/25, R8's vital signs were documented, however, the documentation did not indicate if a shower was provided or if nail care was done. On 4/29/25 at 12:15 PM, Surveyor interviewed Restorative Aide (RA)-E who verified R8's fingernails were long. On 4/30/25 at 10:24 AM, Surveyor interviewed Director of Nursing (DON)-B who verified documentation indicated R8's nails were last trimmed on 3/18/25. DON-B indicated R8's nails should be kept short.

Based on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R18) of 1 sampled resident. R18 had an order for 1 to 4 liters of oxygen as needed via nasal cannula for respiratory distress or discomfort, titrate to maintain greater than 90% (oxygen saturation level) with a start date of 3/21/22. R18 did not have an order to change or maintain R18's oxygen equipment or a care plan for respiratory therapy. Findings include: The facility's Oxygen Therapy Policy and Procedure, dated 5/22/23, indicates: .Change tubing weekly, unless otherwise specified in patient's orders .Care plan is updated regularly by licensed nursing staff. From 4/28/25 to 4/30/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, complete traumatic amputation at knee level left lower leg, and unspecified chronic kidney disease. R18's Minimum Data Set (MDS) assessment, dated 2/7/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R18 had little to no cognitive impairment. The MDS assessment also indicated R18 used continuous oxygen therapy. On 4/28/25 at 9:53 AM, Surveyor attempted to interview R18, however, R18 was asleep in a wheelchair. R18 was receiving 2 liters of oxygen via nasal cannula. R18's medical record contained an order for as needed oxygen with a start date of 3/21/22 (from a prior admission). Staff tracked R18's oxygen use per minute starting on 3/23/25. R18 used oxygen 50 to 880 minutes per day in April 2025 for the time frame that was reviewed. R18's Treatment Administration Record (TAR) did not contain a maintenance order for oxygen tubing. R18 also did not have a care plan for oxygen therapy. On 4/29/25, Surveyor reviewed R18's plan of care and noted an oxygen therapy care plan dated 4/29/25 as well as tubing change and PRN oxygen orders dated 4/29/25. On 4/29/25 at 1:02 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R18's oxygen therapy care plan was initiated that day. DON-B indicated R18 did not need oxygen, however, R18 had requested oxygen since March (2025) and the facility monitored the amount R18 had been using. DON-B verified a care plan should have been developed when R18 started using oxygen on a consistent basis. DON-B also indicated there should be an order in R18's TAR to change R18's oxygen tubing weekly per the facility's policy.

Based on staff interview and record review, the facility did not ensure adequate assistance to prevent falls was provided for 2 residents (R) (R3 and R5) of 5 sampled residents. On 8/19/24, Certified Nursing Assistant (CNA)-E transferred R3 without a gait belt which was required per R3's plan of care. R3 fell and sustained a 4 centimeter (cm) forehead laceration and a subdural hematoma that required steri-strips and neurological monitoring. CNA-E was not provided education prior to returning to work on 8/24/24 (which was before the facility's investigation was completed.) On 8/24/24, CNA-E was observed transferring R5 without a mechanical lift which was required per R5's plan of care. The facility's failure to ensure a staff who transferred a resident incorrectly which resulted in a fall with injury was educated prior to returning to work and transferring another resident incorrectly created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy that began on 8/19/24. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 10/17/24 at 8:22 AM. The immediate jeopardy was removed on 8/26/24, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's undated Abuse, Neglect, Mistreatment, and Misappropriation policy indicates residents will be kept safe during an investigation and staff will be educated as necessary pending a full investigation. The facility's undated Transfer/Lift policy indicates staff are responsible to use the gait belt with any resident who is not independent with transfers and/or ambulation or use an assisted mechanical device (i.e., sit-to-stand and full body lift (Hoyer)) and that transfer status will be detailed in the resident's care plan. On 10/16/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, delusional disorder, arthritis, and chronic pain. R3's most recent Minimum Data Set (MDS) assessment, dated 8/8/24, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R3 had severe cognitive impairment. R3's care plan, revised 8/8/24, indicated R3 required a gait belt and the assistance of one staff for transfers. On 10/16/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and chronic kidney disease. R5's most recent MDS assessment, dated 8/8/24, had a BIMS score of 0 out of 15 which indicated R5 had severe cognitive impairment. R5's care plan, implemented 11/30/23, indicated R5 required a mechanical sit-to-stand lift and the assistance of one staff for transfers. On 10/16/24, Surveyor reviewed a facility-reported incident (FRI) submitted to the SA on 8/19/24 that indicated CNA-E transferred R3 without a gait belt which resulted in a fall. The investigation indicated: ~ CNA-E confirmed CNA-E did not use a gait belt when CNA-E transferred R3. ~ Registered Nurse (RN)-F indicated CNA-E asked several times if CNA-E would get fired after the incident. RN-F indicated CNA-E was known to transfer residents without a gait belt. ~ RN-F's assessment indicated R3 sustained a 4 cm forehead laceration, a depression to the forehead, and a hematoma. ~ Licensed Practical Nurse (LPN)-G indicated CNA-E returned to work on 8/24/24 and was observed transferring R5 without a mechanical lift or gait belt by a CNA in training. On 10/16/24 at 10:39 AM, Surveyor interviewed RN-F regarding the incident on 8/19/24. RN-F indicated RN-F thought R3 needed stitches, however, Hospice staff declined to send R3 to the hospital. RN-F stated Hospice staff applied steri-strips and a foam border dressing to the wound and completed neurological checks. RN-F verified RN-F worked with CNA-E for a couple years and knew to watch out for CNA-E completing unsafe transfers. RN-F indicated management was told in the past that CNA-E completed unsafe transfers, however, RN-F was not sure if anything was done. On 10/16/24 at 1:13 PM, Surveyor interviewed LPN-G regarding the incident on 8/24/24. LPN-G was aware that something occurred with CNA-E and R3 on 8/19/24 but was not sure what. LPN-G stated LPN-G heard CNA-E was known to not follow care plan interventions related to transfers. LPN-G assigned a CNA in training to work with CNA-E during the 8/24/24 AM shift. LPN-G was not aware if CNA-E received education prior to returning to work. LPN-G indicated the CNA in training reported that CNA-E transferred R5 without a mechanical lift or gait belt. LPN-G notified administration immediately. On 10/16/24 at 2:45 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the incident on 8/19/24. DON-B verified CNA-E confirmed CNA-E did not use a gait belt when transferring R3 on 8/19/24. DON-B instructed RN-F to send R3 to the hospital, however, R3's Hospice agency declined to do so and chose to assess and provide care at the facility. DON-B verified CNA-E was not provided education related to following care plan interventions prior to returning to work on 8/24/24 because it was the weekend and administrative staff were not available to provide the education. On 10/16/24, Surveyor reviewed CNA-E's personnel file and noted the following: ~ CNA-E was provided transfer education during orientation on 8/5/24. ~ A Coaching/Counseling Plan, dated 7/18/23, indicated CNA-E was involved in an incident in which a resident incurred an ankle fracture during a transfer with a sit-to-stand lift. The Plan of Action indicated CNA-E would alert nursing staff immediately if an injury occurred during a transfer and would ensure residents' care plans were followed. The document indicated a 6 month review would be completed in 2024. On 10/16/24 at 2:45 PM, Surveyor interviewed DON-B regarding CNA-E's Coaching/Counseling Plan from 7/18/23. DON-B could not recall details of the incident or why the note about following the care plan was documented. DON-B verified CNA-E's 6 month follow-up related to the incident did not occur. The failure to educate CNA-E on following a resident's care plan during a transfer (which resulted in a fall with injury) and allowing CNA-E to return to work without education and transfer another resident incorrectly created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 8/26/24 when it completed the following: 1. Educated direct care/nursing staff on following care cards/care plan interventions related to transfer status. 2. Updated a binder to be kept at the nurses' station with care cards and individual service plans for residents. 3. Conducted audits to ensure accuracy of transfer status.

Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher-level degree in food service management or hospitality. This had the potential to affect all 23 residents residing in the facility. Dietary Manager (DM)-D did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: The facility provided a staff roster that indicated DM-D was a lead cook and was hired on 3/26/24. On 10/16/24 at 8:13 AM, Surveyor entered the kitchen and spoke with DM-D who was the Dietary Manager. DM-D indicated a Registered Dietitian came to the facility roughly monthly and was in contact with DM-D on a regular basis. DM-D indicated DM-D started as the DM around April of 2024. During a continuous kitchen observation that started at 11:50 AM on 10/16/24, DM-D indicated DM-D was ServSafe certified and was going to enroll in a Certified Dietary Manager (CDM) program soon. On 10/16/24 at 12:24 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DM-D was the Dietary Manager and was going to enroll in the training program. DON-B indicated DM-D was previously employed by the facility but left employment when the facility hired a new Dietary Manager. The previous Dietary Manager left employment and DM-D was rehired in April of 2024. DON-B confirmed DM-D was hired in April of 2024 to be the Dietary Manager and the facility was not currently looking for a Dietary Manager. DON-B indicated DM-D was going to complete the CDM course. On 10/16/24 at 12:34 PM, Surveyor interviewed Business Office Manager (BOM)-C who indicated DM-D was going to take the Dietary Manager certification course but had to leave employment. When DM-D was rehired, DM-D was going to take the course but had not started it yet. BOM-C indicated DM-D was going to take the course but confirmed DM-D was not currently enrolled in the course and had not been enrolled since DM-D was rehired in April of 2024.

Based on staff interview and record review, the facility did not ensure medical records contained complete information for 4 residents (R) (R3, R5, R6, and R8) of 5 sampled residents. Physician visit notes were not readily accessible and available in R3, R5, R6, and R8's medical records. Findings include: The facility's undated Long Term Facilities Retention Plan indicates medical records should be kept 7 years after discharge. On 10/22/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and hypertension. On 10/22/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including dementia. On 10/22/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, and hypertension. On 10/22/24, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, arthritis, and hypertension. Surveyor noted physician visit notes were missing from R3, R5, R6, and R8's medical records and requested the notes from Director of Nursing (DON)-B. On 10/22/24 at 3:30 PM, Surveyor had not received the physician visit notes and interviewed DON-B who indicated the facility contacted the physician's office and was waiting for the notes to be sent. DON-B indicated the facility switched providers around December of 2023 and said the facility had access to physician visit notes through the previous provider's electronic portal system. DON-B indicated the facility did not have access to medical records through the current provider's portal because the portal had not been set up. DON-B confirmed physician visit notes should be part of residents' medical records and should be easily accessible. On 10/24/24 at 8:43 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-H via phone who indicated the physician's office had sent all but R5's physician visit notes. On 10/24/24 at 9:08 AM, Surveyor received an email with physician visit notes for R3, R6, and R8 and noted there was 1 physician visit note for R3, 3 physician visit notes for R6, and 1 physician visit note for R8. On 10/24/24 at 1:48 PM, Surveyor received an email which contained 2 of R5's physician visit notes.

Based on staff interview and record review, the facility did not ensure an allegation of potential neglect was thoroughly investigated for 1 resident (R) (R3) of 5 sampled residents. On 8/19/24, Certified Nursing Assistant (CNA)-E transferred R3 without a gait belt. R3 fell and incurred a forehead laceration and hematoma. The facility did not complete the investigation or provide education to CNA-E before CNA-E returned to work on 8/24/24. Findings include: The facility's undated Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy indicates: Staff will receive education about resident mistreatment and neglect .that an alleged perpetrator of abuse or neglect will immediately be removed and will remain removed pending the results of a thorough investigation .If the investigation shows maltreatment occurred, reporting to the appropriate agencies and education will be provided to all parties as needed. On 10/16/24, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the State Agency (SA) on 8/19/24. The report stated CNA-E was accused of transferring R3 without a gait belt as care planned. As a result, R3 fell and sustained a 4 centimeter laceration to the forehead and a hematoma. CNA-E was suspended on 8/19/24 pending a thorough investigation. It was determined through interviews that the allegation of neglect was substantiated. Upon review of the investigation, Surveyor noted CNA-E returned to work on 8/24/24. A statement from Licensed Practical Nurse (LPN)-G indicated CNA-E transferred R5 (who required a sit-to-stand lift for all transfers) from R5's bed to wheelchair without a sit-to-stand lift or a gait belt on 8/24/24. On 10/16/24 at 1:14 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff were educated about falls and following care plan interventions beginning on 8/26/24. DON-B verified CNA-E was not provided education prior to returning to work on 8/24/24. DON-B also verified the facility's final investigation was not completed or submitted to the SA until 8/26/24.

Based on staff interview and record review, the facility did not ensure 2 staff (Certified Nursing Assistance (CNA)-I and CNA-J) of 5 staff reviewed for education requirements received Quality Assurance and Performance Improvement (QAPI) training. CNA-I and CNA-J did not receive QAPI training. Findings include: On 10/22/24, the facility provided a list of trainings that new employees receive on their first day of employment. Onboarding Training Day 1 was handwritten on the form. QAPI was listed as a training that new employees should receive. Surveyor noted CNA-I was hired by the facility on 5/16/17 and CNA-J was hired by the facility on 7/22/15. On 10/22/24, Surveyor reviewed one year of electronic and paper training records for CNA-I and CNA-J which did not include QAPI training. Surveyor requested CNA-I and CNA-J's QAPI training documents. On 10/22/24 at 2:00 PM, Business Office Manager (BOM)-C indicated BOM-C was responsible for training and onboarding but could not locate CNA-I and CNA-J's QAPI training records. BOM-C indicated staff are trained on QAPI during orientation. BOM-C confirmed the facility should have a record of QAPI training for CNA-I and CNA-J.

Based on observation and staff, resident, and family interview, the facility did not ensure a safe, clean, and home-like environment for 4 Residents (R) (R1, R2, R3, and R4) as well as other residents who use the 100 wing lounge. Facility administration indicated water from heavy rains penetrated the exterior walls of R1, R2, R3, and R4's rooms on 7/5/24. In each of the rooms, Surveyor noted a black and/or dark green, damp, and smudgeable substance on baseboards removed from the walls and on the drywall surface of the lower walls. In addition, Surveyor observed a white fuzzy growth on the surfaces and noted a mildew-like smell in R1, R2, and R3's rooms. In addition, the 100 wing lounge contained remodeling supplies including seven approximately six-foot long wooden baseboards, three pieces of drywall, a roll of insulation, and a bed stored in the center of the room. Findings include: A Post Crescent news article, dated 7/6/24, stated, Up to 100 homes, including a nursing home, were evacuated Friday (7/5) after erosion caused the bank of the edge of the Manawa Mill Pond dam to fail .mid-morning Friday, Manawa started getting heavy rain that amounted to about 4 inches .We started experiencing high flooding . The Centers for Disease Control and Prevention (CDC) website section, dated 5/29/24, titled Mold indicates: Stachybotrys chartarum is a greenish-black mold. It can grow on material with a high cellulose content, such as fiberboard, gypsum board, and paper. Growth occurs when there is moisture from water damage, water leaks, condensation, water infiltration, or flooding. Constant moisture is required for its growth .At present, no test exists that proves an association between Stachybotrys chartarum and particular health symptoms. Individuals with persistent symptoms should see their physician. However, if Stachybotrys chartarum or other molds are found in a building they should be removed . On 7/26/24 at 9:37 AM, Surveyor toured the facility and noted a resident lounge on the 100 wing contained a bed in the center of the room. Surveyor also observed seven approximately six-foot long pieces of baseboard on a table, three pieces of drywall, and a roll of insulation. On 7/26/24 at 10:34 AM, Surveyor interviewed Family Member (FM)-C who was visiting R5. FM-C stated FM-C toured the facility on 7/17/24 which the day before residents returned from an evacuation that occurred on 7/5/24. FM-C stated FM-C smelled something that wasn't right in the lounge and was sensitive to mold-like smells due to asthma. FM-C indicated the facility should have completed water damage repairs while the residents resided at the evacuation facility from 7/5/24 to 7/17/24. FM-C stated FM-C brought concerns to facility management who immediately began work on the lounge. FM-C stated R5's room was moved until the lounge carpet was removed and replaced and work was completed in other areas of the lounge. FM-C stated the facility did not block off the lounge while they worked on repairs. On 7/26/24 at 12:50 PM, Surveyor toured R1, R2, R3, and R4's rooms which were on the side of the facility where flooding through exterior walls occurred. When interviewed about the flooding, R1 stated, I feel pretty good about it just as long as there is not mold. Surveyor noted the vinyl baseboard on R1's exterior wall was removed and propped against the wall. The baseboard and drywall surface on the lower wall contained a black and dark green substance that was damp and smudgeable with a finger. Surveyor also noted smaller areas on the drywall that contained a white fuzzy substance and noted a mildew/musty smell near the lower wall. In R4's room, Surveyor noted the vinyl baseboard on the exterior wall was removed and propped against the wall. The baseboard and drywall surface on the lower portion of the wall contained a black and dark green substance that was damp and smudgeable with a finger. Surveyor also noted smaller areas on the drywall that contained a white fuzzy substance and noted a mildew/musty smell near the lower wall. In R2's room, Surveyor noted the vinyl baseboard on the exterior wall was removed and propped against the wall. The baseboard and drywall on the lower wall contained a significant amount of black and dark green spore-like substance that was damp and smudgeable with a finger. Surveyor also noted areas on the baseboard and drywall that contained a white fuzzy substance and noted a mildew/musty smell near the exterior wall. R2's bed was in a low position and approximately two feet from the exterior wall. In R3's room, Surveyor noted the vinyl baseboard was removed from the exterior wall and laying on the floor nearby. The baseboard and drywall on the lower wall contained a small amount of black substance that was damp and smudgeable with a finger. The growth was not as extensive as R1, R2, and R4's rooms. On 7/26/24 at 1:07 PM, Surveyor observed R2's room with Nursing Home Administrator (NHA)-A who stated NHA-A found the same substance while doing repairs in other areas where rainwater flooded through the exterior walls. NHA-A stated R1, R2, R3, and R4's rooms would be repaired within a few days to a week. NHA-A stated NHA-A was working on two other vacated rooms which would be used to house R1, R2, R3, and R4 while their rooms were repaired. On 7/26/24 at 3:40 PM, NHA-A received instructions from the County Public Health Department that the above-noted substances needed to be tested to determine what they were, however, if they were assumed to be mold, NHA-A could clean the areas with a water/bleach solution to eliminate the mold. On 7/26/24 at 3:50 PM, NHA-A received instructions from the facility's Medical Director to monitor R1, R2, R3, and R4 for respiratory symptoms while they resided in their rooms and to relocate any resident with symptoms indicative of an allergy to the substance. Following NHA-A's conversations with the County Public Health Department and the Medical Director, Surveyor observed NHA-A coordinate with R1, R2, R3, and R4 to clean their rooms during supper that evening.

Based on staff interview and record review, the facility did not ensure allegations of abuse were reported to Nursing Home Administrator (NHA)-A, the State Agency (SA), and/or local law enforcement for 4 residents (R) (R1, R2, R3, and R6) of 6 sampled residents. On 5/29/24 and 6/9/24, R1 verbally abused R2. Staff did not report the allegations of abuse to NHA-A in a timely manner. In addition, the allegations of abuse were not reported to the SA. On 6/2/24, R1 verbally abused R3. Staff did not report the allegation of abuse to NHA-A in a timely manner. In addition, the allegation of abuse was not reported to the SA. On 6/7/24, R6 allegedly sexually abused R2. Staff did not report the allegation of abuse to NHA-A in a timely manner. In addition, the allegation of abuse was not reported to the SA or local law enforcement. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, dated February 2023, indicates: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property .Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report to the Nursing Home Administrator or designee. The Nursing Home Administrator or designee will report abuse to the State Agency per state and federal requirements .A resident-to-resident altercation should be reviewed as a potential situation of abuse .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions .Staff should monitor for any behaviors that may provoke a reaction by residents or others which include, but are not limited to: Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating .Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing .All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated . On 6/12/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including dysthymic disorder (a type of depression that occurs over a long period of time), alcohol-induced dementia, low back pain, and anxiety disorder. R1's Minimum Data Set (MDS) assessment, dated 5/23/24, stated R1's Brief Interview for Mental Status (BIMS) score was 00 out of 15 which indicated R1 had severe cognitive impairment. R1's medical record indicated R1's Power of Attorney for Healthcare (POAHC) was responsible for R1's healthcare decisions. On 6/12/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including Huntington's chorea (a neurodegenerative disease exhibited by problems with mood or mental abilities and a general lack of coordination). R2's MDS assessment, dated 4/18/24, stated R2's BIMS score was 10 out of 15 which indicated R2 had moderate cognitive impairment. R2's medical record indicated R2's POAHC was responsible for R2's healthcare decisions. On 6/12/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement). R3's MDS assessment, dated 4/25/24, stated R3's BIMS score was 8 out of 15 which indicated R3 had moderate cognitive impairment. R3's medical record indicated R3's POAHC was responsible for R3's healthcare decisions. On 6/12/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease. R6's MDS assessment, dated 5/11/24, stated R6's BIMS score was 15 out of 15 which indicated R6 had no cognitive impairment. R6's medical record indicated R6 was responsible for R6's healthcare decisions. On 6/12/24, Surveyor reviewed R1's nursing notes which included the following: ~ A note, dated 5/19/24, indicated: R1 was aggressive with PM shift staff upon shift change. R1 yelled at and pushed R2 in R2's wheelchair. Staff attempted to intervene. R1 cursed and yelled, I'm going to kill you. I should just off you now. Staff attempted to re-direct R1 and move R1 away from R2 who was tearful and upset. The Activity Director provided 1:1 with R1 in a separate room until R1 settled. ~ A note, dated 6/2/24, indicated: R1 got into an argument with R3 by the nurses' station. R1 stated to R3, Go to hell. You're in my house. You don't live here. Get the f*** out. A Certified Nursing Assistant (CNA) separated R1 and R3. R1 was reluctant to leave the area and cursed and pushed the CNA. All interventions and re-direction were ineffective. R3's medical record did not contain a corresponding nursing note for the incident on 6/2/24. ~ A note, dated 6/9/24, indicated: R1 talked to R2. It was unknown what R1 said but it upset R2. R1 was not easily redirected. R2's medical record contained the following corresponding nursing note for the incident on 6/9/24: ~ A note, dated 6/9/24, indicated: R1 stood by R2 and said something unknown. R2 screamed at R1 and stated, Leave me alone, I don't like you. R2's face was beet red. R2 cried, kicked R2's legs, and threw R2's arms up. Staff took R2 to another part of the building. On 6/12/24 at 9:40 AM, Surveyor interviewed Hospitality Aide (HA)-C who stated R1 does not interact in a kind or friendly manner. HA-C stated R1 cusses and scowls at other residents and occasionally touches other residents. On 6/12/24 at 10:46 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D via phone. LPN-D stated LPN-D works PM shifts at the facility and often tells Director of Nursing (DON)-B and the Social Worker (SW) the next day to check LPN-D's nursing notes after an incident occurs between R1 and another resident. LPN-D stated resident-to-resident incidents happen pretty often with R1. LPN-D stated, I get the brunt of it on PM shift. When asked if the above incidents were reportable, LPN-D stated, Yes I would say so. I reported to (DON-B). LPN-D stated the incidents were not always reported at the time they occurred because it happens so often. On 6/12/24 at 11:13 AM, Surveyor interviewed DON-B who stated R1's behaviors had worsened with increased agitation and sun-downing. DON-B verified R1 was verbally aggressive with other residents. Following a review of the above incidents, DON-B verified the incidents were reportable resident-to-resident altercations. When asked when DON-B learned of the incidents, DON-B stated, A couple of them just now. DON-B stated staff should report incidents as soon as everyone is safe. When asked if waiting until the next day to report is acceptable, DON-B stated, I would prefer not. In addition, R2's medical record contained the following nursing note: ~ A note, dated 6/7/24, indicated: R2 cried today after R6 grabbed R2's hand and asked R2 to touch R6. Staff moved R2 away from R6 and kept R2 close so staff could monitor R2. R6's medical record contained the following nursing notes: ~ A note, dated 5/11/24, indicated: Two CNAs witnessed R6 outside R2's room while R2 was in R2's wheelchair watching TV. R6 asked R2 for a kiss. The CNAs told R6 that was not okay and asked R6 to leave R2's doorway. When R6 was asked if R6 asked R2 for a kiss, R6 stated R6 did but said R6 would never kiss (R2) but blows kisses. Staff told R6 that R6 cannot ask R2 or any other residents for kisses or blow kisses. R6 stated R6 would no longer do that and called the two CNAs stupid. ~ A note, dated 5/13/24 and written by the SW, indicated: There has been an increase in R6's unwanted sexual interest in a younger resident and an increase in R6's inappropriate sexual comments toward some of the younger staff members. R6 admitted R6 asked R2 if R2 wants a kiss. R6 stated if R2 says yes, R6 blows R2 a kiss, and if R2 says no, R6 leaves R2 alone. The SW informed R6 the behavior was upsetting to R2 and staff. R6 stated R6 didn't expect to kiss R2 but asked R2 for a kiss as a way to interact with R2. The SW suggested R6 say hello if R6 wanted to interact with R2. R6 agreed. ~ A note, dated 6/7/24, indicated: R6 held R2's hand and asked R2 to touch R6. Staff moved R2 away which upset R6 who asked multiple times why staff moved R2. R6 wanted staff to bring R2 back so R6 could talk to R2. R2 appeared upset and staff keep the residents separated. ~ A note, dated 6/8/24, indicated: R6 again attempted to touch/be close to R2. R6 was reminded that R6's behavior was unwanted and inappropriate. R6 yelled and stated, You take the fun out of everything. Staff again explained the seriousness of the situation. Staff returned R6 to R6's room. Staff will update DON-B and the SW. R6's care plan contained the following problem statement, initiated on 3/1/22: I have been verbally sexually inappropriate with (opposite gender) staff members. No additional updates were made to R6's care plan regarding inappropriate behavior with R2 or other residents. On 6/12/24 at 11:35 AM, Surveyor interviewed DON-B who, following a review of the incident between R6 and R2 on 6/7/24, stated, I didn't know about that either. DON-B verified the incident should have been reported to the SA and verified the documentation sounded sexual in nature. During an exit conference on 6/12/24 at 1:35 PM, DON-B verified the incident between R6 and R2 on 6/7/24 should have been reported to local law enforcement.

Based on staff interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 4 residents (R) (R1, R2, R3, and R6) of 6 sampled residents. On 5/29/24 and 6/9/24, R1 verbally abused R2. The facility did not thoroughly investigate the allegations of abuse. On 6/2/24, R1 verbally abused R3. The facility did not thoroughly investigate the allegation of abuse. On 6/7/24, R6 allegedly sexually abused R2. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, dated February 2023, indicates: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property .The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation process immediately. A root cause investigation and analysis will be completed . On 6/12/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including dysthymic disorder (a type of depression that occurs over a long period of time), alcohol-induced dementia, low back pain, and anxiety disorder. R1's Minimum Data Set (MDS) assessment, dated 5/23/24, stated R1's Brief Interview for Mental Status (BIMS) score was 00 out of 15 which indicated R1 had severe cognitive impairment. R1's medical record indicated R1's Power of Attorney for Healthcare (POAHC) was responsible for R1's healthcare decisions. On 6/12/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including Huntington's chorea (a neurodegenerative disease exhibited by problems with mood or mental abilities and a general lack of coordination). R2's MDS assessment, dated 4/18/24, stated R2's BIMS score was 10 out of 15 which indicated R2 had moderate cognitive impairment. R2's medical record indicated R2's POAHC was responsible for R2's healthcare decisions. On 6/12/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement). R3's MDS assessment, dated 4/25/24, stated R3's BIMS score was 8 out of 15 which indicated R3 had moderate cognitive impairment. R3's medical record indicated R3's POAHC was responsible for R3's healthcare decisions. On 6/12/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease. R6's MDS assessment, dated 5/11/24, stated R6's BIMS score was 15 out of 15 which indicated R6 had no cognitive impairment. R6's medical record indicated R6 was responsible for R6's healthcare decisions. On 6/12/24, Surveyor reviewed R1's nursing notes which included the following: ~ A note, dated 5/19/24, indicated: R1 was aggressive with PM shift staff upon shift change. R1 yelled at and pushed R2 in R2's wheelchair. Staff attempted to intervene. R1 cursed and yelled, I'm going to kill you. I should just off you now. Staff attempted unsuccessfully to re-direct R1 and move R1 away from R2 who was tearful and upset. The Activity director provided 1:1 with R1 in a separate room until R1 settled. ~ A note, dated 6/2/24, indicated: R1 got into an argument with R3 by the nurse's station and stated to R3, Go to hell. You're in my house. You don't live here. Get the f*** out. A Certified Nursing Assistant (CNA) separated R1 and R3. R1 was reluctant to leave the area and cursed at and pushed the CNA. All interventions and re-direction were ineffective with R1's behaviors. R3's medical record did not contain a corresponding nursing note. ~ A note, dated 6/9/24, indicated: R1 talked to R2. It was unknown what R1 said but R2 was upset. R1 was not easily redirected. R2's medical record contained the following corresponding nursing note: ~ A note, dated 6/9/24, indicated: R1 stood by R2 and said something unknown. R2 screamed at R1 and said, Leave me alone. I don't like you. R2 was worked up and R2's face was beet red. R2 cried, kicked R2's legs, and threw R2's arms up. Staff removed R2 and took R2 to another part of the building. On 6/12/24 at 11:13 AM, Surveyor interviewed Director of Nursing (DON)-B who stated R1's behaviors had worsened with increased agitation and sun-downing. DON-B verified R1 was verbally aggressive with other residents. Following a review of the above incidents, DON-B verified the incidents were reportable resident-to-resident altercations. When asked when DON-B learned of the incidents, DON-B stated, A couple of them just now. DON-B was unsure if the incidents were thoroughly investigated. In addition, R2's nursing notes contained the following: ~ A note, dated 6/7/24, indicated: R2 cried today. R6 grabbed R2's hand and asked R2 to touch R6. Staff moved R2 away from R6 and kept R2 closer so staff could monitor R2. R6's medical record contained the following notes: ~ A note, dated 5/11/24, indicated: Two CNAs witnessed R6 outside R2's room while R2 was in a wheelchair watching TV. R6 asked R2 for a kiss. The CNAs told R6 that was not okay and asked R6 to leave R2's doorway. R6 was interviewed and admitted R6 asked R2 for a kiss. R6 said R6 would never kiss R2 but blows kisses. Staff told R6 that R6 cannot ask R2 or anyone else for kisses or blow kisses. R6 stated R6 would no longer do that and called the two CNAs stupid. ~ A note, dated 5/13/24, indicated: There has been an increase in R6's unwanted sexual interest in a younger resident and an increase in R6's inappropriate sexually charged comments toward some of the younger staff members. R6 admitted that R6 asked R2 if R2 'wants a kiss'. R6 stated if R2 says yes, R6 blows R2 a kiss, but if R2 says no, R6 leaves R2 alone. R6 was informed R6's behavior was upsetting to R2 and staff. R6 stated R6 didn't expect to kiss R2, but just asks R2 for a kiss as a way of interacting with R2. Staff suggested R6 say hello if R6 wants to interact with R2. R6 agreed. ~ A note, dated 6/7/24, indicated: R6 held R2's hand and asked R2 to touch R6. Staff moved R2 away which upset R6. R6 asked multiple times why staff moved R2 and wanted staff to bring R2 back so R6 could talk to R2. R2 appeared upset and staff kept the residents separated. ~ A note, dated 6/8/24, indicated: R6 again attempted to touch/be close to R2. R6 was reminded that R6's behavior was unwanted and inappropriate. R6 yelled at writer, You take the fun out of everything. Staff again explained the seriousness of the situation and returned R6 to R6's room. Staff will update DON-B and the SW. R6's care plan contained the following problem statement, dated 3/1/22: I have been verbally sexually inappropriate with (opposite gender) staff members. No additional updates were made to R6's care plan regarding inappropriate behavior with R2 or other residents. On 6/12/24 at 11:35 AM, Surveyor interviewed DON-B who, following a review of the above incident between R6 and R2 on 6/7/24, stated, I didn't know about that either. On 6/12/24 at 1:20 PM, Surveyor interviewed DON-B who verified the facility did not have documentation that any of the above incidents were investigated.

Based on staff interview and record review, the facility did not ensure allegations of abuse and misappropriation were reported to the Nursing Home Administrator (NHA), the State Agency (SA), or local law enforcement in a timely manner for 4 residents (R) (R2, R4, R5, and R3) of 5 sampled residents. On 4/9/24, Licensed Practical Nurse (LPN)-C administered a dose of R4's lorazepam (a sedative medication) to R2 to stop R2 from pacing. R2 did not have a physician's order for lorazepam or consent from R2's Power of Attorney for Healthcare (POAHC). Staff did not report the allegations of abuse and misappropriation to administration or local law enforcement in a timely manner. On 4/10/24, Hospitality Aide (HA)-E alleged that Certified Nursing Assistant (CNA)-J physically abused R5 with a hot washcloth on an undisclosed date. Staff did not report the incident to administration in a timely manner and did not report the allegation of abuse to the SA. On 4/25/24, CNA-I alleged LPN-C misappropriated a dose of R3's lorazepam on 7/17/23. Staff did not report the incident to administration in a timely manner and did not report the allegation of misappropriation to the SA. Findings include: The facility's undated Freedom from Abuse, Neglect and Exploitation Policy and Procedure indicates: All staff will be trained during orientation and on an annual basis .The training program will consist of but not be limited to: .How and when to report suspected abuse, neglect and misappropriation .How to recognize resident and staff behaviors that could suggest a potential for abuse .Any allegation involving mistreatment, neglect or abuse, including those of .misappropriation of resident property will immediately be reported to the charge nurse and the charge nurse will immediately notify the RN (Registered Nurse) on call. The RN on call will contact the Administrator or designee if applicable. The Administrator or designee will complete the online report (to the SA) immediately .Allegations of abuse will be reported to other agencies, such as Adult Protective Services or law enforcement immediately . 1. On 5/1/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dysthymic disorder (a type of depression that occurs over a long period of time), unspecified dementia, anxiety, and major depressive disorder. R2's Minimum Data Set (MDS) assessment, dated 2/22/24, stated R2's Brief Interview for Mental Status (BIMS) score was 00 out of 15 which indicated R2 had severely impaired cognition. R2's medical record indicated POAHC-H was responsible for R2's healthcare decisions. On 5/1/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including aortic stenosis (a heart valve disease that reduces or blocks blood flow from the heart to the aorta and body), myocardial infarction (heart attack/death of heart muscle), and chronic kidney disease. R4's MDS assessment, dated 2/28/24, stated R4's BIMS score was 15 out of 15 which indicated R4 had intact cognition. R4's medical record indicated R4's POAHC was responsible for R4's healthcare decisions. On 5/1/24, Surveyor reviewed a facility investigation that indicated: On 4/10/24, Director of Nursing (DON)-B received a text message from Business Office Manager (BOM)-D. DON-B called BOM-D at 8:05 PM and was notified that HA-E stated LPN-C told HA-E that LPN-C administered lorazepam to R2 for R2's anxiety on the 4/9/24 PM shift and the lorazepam came from another resident (R4). HA-E initially told LPN-F the next evening who advised HA-E to call BOM-D immediately. The investigation indicated R2 was not prescribed lorazepam, an order was not obtained to administer lorazepam, and consent was not obtained from POAHC-H. LPN-C told the staff that LPN-C gave R2 the lorazepam because R2 was pacing and upset, however, but LPN-C denied actually administering the medication. The facility's investigation contained a handwritten statement from HA-E, dated 4/10/24, that indicated: On the 4/9/24 PM shift around dinner time, LPN-C stated to HA-E, I just gave (R2) some of (R4)'s lorazepam. LPN-C also said, I just can't handle this tonight regarding R2. HA-E knew R2 didn't have an order for lorazepam and that LPN-C gave R2 lorazepam against POAHC-H's wishes. When HA-E left the building at approximately 6:55 PM, R2 was calm and relaxed which was unlike R2. LPN-C said, Seems like it's finally kicking in. On 5/1/24, Surveyor reviewed an email from Police Chief (PC)-G to DON-B, dated 4/11/24, that indicated: PC-G interviewed LPN-C who said the CNAs and HA-E were yelling back and forth with R2 and LPN-C told them that LPN-C gave R2 medication to calm R2 down. LPN-C told staff to let R2 sit in the chair and LPN-C would be back in 15 minutes to talk to R2. LPN-C said LPN-C was busy and didn't have time to deal with it. On 5/1/24 at 1:34 PM, Surveyor interviewed DON-B who verified HA-E did not report the above incident to administration in a timely manner. DON-B indicated HA-E was educated on timely reporting. DON-B verified the facility did not educate all staff on timely reporting. DON-B stated the facility reported the above incident to law enforcement on 4/11/24. On 5/3/24, following an open records request, Surveyor reviewed a report completed by PC-G that indicated: On 4/11/24 at 9:31 AM, PC-G received a call from DON-B who stated earlier in the week an LPN told a staff member that the LPN gave another resident's medication to R2 to calm R2 down. DON-B indicated the facility notified the SA and would like the police to do an investigation. 2. On 5/1/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbances and major depressive disorder. R5's MDS assessment, dated 4/11/24, indicated R5 was rarely/never understood. R5's medical record indicated R5's POAHC was responsible for R5's healthcare decisions. On 5/1/24, Surveyor reviewed a facility investigation that included a handwritten statement from HA-E, dated 4/10/24, that indicated: HA-E was asked to help put R5 to bed. HA-E turned on the faucet and put washcloths in the sink. HA-E lowered R5's bed and retrieved a brief. When CNA-J wiped R5's face, CNA-J did not allow the washcloth to cool which caused R5 pain. R5 yelled ow, ow stop, that's hot, and please stop it's hot. HA-E stated R5 might lack the ability to form sentences, but it was very very clear that R5 was in pain. The investigation contained a document that indicated: Reviewed note from HA-E. Education was provided to staff on 4/10/24 related to Hospitality Aide duties that outlined what Hospitality Aides are able to do. Regarding R5 stating the water was hot, skin checks were done with no reports of injury. HA-E and CNA-J both worked on 4/5/24. R5's progress notes indicated there was no incident or concern with behaviors or injuries. On 5/1/24 at 1:34 PM, Surveyor interviewed DON-B who verified HA-E did not report the incident to administration in a timely manner. DON-B indicated HA-E was educated on timely reporting. DON-B verified the facility did not educate all staff on timely reporting. DON-B verified when CNA-J did not stop when R5 indicated the water was too hot could be considered abuse and should have been reported to the SA. 3. On 5/1/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. R3's MDS assessment, dated 2/9/24, indicated R3 was rarely/never understood. R3's medical record indicated R3's POAHC was responsible for R3's healthcare decisions. On 5/1/24, Surveyor reviewed a facility investigation that contained a handwritten statement from CNA-I, dated 4/25/24, that indicated: On 7/17/23, Assisted Living Resident (ALR)-K started to have behaviors and showed signs of anxiety when ALR-K couldn't go to the farm to milk cows which was a normal behavior that occurred on the PM shift. CNA-I stated ALR-K's behavior started when CNA-I started work. CNA-I stated LPN-C administered ALR-K's scheduled dose of 0.5 mg of lorazepam during medication pass. After supper, ALR-K was still unable to be redirected. CNA-I and LPN-C went to LPN-C's medication cart which was in front of the medication room in the nurses' station. CNA-I didn't realize until later in the night that LPN-C took R3's lorazepam card and punched one tablet into a medication cup. CNA-I stated LPN-C went to the Skilled Nursing Narcotics binder, crossed out the medication, and wrote wasted at approximately 6:00 PM. On 5/1/24 at 10:51 AM, Surveyor interviewed DON-B who verified the facility did not report the allegation of misappropriation to the SA. DON-B verified CNA-I did not report incident to administration in a timely manner. DON-B indicated CNA-I initially reported the incident during a police interview regarding the incident on 4/9/24 (listed above) and then provided a handwritten report on 4/25/24.

Based on staff interview and record review, the facility did not ensure all allegations of abuse and misappropriation were thoroughly investigated for 4 residents (R) (R2, R4, R5 and R3) of 5 sampled residents. On 4/9/24, Licensed Practical Nurse (LPN)-C administered a dose of R4's lorazepam (a sedative medication) to R2 to stop R2 from pacing. R2 did not have a physician's order for lorazepam and the facility did not obtain consent from R2's Power of Attorney for Healthcare (POAHC) to administer lorazepam. The facility did not thoroughly investigate the allegations of abuse and misappropriation. On 4/10/24, Hospitality Aide (HA)-E alleged Certified Nursing Assistant (CNA)-J physically abused R5 with a hot washcloth on an undisclosed date. The facility did not thoroughly investigate the allegation of abuse. On 4/25/24, CNA-I alleged LPN-C misappropriated a dose of R3's lorazepam on 7/17/23. The facility did not thoroughly investigate the allegation of misappropriation. Findings include: The facility's undated Freedom from Abuse, Neglect and Exploitation Policy and Procedure indicates: .A designated staff member will conduct and complete the internal investigation .When an incident of suspected abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved; ii. Resident statements; a. For non-verbal residents, cognitively impaired residents, or residents who refuse to be interviewed, attempt to interview the resident first. If unable, observe the resident, complete an evaluation of the resident's behavior including the affect and response of the interaction, and document the findings; iii. Resident roommate's statement (if applicable); iv. Involved staff and witness statements of events and timeline; v. A description of the resident's behavior and environment at the time of the incident; vi. Injuries present including a resident assessment; vii. Observation of resident and staff behaviors during the investigation; viii. Environmental considerations .The investigation is the process used to try to determine what happened. Designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed . 1. On 5/1/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dysthymic disorder (a type of depression that occurs over a long period of time), unspecified dementia, anxiety, and major depressive disorder. R2's Minimum Data Set (MDS) assessment, dated 2/22/24, stated R2's Brief Interview for Mental Status (BIMS) score was 00 out of 15 which indicated R2 had severely impaired cognition. R2's medical record indicated POAHC-H was responsible for R2's healthcare decisions. On 5/1/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including aortic stenosis (a heart valve disease that reduces or blocks blood flow from the heart to the aorta and body), myocardial infarction (heart attack/death of heart muscle), and chronic kidney disease. R4's MDS assessment, dated 2/28/24, stated R4's BIMS score was 15 out of 15 which indicated R4 had intact cognition. R4's medical record indicated R4's POAHC agent was responsible for R4's healthcare decisions. On 5/1/24, Surveyor reviewed a facility investigation that indicated: On 4/10/24, Director of Nursing (DON)-B received a text message from Business Office Manager (BOM)-D. DON-B called BOM-D at 8:05 PM and was notified that HA-E stated LPN-C told HA-E that LPN-C administered another resident's (R4) lorazepam to R2 for anxiety on the 4/9/24 PM shift. HA-E told LPN-F the next evening who advised HA-E to call BOM-D immediately. R2 was not prescribed lorazepam, an order was not obtained to administer lorazepam, and permission to administer lorazepam was not obtained from POAHC-H. LPN-C told staff that LPN-C gave R2 lorazepam because R2 was pacing and upset, however, LPN-C denied actually administering the medication. The facility's investigation included a handwritten statement from HA-E, dated 4/10/24, that indicated: On the 4/9/24 PM shift around dinner time, LPN-C stated to HA-E, I just gave (R2) some of (R4)'s lorazepam. LPN-C also said, I just can't handle this tonight regarding R2. HA-E knew R2 didn't have an order for lorazepam and that LPN-C gave R2 lorazepam against POAHC-H's wishes. When HA-E left the building at approximately 6:55 PM, R2 was calm and relaxed which was unlike R2. LPN-C said, Seems like it's finally kicking in. The investigation included a urine drug panel for R2, collected on 4/11/24, that indicated 135 nanograms per milliliter (ng/ml) of lorazepam was detected in R2's urine. A urine drug panel for R4, collected on 4/11/24, indicated 110 ng/ml of lorazepam was detected in R4's urine. R2's medical record did not contain a physician's order for lorazepam and R2's nursing notes did not contain any documentation for 4/9/24. R2's nursing notes contained documentation prior to and after 4/9/24 that indicated R2's behaviors were unchanged as a result of the incident on 4/9/24. R4's medical record contained the following orders: ~ Lorazepam oral tablet 0.5 mg (milligrams) give 1 tablet by mouth every 2 hours as needed for anxiety ~ Lorazepam oral tablet 0.5 mg give 2 tablets by mouth every 2 hours as needed for moderate to severe anxiety R4's April 2024 Medication Administration Record (MAR) indicated LPN-C administered two tablets of lorazepam 0.5 mg to R4 at 3:00 PM on 4/9/24. On 5/1/24, Surveyor reviewed an email from Police Chief (PC)-G to DON-B, dated 4/11/24, that indicated: PC-G interviewed LPN-C who said the CNAs and HA-E were yelling back and forth with R2 and LPN-C told them LPN-C gave R2 medication to calm R2 down. LPN-C told staff to let R2 sit in the chair and LPN-C would be back in 15 minutes to talk to R2. LPN-C said LPN-C was busy and didn't have time to deal with it. On 5/1/24 at 1:34 PM, Surveyor interviewed DON-B who verified the facility did not interview other residents to determine if other residents were affected. DON-B also verified not all staff were interviewed, including the night shift nurses who conducted controlled substance counts with LPN-C. On 5/1/24 at 1:52 PM, Surveyor interviewed LPN-L who verified LPN-L worked night shifts at the facility. LPN-L stated LPN-L was not interviewed regarding the incident and indicated LPN-L did not notice anything unusual about the controlled substance counts LPN-L completed with LPN-C. 2. On 5/1/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbances and major depressive disorder. R5's MDS assessment, dated 4/11/24, indicated R5 was rarely/never understood. R5's medical record indicated R5's POAHC was responsible for R5's healthcare decisions. On 5/1/24, Surveyor reviewed a facility investigation that contained a handwritten statement from HA-E, dated 4/10/24, that indicated: HA-E was asked to help put R5 to bed. HA-E turned on the faucet and put washcloths in the sink. HA-E lowered R5's bed and retrieved a brief. When CNA-J wiped R5's face, CNA-J did not allow the washcloth to cool which caused R5 pain. R5 yelled ow, ow stop, that's hot, and please stop it's hot. HA-E stated R5 might lack the ability to form sentences, but it was very very clear that R5 was in pain. The investigation contained a document that indicated: Reviewed note from HA-E. Education was provided to staff on 4/10/24 related to Hospitality Aide duties that outlined what Hospitality Aides were able to do. Regarding R5 stating the water was hot, skin checks were done with no reports of injury. HA-E and CNA-J both worked on 4/5/24. R5's progress notes indicated there was no incident or concern with behaviors or injuries. The investigation included water temperature audits conducted on 4/18/24 that indicated all water temperatures were found in acceptable ranges. The investigation also included perineal care competency checklists (which indicated the use of warm water was expected) for several CNAs, including CNA-J (dated 4/18/24). CNA-J's time cards indicated CNA-J worked on 4/10/24 from 2:00 PM to 8:10 PM, on 4/11/24 from 2:00 PM to 8:00 PM, and on 4/18/24 from 2:00 PM to 8:00 PM. On 5/1/24 at 12:00 PM, Surveyor interviewed DON-B who indicated administration talked to CNA-J regarding the allegation of abuse but did not document the interview. On 5/1/24 at 12:18 PM, Surveyor interviewed CNA-J via phone. CNA-J did not recall administration talking to CNA-J about a hot water concern and stated CNA-J did not receive education regarding hot water temperatures while providing cares. On 5/1/24 at 1:34 PM, Surveyor interviewed DON-B who verified the facility did not interview other residents to determine if other residents were affected. DON-B verified other staff were not interviewed, including staff who routinely worked with CNA-J. 3. On 5/1/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. R3's MDS assessment, dated 2/9/24, indicated R3 was rarely/never understood. R3's medical record indicated R3's POAHC was responsible for R3's healthcare decisions. On 5/1/24, Surveyor reviewed a facility investigation that included a handwritten statement from CNA-I, dated 4/25/24, that indicated: On 7/17/23, Assisted Living Resident (ALR)-K started to have behaviors and showed signs of anxiety when ALR-K couldn't go to the farm to milk cows which was a normal behavior that occurred on the PM shift. CNA-I stated ALR-K's behavior started when CNA-I started work. LPN-C administered ALR-K's scheduled dose of 0.5 mg of lorazepam during medication pass. After supper, ALR-K was still unable to be redirected. CNA-I and LPN-C went to LPN-C's medication cart which was in front of the medication room in the nurses' station. CNA-I didn't realize until later in the night that LPN-C took R3's lorazepam card and punched one tablet into a medication cup. CNA-I stated LPN-C went to the Skilled Nursing Narcotics binder, crossed out the medication, and wrote wasted at approximately 6:00 PM. The investigation also contained information that indicated: During an interview regarding the incident on 4/9/24, CNA-I stated CNA-I was aware of a situation that occurred in which ALR-K received lorazepam that was not ALR-K's. The date on the controlled drug use record was crossed off and the time was altered. Admission notes for ALR-K indicated ALR-K was combative and assaulted staff. On 7/2/23, a telephone order was obtained for lorazepam. In the CBRF (community-based residential facility) (which was attached to skilled nursing facility), staff were not allowed to pull from contingency and had to wait for the pharmacy to deliver the medication. CNA-I submitted a verbal statement to the police on 4/25/24 that the incident occurred in the fall of 2023. While reviewing CNA-I's statement and the controlled substance sign out forms, the writer noted there was a day in July where a dose of R3's lorazepam was wasted. The date was difficult to read. Based on CNA-I's statement, the date was narrowed to 7/17/23 when ALR-K was administered ALR-K's scheduled 3:00 PM dose of lorazepam, continued to be difficult to redirect, and was administered another PRN (as needed) dose by CNA-I and LPN-C at 6:00 PM. Surveyor reviewed R3's nursing notes which did not contain documentation from LPN-C on 7/17/23. R3's July 2023 MAR indicated R3 was administered 0.5 mg of lorazepam at 10:22 AM by another nurse on 7/18/23. There were no other lorazepam doses documented for R3. On 5/1/24 at 1:34 PM, Surveyor interviewed DON-B who verified the facility did not interview other residents to determine if other residents were affected. DON-B also verified other staff were not interviewed, including night shift nurses who conducted controlled substance counts with LPN-C.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R2) of 5 sampled residents was free from a chemical restraint administered for behavior and not prescribed to the resident. On 4/9/24, Licensed Practical Nurse (LPN)-C administered lorazepam (a sedative medication) to R2 to stop R2 from pacing. R2 did not have a physician's order for lorazepam and consent was not obtained from R2's activated Power of Attorney for Healthcare (POAHC). Findings include: The facility's Resident Rights policy, with an effective date of 4/4/17, indicates: .be free from mental and physical abuse, and be free from chemical and physical restraints except as authorized in writing by a physician, physician assistant, or advanced practice nurse prescriber for a specified and limited period of time and documented in the resident's medical record . On 5/1/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dysthymic disorder (a type of depression that occurs over a long period of time), unspecified dementia, anxiety, and major depressive disorder. R2's Minimum Data Set (MDS) assessment, dated 2/22/24, stated R2's Brief Interview for Mental Status (BIMS) score was 00 out of 15 which indicated R2 had severely impaired cognition. R2's medical record indicated POAHC-H was responsible for R2's healthcare decisions. On 5/1/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including aortic stenosis (a heart valve disease that reduces or blocks blood flow from the heart to the aorta and body), myocardial infarction (heart attack/death of heart muscle), and chronic kidney disease. R4's MDS assessment, dated 2/28/24, stated R4's BIMS score was 15 out of 15 which indicated R4 had intact cognition. R4's medical record indicated R4's POAHC was responsible for R4's healthcare decisions. On 5/1/24, Surveyor reviewed an investigation that indicated: On 4/10/24, Director of Nursing (DON)-B received a text message from Business Office Manager (BOM)-D. DON-B called BOM-D at 8:05 PM and was notified that Hospitality Aide (HA)-E stated LPN-C told HA-E that LPN-C administered another resident's lorazepam to R2 for anxiety on the 4/9/24 PM shift. HA-E told LPN-F the next evening who advised HA-E to call BOM-D immediately. R2 was not prescribed lorazepam, an order was not obtained to administer lorazepam, and consent to administer lorazepam was not obtained from POAHC-H. LPN-C told staff that LPN-C administered lorazepam because R2 was pacing and upset, however, LPN-C denied actually administering the medication. The facility's investigation included a handwritten statement from HA-E, dated 4/10/24, that indicated: On the 4/9/24 PM shift around dinner time, LPN-C stated to HA-E, I just gave (R2) some of (R4)'s lorazepam. LPN-C also said, I just can't handle this tonight regarding R2. HA-E knew R2 didn't have an order for lorazepam and LPN-C gave R2 lorazepam against POAHC-H's wishes. When HA-E left the building at approximately 6:55 PM, R2 was calm and relaxed which was unlike R2. LPN-C said, Seems like it's finally kicking in. The facility's investigation contained a urine drug panel for R2, collected on 4/11/24, that indicated 135 nanograms per milliliter (ng/ml) of lorazepam were detected in R2's urine. A urine drug panel for R4, collected on 4/11/24, indicated 110 ng/ml of lorazepam were detected in R4's urine. R2's medical record did not contain a physician's order for lorazepam or any documentation from 4/9/24. R2's nursing notes contained documentation prior to and after 4/9/24 that indicated R2's behaviors were unchanged as a result of the incident on 4/9/24. R4's medical record contained the following orders: ~ Lorazepam oral tablet 0.5 mg (milligrams) give 1 tablet by mouth every 2 hours as needed for anxiety ~ Lorazepam oral tablet 0.5 mg give 2 tablets by mouth every 2 hours as needed for moderate to severe anxiety R4's April 2024 Medication Administration Record (MAR) indicated LPN-C administered two 0.5 mg tablets of lorazepam to R4 on 4/9/24 at 3:00 PM. On 5/1/24, Surveyor reviewed an email from Police Chief (PC)-G to DON-B, dated 4/11/24, that indicated: PC-G interviewed LPN-C who said the Certified Nursing Assistants (CNAs) and HA-E were yelling back and forth with R2 and LPN-C told them LPN-C gave R2 medication to calm R2 down. LPN-C told the staff to let R2 sit in the chair and LPN-C would be back in 15 minutes to talk to R2. LPN-C said LPN-C was busy and didn't have time to deal with it. On 5/1/24 at 2:56 PM, Surveyor interviewed DON-B via phone who verified LPN-C's actions were considered a chemical restraint which was against the facility's policy. On 5/3/24, following an open records request to PC-G, Surveyor reviewed a Deputy Supplemental Report completed by PC-G, dated 4/16/24, that indicated: PC-G asked DON-B and BOM-D for records regarding the delivery of medication for R4 and R2. DON-B provided the records and explained them to PC-G. On 4/9/24 at 3:00 PM, LPN-C documented that LPN-C administered two 0.5 mg tablets of lorazepam to R4 and none to R2. DON-B and BOM-D interpreted the lab results as proof that LPN-C administered one 0.5 mg tablet of lorazepam to R4 and one 0.5 mg tablet of lorazepam to R2. At approximately 4:00 PM, PC-G interviewed HA-E who stated HA-E worked at the facility on 4/9/24 after school. HA-E said R2 was R2's normal self when HA-E saw R2. HA-E stated R2 walks around and talks to people and tells them what's on R2's mind. At approximately 5:30 PM, R2 was sitting in a chair by the dinning room and the nurses' station. LPN-C approached R2 and administered R2's medication in applesauce. LPN-C stated LPN-C couldn't handle this tonight and gave R2 some of R4's lorazepam. HA-E said R2 became drowsy and sat quietly in the chair until HA-E went home at 7:00 PM, however, R2 was usually very active and followed LPN-C around during HA-E's shift. When HA-E was ready to go home, LPN-C indicated something was finally kicking in. HA-E took that to mean the lorazepam LPN-C stated LPN-C gave R2. On 5/3/24, Surveyor reviewed a Deputy Supplemental Report completed by PC-G, dated 4/24/24, that indicated: On 4/24/24 at approximately 7:30 AM, PC-G spoke to POAHC-H and confirmed that POAHC-H did not give consent to treat or administer any prescription medication to R2 without proper prescription or consent.

Based on observation, resident and staff interview, and record review, the facility did not provide adequate supervision to prevent further abuse following a visitor-to-resident altercation for 1 Resident (R) (R3) of 2 residents. Assisted Living Resident (ALR)-G visited ALR-G's spouse (R4) in the facility and had a known history of physical aggression. On 2/13/24, R3 was struck in the face by ALR-G during an altercation. Following the incident, the facility did not implement measures to supervise ALR-G while ALR-G was in the facility. Although R3 did not recall the incident due to a diagnosis of dementia, the reasonable person standard was implemented as a person who was hit in the face by a visitor in their home would likely incur mental anguish. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriating of Resident Property policy, revised 1/10/24, indicates the facility has the right to set visitation policies with safety restrictions such as denying access or providing limited and supervised access to a visitor who has been found to be abusive. The policy indicates physical abuse includes hitting, slapping and other forms of aggression. From 3/10/24 through 3/12/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including dementia, depression, and anxiety. R3's Minimum Data Set (MDS) assessment, dated 1/10/24, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R3 had moderately impaired cognition. The MDS also indicated R3 was hard of hearing and required assistance with activities of daily living (ADLs). From 3/10/24 through 3/12/24, Surveyor reviewed a facility-reported incident (FRI) involving R3 and ALR-G. The investigation indicated on 2/13/24 at 9:30 AM, staff heard yelling near the dining room, observed ALR-G with ALR-G's hand raised, and observed R3 holding R3's cheek. Staff separated R3 and ALR-G. The investigation indicated ALR-G hit R3 twice across the face with an open hand and was the third incident of physical aggression by ALR-G since ALR-G's admission to the building's assisted living facility on 6/28/23. ALR-G was interviewed and stated ALR-G was walking behind R4's wheelchair when R3 backed into R4's wheelchair and did not hear ALR-G tell R3 to stop. ALR-G stated ALR-G lost it because R3 was going to hurt (R4). An assessment indicated R3 had no injuries. R3 was interviewed by staff immediately following the incident, but did not recall the incident. From 3/10/24 through 3/12/24, Surveyor also reviewed a FRI involving R16 and ALR-G. The investigation indicated on 1/21/24, ALR-G was visiting in R4's room when R16 pushed R15 (who was in a wheelchair) into R4's room. When ALR-G pushed R15 out of the room, R16 yelled at ALR-G and ALR-G hit R16 on the left arm with the back of ALR-G's hand. Staff separated R16 and ALR-G. An assessment indicated R16 had no injuries. ALR-G was interviewed and indicated R16 pushed R15 into R4's room and ALR-G pushed R15 back into the hallway. ALR-G stated R16 yelled at ALR-G and ALR-G yelled back, lost ALR-G's temper, and hit R16 to make R16 stop. ALR-G was educated to ask for assistance when ALR-G was frustrated with another resident or staff. On 3/11/24 at 9:00 AM, Surveyor observed ALR-G in the 300 wing lobby with R4 and a staff member who was working with another resident. On 3/11/24 at 10:30 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff monitored ALR-G's whereabouts when ALR-G visited R4. On 3/11/24 at 11:45 AM, Surveyor interviewed Social Worker (SW)-D who indicated after the incident between R16 and ALR-G, staff worked with R16 to stop R16 from pushing other residents' wheelchairs. DON-B stated R16 thought R16 was an employee of the facility and was trying to be helpful. Following the incident between R3 and ALR-G, SW-D indicated staff felt congestion when entering and exiting the dining room during meal times led to the altercation. SW-D indicated measures were put in place to decrease congestion during meal times. SW-D was not aware of specific interventions that were implemented to supervise ALR-G or restrict ALR-G's access to other residents. On 3/11/24 at 12:00 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who indicated staff monitored ALR-G's whereabouts when ALR-G visited R4, but ALR-G's access to other residents was not restricted. On 3/11/24 at 12:05 PM, Surveyor interviewed CNA-F who also indicated staff monitored ALR-G's whereabouts when ALR-G visited R4, but indicated ALR-G's access to other residents was not restricted. Additional nursing staff interviews indicated ALR-G came and went without a set schedule and accessed the facility through a doorway that separated the skilled nursing and assisting living portions of the building. Staff interviews indicated there were no specific monitoring interventions in place for ALR-G. On 3/11/24 at 12:10 PM, Surveyor observed ALR-G in the doorway of R4's room requesting staff assistance. On 3/11/24 at 1:00 PM, Surveyor observed ALR-G in R4's room. On 3/12/24 at 8:15 AM, Surveyor observed ALR-G in the dining room at a table with R4. On 3/12/24 at 11:30 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who verified specific monitoring interventions should have been implemented to restrict ALR-G's access to other residents or supervise ALR-G more closely.

Based on record review and staff interview, the facility did not promptly consult with a physician regarding resident change of condition for 2 Residents (R) (R10 and R21) of 13 sampled and supplemental sampled residents. R10 had a change of condition on [DATE]. Facility failed to immediately consult with the physician when R10's pulse oxygen saturation level fell to 77% and when, on two occasions, blood pressure readings were outside physician ordered parameters on [DATE]. R10 expired at the facility on [DATE]. Facility failure to notify promptly consult with the physician when indicated created a finding of Immediate Jeopardy (IJ) (situation has caused or is likely to cause serious injury, impairment or death) that began [DATE]. DON (Director of Nursing)-B was notified of the IJ on [DATE] at 10:00 AM. The IJ was removed on [DATE], however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced in the following example. A fax regarding R21's cold symptoms was sent to the physician on [DATE] asking for intervention of cold symptoms. On [DATE], the facility had not received an answer from the physical regarding R21's symptoms. Findings include: Facility policy titled Change in Condition: Notification Parameters stated, It is the policy of this facility, except in medical emergencies, to notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status . Nursing services shall be responsible for notifying the resident's attending physician when . there is a significant change in the resident's physical, mental, or emotional status . Within this policy is a section titled When to Call the Doctor - Physician Notification of Resident Change of Condition which indicated the physician should be immediately notified if systolic BP (blood pressure) is greater than 200 or less than 90. 1. On [DATE] at 1:53 PM, Surveyor reviewed the medical record of R10. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].(medical condition in which there is an extremely low oxygen content in the blood) with [MEDICAL CONDITION] (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), and Chronic [MEDICAL CONDITION] (progressive heart failure which leads to the build-up of fluids in the body). R10's medical record contained physician orders [REDACTED].>~BP Parameters: if Diastolic (bottom number of BP) above 100 or below 50, OR if Systolic (top number of BP) is above 170 or below 90, check BP every 15 minutes x 4. If remains abnormal or if symptomatic call MD (physician) ~1500mL (milliliter) fluid restriction ~[MEDICATION NAME] (medication used to treat fluid retention) 0.5mg (milligrams) twice daily for heart failure ~[MEDICATION NAME] XL (used to treat chest pain, heart failure, and high blood pressure) 25mg at bedtime for hypertension ~Continuous oxygen at 1 lpm (liters per minute) via nasal cannula, may wean as able when O2 (oxygen) sats (saturation levels) are 96% (percent) or greater ~O2 at 2L (liters) PRN (as needed) per nasal cannula for respiratory distress or discomfort ~DNR (do not resuscitate) R10's medical record indicated that on [DATE] and [DATE] staff was monitoring R10 for cold symptoms and R10's vital signs were within parameters during these days. R10's medical record contained the following nursing documentation: ~On [DATE] at 11:25 AM (R10) seems to be a little under the weather today. (R10) needed both hands to hold onto (R10's) Prostat (protein supplement) when taking (R10's) morning pills today. Down for am (morning) nap. VS (vital signs) T (temperature) 98.6 P (pulse) 88 R (respirations) 16 BP ,[DATE]. LCTA (lungs clear to auscultation). Non productive cough. No LE (lower extremity) [MEDICAL CONDITION] noted. Did note that while laying down in bed; (R10's) oxygen saturation was low. (R10) ran ,[DATE]%. (normal oxygen saturation is greater than 90%) Did note (R10) had long tubing; so changed to shorter tubing and did get it to come up to 84%. No SOB (shortness of breath) noted. Did raise HOB (head of bed) some. Will recheck at lunch when sitting upright. Nursing did not check R10's blood pressure every 15 minutes x 4 when outside MD parameter and did not inform the physician of the low systolic reading. Nursing did not promptly consult with the physician regarding R10's low oxygen saturation level of 77% or of the fact that it remained below 90% even when the oxygen tubing was shortened. ~On [DATE] at 1:40 PM Fax out for orders for [MEDICATION NAME] DM (used to treat cough) 2 tsp. (teaspoons) q (every) 6 hours cough/congestion; and asked if he'd like CXR (chest x-ray) with (R10's) Hx (history) of hospitalization s for [MEDICAL CONDITION] ([MEDICAL CONDITION].) R10's medical record contained a fax form to the physician dated [DATE] which stated, Chief Complaint: non-productive / lungs OK (okay) but Hx [MEDICAL CONDITION] / no LE (lower extremity) [MEDICAL CONDITION]. Onset/Duration: last couple of days. Reason for Fax/Update: Needs [MEDICATION NAME] DM - ?CXR? Hx hospitalization . Current Medications r/t (related to) this issue: none - note is on Iron daily for low HH (hemoglobin and hemacrit which are blood values) Vitals: T-98.6, P-88, R-16, BP-,[DATE], SPO2 (oxygen saturation)-89% on 2 L oxygen. Physical Assessment/body system involved along with complaint/concern: Weaker - holding cup with 2 hands now, appetite down - assisted and allowed help. No calling out noted. Request: 1) [MEDICATION NAME] 2 tsp every 6 hrs PRN for cough/congestion 2) CXR - Hx [MEDICAL CONDITION] with hospitalization . This fax did not contain documentation that the physician was notified of the oxygen saturation level reaching as low as 77% as indicated in the above note timed 11:15 AM. ~On [DATE] at 3:23 PM Fax received with new orders for [MEDICATION NAME] DM 2 tsp. q 6 hours PRN cough/congestion. Also received order for CXR and call placed and ordered. MAR (medication administration record) updated and pharmacy faxed. ~On [DATE] at 8:07 PM (R10) was up and VS (vital signs) were Temp. 98.6 P 72 R 24 BP ,[DATE] O2 was at 97% (R10) ate meal took (R10) back to (R10's) room for chest x-ray when done with that the CNA (certified nursing assistant)'s were getting (R10) washed up ready for bed. They called me in took (R10's) P and BP put oxygen mask on instead of the nasal can (cannula). came out called for a ambulance. Call (RN) to see who else I had to call and what papers I needed to send out with (R10). before EMT (emergency medical technician)'s got here (R10) stopped breathing. was pronounced at 1915 (7:15 PM). Daughter was called. Funeral Home was called. R10's medical record indicated the BP and other vital signs mentioned in the above note timed 8:07 PM were obtained at 4:05 PM. R10's medical record did not contain documentation indicating facility obtained any repeat BPs as ordered by physician when BP was outside of physician ordered parameters. There was no documentation of the values of the P and BP mentioned in the above note timed 8:07 PM which was stated to be obtained after nurse notification of unresponsiveness by CNAs. R10's medical record did not contain documentation to show that every 15 min BPs were obtained when BP was found outside parameters as ordered by physician. On [DATE] at 1:22 PM, Surveyor interviewed DON-B who verified facility should have immediately called, not faxed, R10's physician after 11AM and 4 PM BPs were found outside physician ordered parameters. DON-B verified facility should have immediately notified physician of oxygen saturation found at 77%. DON-B verified R10's medical record did not contain documentation to show that every 15 min BPs were obtained when BP was found outside parameters as ordered by physician. DON-B verified the expectation is for staff to follow physician orders [REDACTED]. According to http://heartfailuresolutions.com/4782/oxygen/5-facts-to-remember-about-blood-oxygen-saturation-levels, .When oxygen saturation levels fall below 92%, the pressure of the oxygen in your blood is too low to penetrate the walls of the red blood cells. So, oxygen is unable to access transportation to your cells, tissues, and organs . (and) the cells of your body are oxygen starved! . The possible short term effects are stroke, [MEDICAL CONDITION] and sudden death. Low Blood Oxygen Saturation Levels are a serious health condition! Facility failure to promptly consult with the physician of R10's abnormal vital signs created a finding of Immediate Jeopardy (I[NAME]) The facility removed the IJ [DATE] when it completed the following: -All nursing staff review proper and complete documentation. -All nursing staff will be educated on monitoring and assessing vital signs immediately. Competency will be evaluated immediately and quarterly thereafter. -Creating blood pressure monitoring policy and pulse oxygen level policy that will be completed [DATE]. The training will be completed today and reviewed quarterly and upon hire. -All nursing staff will be educated to check the physician orders [REDACTED]. This will be done before next working shift. -All nursing staff to be educated on change of condition, when and who to contact, physician parameters, standard of practice and expectations of when to be notified. This will be done immediately, upon hire and quarterly thereafter. -All nursing staff will be educated on facility policy and procedure of change of condition, immediate notification via phone call or with fax. -All nursing staff will be educated to check the physician orders [REDACTED]. -On [DATE] facility staff reviewed policy and procedure for change of condition, MD orders related to parameters for vital signs that fall outside parameters and expectations of nursing staff when monitoring and assessing residents with changes in condition. Policy was updated to include when to notify a doctor via phone call or fax. Policy was created to include what blood pressures are, what expectation of the facility and MD is for notification of blood pressures that fall outside of parameters. This is done in coordination with medical director. Policy was created to include what pulse oxygen level is, its importance, indications, procedure of what to do in the event that levels fall below MD parameters and facility expectation of notifications. -On [DATE] facility staff reviewed policy and procedure for change of condition. Policy was updated to include when to notify a doctor via phone call or fax. Also added to the policy that if unable to talk with the resident's primary physician to call the medical director. -DON provided staff education to all nursing staff on change of condition, monitoring change of condition, when and who to contact for vital signs that fall outside of parameters, complete and proper documentation, new policies created immediately, reviewed at nurses meeting, upon hire and quarterly. Education and competency of nursing staff's vital sign assessment skills will be done immediately prior to next working shift and quarterly for the next 2 quarters, then every 6 months. The results of the audits will be reviewed at the monthly QA meeting and at the QAA meeting for further recommendations. The facility assessment will be updated related to competency of nursing staff. -The DON will do formal audits of charting daily for 4 weeks. Results will be reviewed at the monthly QA meeting and quarterly QAA meetings for the need to further education and monitoring. Facility assessment will be updated related to education provided to staff related to documentation and acute change of condition. -DON will do audits of communication with physicians daily for 3 weeks, weekly for 8 weeks to ensure doctors are being updated timely, with all information, in proper form for situation. The results of the audit will be reviewed during the monthly QA meeting and quarterly QAA meeting. Facility assessment will be updated to reflect staff training/education and competencies that are necessary to provide the level and types of support and care needed for our resident population. The deficient practice continues at a scope/severity of D based on the following example: 2. R21 was observed on survey by the Surveyor to have a cough, sinus drainage, and sneezing during the duration of survey. R21's medical record documented the following nurses notes: ~ [DATE] at 5:39 PM., Resident has very hoarse voice, minor non-productive cough here and there. ~ [DATE] at 11:30 AM, Resident has loose sounding cough noted at breakfast today. No [MEDICATION NAME] (cough medicine) when checked. Lungs auscultated and noted right to be clear; but left had rhonchi (abnormal sound) present. Will fax out as sounds as if R21 could use CXR (chest x-ray) to rule out pneumonia. ~ [DATE] at 3:38 AM., Resident has hoarse voice. No other complaints. R21 is able to sleep without any difficulty. Will continue to monitor for signs and symptoms of cold. ~ [DATE] at 5:56 AM., Slept well throughout the night; during cares intermittent congested noted; not other issues noted. ~ [DATE] at 2:50 PM., Non-productive cough remains. Does cover cough when seated at lunch. Does prompts to wipe runny nose. No new orders as of yet for [MEDICATION NAME] (a cough medicine) and CXR. ~ [DATE] at 8:12 PM., Continues with minor cold sign and symptoms today. ~ [DATE] at 6:48 AM., Slept well throughout the night; minimal coughing noted, On [DATE] the facility sent a fax regarding R21 to the physician requesting a response within 24 hours which documented the following concerns R21: ~ Loose cough ~ Lung - right clear - left rhonchi/congested ~ Physical assessment of R21 documented R21 to have low energy and low appetite. The fax documented a request for cough medicine and a chest x-ray because the facility was concerns R21 had pneumonia. On [DATE], R21's medical record did not include information that the fax sent on [DATE] had been answered by the physician. On [DATE] at 1:22 PM., the Surveyor interviewed DON-B who informed the Surveyor the fax regarding R21 from [DATE] had not been answered by the physician. DON-B states staff should have called the physician within 15 minutes of the fax not being answered. DON-B stated the facility should not have continued to waited over two days for a response from the physician. On [DATE] at 2:00 PM., DON-B informed the Surveyor the facility had followed up with the physician, and the physician asked the facility to send the fax again because the original fax was never received by the physician.

Based on record review and staff interview, the facility did not follow physician orders [REDACTED]. In addition, facility failed to properly assess R10 when vital signs were noted outside of physician ordered parameters. R10 had a change of condition on [DATE]. Facility failed to immediately notify physician of vital signs outside physician ordered parameters two separate times on [DATE]. R10 expired at the facility on [DATE]. Facility failure to follow physician orders [REDACTED]. DON (Director of Nursing)-B was notified of the IJ on [DATE] at 10:00 AM. The IJ was removed on [DATE], however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: On [DATE] at 1:53 PM, Surveyor reviewed the medical record of R10. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].(medical condition in which there is an extremely low oxygen content in the blood) with [MEDICAL CONDITION] (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), and Chronic [MEDICAL CONDITION] (progressive heart failure which leads to the build-up of fluids in the body.) R10's medical record contained physician orders [REDACTED].>~BP Parameters: if Diastolic (bottom number of BP) above 100 or below 50, OR if Systolic (top number of BP) is above 170 or below 90, check BP every 15 minutes x 4. If remains abnormal or if symptomatic call MD (physician) ~1500mL (milliliter) fluid restriction ~[MEDICATION NAME] (medication used to treat fluid retention) 0.5mg (milligrams) twice daily for heart failure ~[MEDICATION NAME] XL (medication used to treat chest pain, heart failure, and high blood pressure) 25mg at bedtime for hypertension ~Continuous oxygen at 1 lpm (liters per minute) via nasal cannula, may wean as able when O2 (oxygen) sats (saturation levels) are 96% (percent) or greater ~O2 at 2L (liters) PRN (as needed) per nasal cannula for respiratory distress or discomfort ~DNR (do not resuscitate) R10's medical record indicated that on [DATE] and [DATE] staff was monitoring R10 for cold symptoms and R10's vital signs were within MD order parameters during these days. R10's medical record contained the following nursing documentation for [DATE]: ~On [DATE] at 11:25 AM, (R10) seems to be a little under the weather today. (R10) needed both hands to hold onto (R10's) Prostat (protein supplement) when taking (R10's) morning pills today. Down for am (morning) nap. VS (vital signs) T (temperature) 98.6 P (pulse) 88 R (respirations) 16 BP ,[DATE]. LCTA (lungs clear to auscultation). Non productive cough. No LE (lower extremity) [MEDICAL CONDITION] noted. Did note that while laying down in bed; (R10's) oxygen saturation was low. (R10) ran ,[DATE]%. (normal oxygen saturation is greater than 90%) Did note (R10) had long tubing; so changed to shorter tubing and did get it to come up to 84%. No SOB (shortness of breath) noted. Did raise HOB (head of bed) some. Will recheck at lunch when sitting upright. Despite the fact that R10's systolic blood pressure reading was below 90, staff did not follow MD orders and did not monitor blood pressure four times every 15 minutes. There is no documentation to indicate that staff rechecked R10 after lunch. There is no documentation that staff promptly consulted with a physician about R10's low pulse oxygen reading, which continued to be less than 90% even when shorter tubing was used. ~On [DATE] at 1:40 PM, Fax out for orders for [MEDICATION NAME] DM (used to treat cough) 2 tsp. (teaspoons) q (every) 6 hours cough/congestion; and asked if he'd like CXR (chest x-ray) with (R10's) Hx (history) of hospitalization s for [MEDICAL CONDITION] ([MEDICAL CONDITION].) R10's medical record contained a fax form to the physician dated [DATE] which stated, Chief Complaint: non-productive / lungs OK (okay) but Hx [MEDICAL CONDITION] / no LE (lower extremity) [MEDICAL CONDITION]. Onset/Duration: last couple of days. Reason for Fax/Update: Needs [MEDICATION NAME] DM - ?CXR? Hx hospitalization . Current Medications r/t (related to) this issue: none - note is on Iron daily for low HH (hemoglobin and hemacrit which are blood values) Vitals: T-98.6, P-88, R-16, BP-,[DATE], SPO2 (oxygen saturation)-89% on 2 L oxygen. Physical Assessment/body system involved along with complaint/concern: Weaker - holding cup with 2 hands now, appetite down - assisted and allowed help. No calling out noted. Request: 1) [MEDICATION NAME] 2 tsp every 6 hrs PRN for cough/congestion 2) CXR - Hx [MEDICAL CONDITION] with hospitalization . R10's medical record did not contain documentation that the physician was notified of the oxygen saturation level reaching as low as 77% as indicated in the above note timed 11:15 AM. ~Per R10's medical record, on [DATE] at 3:23 PM, Fax received with new orders for [MEDICATION NAME] DM 2 tsp. q 6 hours PRN cough/congestion. Also received order for CXR and call placed and ordered. MAR (medication administration record) updated and pharmacy faxed. ~As recorded on [DATE] at 8:07 PM (R10) was up and VS (vital signs) were Temp. 98.6 P 72 R 24 BP ,[DATE] O2 was at 97% These vital signs were taken at 4:05 PM. There is no documentation indicating a nurse obtained repeat BPs per MD order when R10's blood pressure was again outside the parameters. There is no documentation of ongoing monitoring of R10's condition. There is no documentation that staff ever took R10's apical pulse, which could have provided a more comprehensive assessment of R10's cardiac status since abnormalities in rate, amplitude or rhythm may be indications of impaired circulation and heart efficiency. Additionally, a pulse deficit (radial pulse is less than the apical pulse) may signal decreased left ventricular output, which can occur with [MEDICAL CONDITION]. The nursing note at 8:07 PM continued: (R10) ate meal took (R10) back to (R10's) room for chest x-ray when done with that the CNA (certified nursing assistant)'s were getting (R10) washed up ready for bed. They called me in took (R10's) P and BP put oxygen mask on instead of the nasal can (cannula). came out called for a ambulance. Call (RN) to see who else I had to call and what papers I needed to send out with (R10). before EMT (emergency medical technician)'s got here (R10) stopped breathing. was pronounced at 1915 (7:15 PM). Daughter was called. Funeral Home was called. R10's medical record did not contain documentation indicating facility obtained any repeat BPs as ordered by physician based on BP being outside of physician orders. There was no documentation of the values of the P and BP mentioned in the above note timed 8:07 PM which was stated to be obtained after nurse notification of unresponsiveness by CNAs. R10's medical record did not contain documentation to show that every 15 min BPs were obtained when BP was found outside parameters as ordered by physician. On [DATE] at 1:22 PM, Surveyor interviewed DON-B who verified facility should have immediately called, not faxed, R10's physician after 11AM and 4 PM BPs were found outside physician ordered parameters. DON-B verified facility should have immediately notified physician of oxygen saturation found at 77%. DON-B verified R10's medical record did not contain documentation to show that every 15 min BPs were obtained when BP was found outside parameters as ordered by physician. DON-B verified the expectation is for staff to follow physician orders [REDACTED]. Facility failure to follow physician orders [REDACTED].) The facility removed the IJ [DATE] when it completed the following: -All nursing staff review proper and complete documentation. -All nursing staff will be educated on monitoring and assessing vital signs immediately. Competency will be evaluated immediately and quarterly thereafter. -Creating blood pressure monitoring policy and pulse oxygen level policy that will be completed [DATE]. The training will be completed today and reviewed quarterly and upon hire. -All nursing staff will be educated to check the physician orders [REDACTED]. This will be done before next working shift. -All nursing staff to be educated on change of condition, when and who to contact, physician parameters, standard of practice and expectations of when to be notified. This will be done immediately, upon hire and quarterly thereafter. -All nursing staff will be educated on facility policy and procedure of change of condition, immediate notification via phone call or with fax. -All nursing staff will be educated to check the physician orders [REDACTED]. -On [DATE] facility staff reviewed policy and procedure for change of condition, MD orders related to parameters for vital signs that fall outside parameters and expectations of nursing staff when monitoring and assessing residents with changes in condition. Policy was updated to include when to notify a doctor via phone call or fax. Policy was created to include what blood pressures are, what expectation of the facility and MD is for notification of blood pressures that fall outside of parameters. This is done in coordination with medical director. Policy was created to include what pulse oxygen level is, its importance, indications, procedure of what to do in the event that levels fall below MD parameters and facility expectation of notifications. -On [DATE] facility staff reviewed policy and procedure for change of condition. Policy was updated to include when to notify a doctor via phone call or fax. Also added to the policy that if unable to talk with the resident's primary physician to call the medical director. -DON provided staff education to all nursing staff on change of condition, monitoring change of condition, when and who to contact for vital signs that fall outside of parameters, complete and proper documentation, new policies created immediately, reviewed at nurses meeting, upon hire and quarterly. Education and competency of nursing staff's vital sign assessment skills will be done immediately prior to next working shift and quarterly for the next 2 quarters, then every 6 months. The results of the audits will be reviewed at the monthly QA meeting and at the QAA meeting for further recommendations. The facility assessment will be updated related to competency of nursing staff. -The DON will do formal audits of charting daily for 4 weeks. Results will be reviewed at the monthly QA meeting and quarterly QAA meetings for the need to further education and monitoring. Facility assessment will be updated related to education provided to staff related to documentation and acute change of condition. -DON will do audits of communication with physicians daily for 3 weeks, weekly for 8 weeks to ensure doctors are being updated timely, with all information, in proper form for situation. The results of the audit will be reviewed during the monthly QA meeting and quarterly QAA meeting. Facility assessment will be updated to reflect staff training/education and competencies that are necessary to provide the level and types of support and care needed for our resident population.

Based on observation, staff and resident (R) interview, and record review, the facility did not ensure adequate supervision and devices were provided in accordance with the individualized care plan for 1 resident (R1) of 3 residents reviewed for fall safety. R1 was not located in a public area per R1's care plan on 5/26/18 between 1:00 PM and 4:00 PM and fell in R1's individual room resulting in a [MEDICAL CONDITION]. R1's fall care plan also requires the call light button to be placed within reach. R1 was observed seated in a chair in R1's room during survey with the call light button tied to a bedrail which was out of reach for R1. Findings include: On 6/7/18, the Surveyor reviewed R1's medical record including facility submitted self-report which documented: ~[DIAGNOSES REDACTED].) ~R1 had multiple witnessed and unwitnessed falls at the facility. ~Care Plan with dated fall prevention interventions including call light in reach (initiated 11/14/17) and sit in purple wingback chairs between 1:00 PM and 4:00 PM (initiated 5/17/18) as facility noted that fall pattern indicated falls during this timeframe. ~5/20/18 staff intervened with a gait belt when R1 began sliding out of a dining room chair. The Surveyor noted no facility investigation. ~5/20/18 R1's head hit the bathroom wall during a transfer. The Surveyor noted no facility investigation. ~5/26/18 unwitnessed fall at approximately 2:00 PM in R1's room resulting in [MEDICAL CONDITION] and hospitalization for hemiarthroplasty surgery from 5/26/18 through 5/29/18. ~Facility investigation into R1's 5/26/18 fall concluded staff failed to follow the care plan of placing R1 in a public area as noted above. On 6/7/18 at 8:59 AM, the Surveyor observed R1 in R1's resident room seated in a chair. The Surveyor noted R1's call light button cord was tied to the left bedrail and was out of reach for R1. R1 stated, It's not going well but was not able to elaborate. At 9:05 AM, the Surveyor requested Registered Nurse (RN)-B evaluate if R1 could reach the call light button with R1's current position. RN-B requested R1 attempt to use the call light. R1 was not able to reach the button. RN-B repositioned the call light button with the aid of R1's stuffed animal to anchor the cord in place. At that time, RN-B verified R1's call light cord was missing a clip (usually utilized to attach the button in convenient locations.) At 9:48 AM, RN-B reported to the Surveyor that a new clip was located and applied to R1's call light cord. On 6/7/18 at 10:44 AM, the Surveyor interviewed Director of Nursing (DON)-A who verified R1's call light should have been in reach per care plan and per standard of practice. DON-A reviewed R1's 5/26/18 fall with the Surveyor and explained the facility identified the staff on duty at the time were casual workers who were not as familiar with resident care plans. DON-A indicated R1 was to be seated in the purple wingback chairs during the specific timeframe (1:00 PM to 4:00 PM) per the care plan because the chairs were located in a public area that staff could more easily monitor since the Inter-Disciplinary Team (IDT) determined R1's falls had a timing pattern. DON-A explained R1 had so many interventions that the interventions did not fit on the Certified Nursing Assistant (CNA) care card. Therefore, the IDT determined a list of names for residents requiring increased supervision would be placed in a location that CNAs could access. On 6/7/18 at 12:17 PM, the Surveyor reviewed R1's progress notes with DON-A who verified not being aware of an intercepted fall (the person would have fallen if staff did not physically intervene) in the dining room documented on 5/20/18 and a possible fall in the bathroom on the same date (R1 was documented as hitting R1's head on the wall during a bathroom transfer.) DON-A indicated further education would be provided to staff to help identify intercepted falls.