Every finding on record at Meadowbrook at Chetek

Based on interview and record review, the facility did not ensure a safe discharge for 1 of 3 residents (R1) reviewed of a sample of 4 residents.R1 was not allowed to return to the facility after R1 left the building and did not return prior to 11:59 PM. R1 was located by facility staff the next day and given paperwork for discharge against medical advice. R1 was discharged without a safe discharge plan, without R1's belongings or medications. This is evidenced by: Facility policy titled, Administrative Transfer/Discharge Notice, with a revised date of 12/2025, states: Purpose: It is the policy of the facility to provide each operating facility with a process for resident discharges that are initiated by the facility. Of note: policy does not include guidelines of a resident not returning by 11:59 PM being discharged AMA (against medical advice). R1 was admitted to the facility on [DATE] with multiple sclerosis, paraplegia, supra-pubic catheter, and mild cognitive impairment. R1 was discharged from facility on 07/03/26. R1's most recent significant change Minimum Data Set (MDS) assessment, dated 06/10/26, noted a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 has intact cognition. R1 uses a motorized wheelchair and/or scooter and mechanical lift. R1 has impaired range of motion on both sides of lower extremities. R1 requires dependent assist with toileting hygiene, lower body dressing, putting on/off footwear, sitting to lying, lying to sitting, sitting to standing, chair/bed transfers and toilet transfers. R1's medications include an anticoagulant, diuretic, and opioid. R1's care plan, dated 10/01/24, with a target date of 12/09/26, states: [R1] needs assistance with ADLs (activities of daily living). Interventions include assist of 2 with EZ stand for toileting and transfers. R1's care plan, dated 10/01/24, with a target date of 12/09/26, states: [R1] would like to remain long term at facility with [R1's] discharge goal to remain long term. On 07/15/26 at 3:31 PM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding the facility's policy on residents leaving the facility. DON B stated that residents are asked to let staff know and sign-out in the log when leaving. Surveyor asked DON B if anyone monitors this log. DON B stated no. Surveyor asked DON B if residents must be back inside the facility at a specific time. DON B said yes, by 11:59 PM, unless they have a provider order for a longer leave. Otherwise, they are considered to have discharged themselves AMA. Surveyor asked DON B how this is explained to residents. DON B stated verbally on admission. Surveyor asked DON B if there was a written policy regarding this. DON B stated no. Surveyor reviewed R1's medical record: On 07/02/26 at 7:30 PM, R1 left the faciity on motorized wheelchair. Registered Nurse (RN) C observed R1 leaving and reminded R1 to return to the facility by midnight. R1 was documented stating, have my butt back in the building by midnight. Surveyor reviewed facility's sign-in/sign-out log located in the front entryway and noted R1 had not signed in or out of the facility on 07/02/26. -On 07/16/26 at 8:05 AM, Surveyor interviewed RN C (Registered Nurse) regarding incident. Surveyor asked RN C what that meant for R1 to be back by midnight. RN C stated R1 frequently left the facility and staff reminded R1 that they needed to back inside the facility by midnight or they would no longer be a resident. Surveyor asked RN C how residents are made aware of this policy. RN C stated they are informed during admission. Surveyor asked RN C if there was anything documented that R1 was made aware of this policy. RN C stated no. Surveyor asked RN C if R1 had ever been out of the facility after midnight prior to this incident. RN C stated no. Surveyor asked RN C if she attempted to call R1. RN C stated yes, more than once, but R1's number was not in service because she kept getting an error message. Progress notes dated 07/03/26 at 12:09 AM, state RN C documented R1 had not returned to the facility. Staff searched inside/outside facility but were unable to locate R1. DON and NHA were notified. At approximately 2:30 AM, RN D, who was reporting to work, observed R1 outside of a local gas station reclined in their motorized wheelchair. RN D asked R1 if they were ok and why they were out of the facility so late. R1 replied she was a night owl and R1 had to watch over their spouse. RN D left R1 at gas station and went to facility to start their work shift RN D notified the on-duty nurse of R1's whereabouts. On 07/16/26 at 7:29 AM, Surveyor interviewed RN D regarding the incident. Surveyor asked RN D what the facility policy is for residents not returning to the facility by 11:59 PM. RN D stated that if a resident expects to be gone longer, then they should call the facility and let them know. Surveyor asked if this would still be grounds to be discharged AMA. RN D stated no that it can be adjusted if the facility is updated. Surveyor asked RN D if she had ever informed R1 of the policy to be back at facility by 11:59 PM or R1 would be discharged AMA. RN D stated no, not personally. Surveyor asked RN D if all residents are informed of this policy. RN D stated yes that they are all told this. Surveyor asked RN D if this is documented. RN D stated no. Surveyor asked RN D if there is a written policy stating this. RN D stated no. Surveyor asked RN D how she became aware of this policy. RN D stated she was not sure but as far as she was aware it had always been the policy. Progress notes dated 07/03/26 state at approximately 7:30 AM, DON B and Social Worker (SW) E found R1 at the dam in the park. DON B and SW E asked R1 if they were ok. R1 stated they did not know; they fell asleep cause they were busy watching their spouse all night. SW E explained to R1 that by not returning to the facility by 11:59 PM, R1 had discharged themselves from the facility AMA. R1 stated they thought that meant they had to just come back to the facility a couple minutes here and there. SW E stated no, the rule was to be in the facility at 11:59 PM. R1 stated they didn't know that. SW E provided R1 the AMA form noting that R1 left the facility AMA discontinuing all prescribed medical treatment and chose not to come back to the facility. R1 was noted to refuse to sign the form at 8:11 AM. SW E asked R1 their plans. R1 stated not knowing. SW E informed R1 that Adult Protective Services may be able to help and that R1 could also go the ED (emergency department) if there should be any medical emergencies. R1 was not given her medications and belongings at this time. SW E told R1 that they could pick them up at any time.Of note, facility staff left R1 in a park without medications, shelter, their belongings and did not provide a safe discharge plan for R1. On 07/16/26 at 8:28 AM, Surveyor interviewed DON B regarding this incident. Surveyor asked DON B if she asked R1 why they hadn't called the facility to inform them that R1 would not be back by 11:59 PM. DON B stated R1 said they were busy keeping an eye on their spouse and didn't know they fell asleep. Surveyor asked DON B if R1 knew not being back in the facility by 11:59 PM meant they would be discharging themselves AMA. DON B stated yes this was repeated to R1 numerous times. Surveyor asked DON B if there was documentation of this. DON B stated no. Surveyor reviewed R1's EMS (Emergency Medical Services) report: On 07/03/26 at 1:56 PM, EMS received a page to assist R1 in the local park. R1's spouse had called 911 stating R1 had been evicted from the facility, R1's motorized wheelchair battery was dead, and she had blood in her urine. EMS took R1 to the local hospital for assessment. Surveyor reviewed R1's hospital records: On 07/03/26, R1 was admitted to the hospital with principal diagnosis of multiple sclerosis. R1 discharged AMA on 07/05/26. On 07/15/26 at 3:35 PM, Surveyor interviewed DON B and NHA A regarding discharge process. Surveyor asked if the facility's policy of residents not returning before 11:59 PM is in written form. Both DON B and NHA A stated no. NHA A stated after this incident, it will be changed. Surveyor asked how they knew R1 understood this policy. DON B stated that many staff had told R1 about this policy. Surveyor asked DON B if there was any documentation about this. DON B stated no. On 07/16/26 at 9:07 AM, Surveyor interviewed SW E regarding incident. Surveyor asked SW E if she was aware of R1 wanting to discharge from the facility or if discharging to the park was a safe discharge plan. SW E stated no because R1 needed help transferring into wheelchair and had no other home to go to. Surveyor asked SW E what R1 stated when she was given the AMA form and she was being discharged . SW E stated that initially, R1 said OK and then she said she didn't understand. R1 had stated that she thought being back by 11:59 PM meant popping in and out of the facility at some point. SW E corrected R1 that being back at 11:59 PM meant they had to be inside the facility at 11:59 PM. SW E stated that R1 then stated not knowing this. Surveyor asked SW E if it would be good practice to have this in writing to avoid this kind of confusion. SW E stated yes. R1 has MS, paraplegia, a suprapubic catheter and is dependent on staff for all areas of ADLs. Facility staff did not provide R1 with a safe discharge plan. Facility staff discharged R1 AMA without shelter, medications and R1's belongings. R1 was discharged AMA to a park.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive infection prevention and control program was established and maintained. Specifically, the facility failed to ensure staff used Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP), sanitize mechanical lifts between resident use, complete proper hand hygiene, or provide residents with hand-hygiene before meals.-Registered Nurse (RN) C and Licensed Practical Nurse (LPN) D entered R23's room and conducted wound care on R23's open leg wounds without donning PPE prior to and during wound care treatment, having the ability to potentially spread infection to all 75 residents in the facility.-Certified Nursing Assistant (CNA) R and LPN D did not wear PPE while transferring R4 with the Hoyer mechanical lift.-CNA J and CNA G did not clean/sanitize the Hoyer lift after use on R3 who is on enhanced barrier precautions and then used it to transfer R15, having the ability to potentially spread infection to 1 of 1 resident (R15)-RN Q did not sanitize hands after doffing gloves following administration of nasal spray for R72 nor before administering eye drops to R72. This had the ability to potentially affect 1 of 18 residents observed for medication administration.-Facility staff did not offer hand hygiene to 4 of 17 residents present in the dining room for 2 meals. R15, R1, R6, R80 self-propel their wheelchairs to the dining room and feed themselves. Example 1 Facility policy titled Enhanced Barrier Precautions, last revised 5/2026, states, All staff are expected to comply with all designated precautions .an order for enhanced barrier precautions will be obtained for residents with .chronic wounds such as pressure ulcers, indwelling medical devices such as urinary catheters, feeding tubes .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .high contact care activities include: dressing, bathing, transferring, providing hygiene .device care. R23 was admitted to facility on 04/16/2026 with diagnoses that include malignant neoplasm of tongue, pressure ulcer of sacral region (stage 3), and venous ulcers of lower extremities. On 05/18/2026, Surveyor reviewed R23's current physician orders for wound care: -Initiated 4/23/2026 - Coccyx - Cleanse with normal saline, pat dry, apply SSD 1% cream and plain Calcium Alginate to wound bed, skin prep to peri wound, cover with silicone superabsorbent bordered foam dressing. Daily and as needed (PRN). -Initiated 04/23/2026 Bilateral Heels - Apply skin prep and bordered foam dressings every other day and PRN.-Initiated 05/06/2026 Diabetic Toe Ulcers - Paint with Betadine and leave open to air. Weave lamb's wool in between toes every other day and PRN. for diabetic ulcer -Initiated 05/14/2026 Right Lower Extremity Venous Ulcers - Cleanse with normal saline, pat dry, apply Dermaphor to dry skin, xeroform to wound beds, cover with ABD pads, wrap with kerlix and secure using Fix Tape. Every other day and PRN for venous ulcers. On 05/19/2026 at 3:00 PM, Surveyor observed no signage outside of R23's room indicating need for EBP precautions. On 05/19/2026 at 3:05 PM, Surveyor observed RN C and LPN D enter R23's room and conduct wound care on R23's open wound without donning PPE prior to and during wound care treatment. On 05/19/2026 at 3:41 PM, Surveyor observed RN C and LPN D step outside R23's room and don PPE after discussing length of stay for R23 being over 30 days and before continuation of wound care. On 05/19/2026 at 4:08 PM, Surveyor interviewed RN C regarding no EBP signage outside R23's door and no observation of PPE worn prior to doing leg wounds, exiting room after discussion of R23 being admitted over 30 days and don PPE prior to completing wound care on G-tube dressing and coccyx wound. RN C stated just realizing when we were in room doing wound care R23 was here more than 30 days so now wounds are chronic and should be placed on EBP. Surveyor asked if all residents are placed on EBP only after 30 days, and RN C wasn't sure and will need to check. On 05/21/26 at 11:10 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation of no PPE and signage for R23 and asked about the 30-day chronic wound process. DON B was unable to provide evidence or explanation of no signage or donning PPE prior to wound care for R23. Example 2 R4 was admitted to the facility on [DATE] with diagnoses that include intraspinal abscess and granuloma, pressure ulcer of left buttock stage 4, paraplegic and colostomy (bag attached surgically to outside of body to collect feces). On 05/19/2026 at 11:28 AM, Surveyor observed signage outside R4's room indicating EBP to be used during all high contact episodes with R4. On 05/19/2026 at 12:30 PM, Surveyor observed CNA R and LPN D perform a Hoyer lift transfer on R4. CNA R and LPN D did not don PPE upon entering R4's room or during Hoyer lift transfer of R4. Surveyor observed CNA R and LPN D experience high level physical contact with R4 while placing Hoyer sling under R4 when in bed, and during proper positioning of R4 into wheelchair. Example 3 On 05/19/26 at 7:26 AM, Surveyor observed Certified Nursing Assistant (CNA) J and CNA G use the Hoyer lift to transfer R3 from R3's wheelchair to a recliner. R3 is on Enhanced Barrier Precautions (EBP) in relation to a Foley catheter. CNA J then removed the lift to a small room off the dining room for charging. CNA J plugged in the Hoyer lift and did not clean/sanitize it. On 05/19/26 at 7:39 AM, Surveyor observed CNA H and CNA G take the same Hoyer lift that had not been cleaned into R15's room and use it to get R15 out of bed and into R15's wheelchair. On 05/19/26 at 8:27 AM, Surveyor interviewed CNA G about mechanical lift cleaning. CNA G stated that the lifts should be cleaned after every resident to prevent the spreading of germs. CNA G stated each lift has a container of sanitizing wipes in a bag that hangs on the lift. CNA G reported the nursing staff receive education in relation to this and nursing managers perform audits to make sure it is being done. Example 4 The facility policy titled, Hand Hygiene, states, . Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE). R72 was admitted on [DATE] with diagnoses of glaucoma, congestion, nasal crusting, and rhinorrhea. On 05/19/2026 at 7:34 AM, Surveyor observed Registered Nurse (RN) Q sanitize hands, don gloves and administer saline nasal 3% to R72. RN Q doffed gloves and reapplied clean gloves without sanitizing hands, then administered Dorzolamide-Timolol 2-0.5% eye drops to both eyes. RN Q doffed gloves again and applied new gloves without sanitizing hands and at 7:33 AM, RN Q administered Ipratropium Bromide Nasal solution 0.03% to R72. On 05/19/2026 at 10:33 AM, Surveyor interviewed Director of Nursing (DON) B and asked what they expect staff to complete following doffing gloves. DON B stated it is expected staff sanitize their hands every time they doff gloves, before, between, and after each medication administration. Example 5 On 05/18/26 at 12:10 PM, Surveyor observed no hand hygiene offered to residents prior to lunch. R15, R1, R6, and R80 self-propelled their wheelchairs to the dining room and feed themselves. 17 total residents were present. On 05/19/2026 at 8:13 AM, Surveyor observed no hand hygiene offered to residents prior to serving breakfast. R15, R1, R6, and R80 self-propelled their wheelchairs to the dining room and feed themselves. 17 total residents were present.

Based on record review and interview, the facility did not ensure each resident is free from unnecessary drugs as evidenced by facility not providing adeuate drug monitoring for 5 of 5 residents (R) (R2, R5, R9, R11 and R45) reviewed for unnecessary medication reviews.R2 received Hydroxyzine HCl 25 mg by mouth one time a day related to anxiety disorder, unspecified. Physician orders stated for facility to document number of times the resident [R2] exhibits the following behaviors, Nervousness, Restlessness, sweating, increased heart rate, difficulty sleeping or trouble concentrating.)R2 received Trazodone HCL 50mg one time a day for insomnia. Physician orders stated for facility to document number of times the resident exhibits the following behaviors: crying, tearfulness, social isolation, changes in appetite, mood swing, or difficulty sleepingR2's Treatment Administration Record (TAR) only showed documentation using a checkmark that a behavior occurred and not the number of episodes for each behavior.R5's received Risperidone Oral Tablet 1 mg by mouth three times a day for depression, Buspirone HCl Oral Tablet 10 MG 10 mg by mouth three times a day related to anxiety disorder, Trazodone HCl 100 mg by mouth one time a day for insomnia, Duloxetine HCl (aka Cymbalta) Give 2 capsule by mouth one time a day related to major depressive disorder, recurrent. Physician orders stated for facility to document number of times the resident exhibits the following behaviors: crying, tearfulness, social isolation, changes in appetite, mood swing, or difficulty sleeping.3 times a day.R5's TAR only showed documentation using a checkmark that a behavior occurred and not the number of episodes for each behavior.R9 received Bupropion HCl 300 mg. Give 1 tablet by mouth one time a day related to major depressive disorder, Sertraline HCl 100 mg. Give 1 tablet by mouth one time a day related to major depressive disorder. Take with 50mg to equal 150mg, Sertraline HCl Oral Tablet 50 mg. Give 50 mg by mouth one time a day related to major depressive disorder. Take with 100mg to equal 150mg, Trazodone HCl 100 mg. Give 1 tablet by mouth one time a day for insomnia Physician orders stated for facility to document number of times the resident exhibits the following behaviors: crying, tearfulness, social isolation, changes in appetite, mood swing, or difficulty sleeping.R9's TAR only showed documentation using a checkmark that a behavior occurred and not the number of episodes for each behavior.R45 received Buspirone HCl. Give 1 tablet by mouth three times a day related to generalized anxiety disorder.R45's care plan states: Resident is prescribed a medication for anxiety. Document number of times the resident exhibits the following behaviors: Nervousness, restlessness, sweating, increased heart rate, difficulty sleeping, or trouble concentrating.R45's TAR only showed documentation using a checkmark that a behavior occurred and not the number of episodes for each behavior.R11 received Seroquel Oral Tablet 50 mg. Give 1 tablet by mouth one time a day related to bipolar disorder, R11's orders stated: Antipsychotic - Resident [R11] is prescribed a medication for anxiety/bipolar disorder. Document number of times the resident exhibits the following behaviors: Delerium, paranoia, hallucinations, mood swings, or agitation.R11's TAR only showed documentation using a checkmark that a behavior occurred and not the number of episodes for each behavior. The facility policy titled, Psychotropic Management, revised December 2025, states: The facility will use psychotropic medication therapy only when clinically indicated to enhance the quality of life, while maximizing functional potential and well-being of the resident.Under section titled Practice Guidelines (5), states: The licensed nurse will institute the appropriate behavior monitoring from associated with the medication category. -a. Identity and document objective and quantifiable specific behaviors. -b. Document the number of episodes of behaviors.-c. Document interventions and outcomes.Example 1R2 was admitted to the facility on [DATE] with diagnoses including insomnia and anxiety disorder.R2's care plan initiated 07/02/25: Mood Problem related to (r/t) anxiety indicates Targeted Behavior of anxiousness, verbal/anger outbursts and isolation/withdrawn. Monitor/record/report to MD as needed (prn) acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skillsR2's psychotropic physician orders state:-On 04/22/2026, Hydroxyzine HCl 25 mg by mouth one time a day related to anxiety disorder, unspecified.-On 11/23/2025, Document number of times the resident exhibits the following behaviors, Nervousness, Restlessness, sweating, increased heart rate, difficulty sleeping or trouble concentrating.) -On 04/22/2026, Trazodone HCL 50mg one time a day for insomnia.-On 11/23/2025, Document number of times the resident exhibits the following behaviors: crying, tearfulness, social isolation, changes in appetite, mood swing, or difficulty sleepingOn 05/20/26 at 9:48 AM, Surveyor reviewed R2's Treatment Administration Record (TAR) for number of behavior episodes. R2's TAR showed documentation of using a checkmark instead of the number of episodes.Example 2R5 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD), major depressive disorder recurrent, obsessive-compulsive disorder, and history of suicide.R5's care plan initiated 11/03/23:- The resident uses antipsychotic medication (Risperidone) r/t major depression with history of suicidal ideation.- The resident uses anti-anxiety medications (Buspar) r/t anxiety disorder. - The resident uses antidepressant medication Cymbalta for major depressive disorder and Trazodone for insomnia.-The resident has depression and anxiety r/t comorbidities and PTSD. Monitor/document/report every shift any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxiety or health-related complaints, tearfulness.-R5's psychotropic physician orders state:-On 4/18/2025 Risperidone Oral Tablet 1 mg by mouth three times a day for depression-7/12/2024 Buspirone HCl Oral Tablet 10 MG 10 mg by mouth three times a day related to anxiety disorder.-On 12/31/2025 Trazodone HCl 100 mg by mouth one time a day for Insomnia please cut in half before giving.-On 10/13/2023 Duloxetine HCl (aka Cymbalta) Give 2 capsule by mouth one time a day related to major depressive disorder, recurrent.-On 11/22/2025 Document number of times the resident exhibits the following behaviors: crying, tearfulness, social isolation, changes in appetite, mood swing, or difficulty sleeping.3 times a day.On 05/20/26 at 9:48 AM, Surveyor reviewed R52's Treatment Administration Record (TAR) for documentation of the number of targeted behavior episodes. The TAR documented a checkmark instead of the number of episodes.Example 3R9 was admitted to facility on 06/19/2024 with diagnoses including major depressive disorder and anxiety disorder.R9's care plan includes:-Initiated 06/28/24 the resident uses antidepressant medications .Sertraline related to depression. Resident is taking Trazodone for insomnia. Monitor/document/report every shift any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxiety or health-related complaints, tearfulness.-Initiated 08/01/25: The resident has a mood problem r/t anxiety disorder and major depressive disorder. Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skillsR9's physician orders state:-On 06/17/2025 Bupropion HCl 300 mg. Give 1 tablet by mouth one time a day related to major depressive disorder.-On 02/20/2025 Sertraline HCl 100 mg. Give 1 tablet by mouth one time a day related to major depressive disorder. Take with 50mg to equal 150mg.-On 12/20/2025 Sertraline HCl Oral Tablet 50 mg. Give 50 mg by mouth one time a day related to major depressive disorder. Take with 100mg to equal 150mg.-On 11/22/2025: Resident is prescribed a medication for depression. Document number of times the resident exhibits the following behaviors: crying, tearfulness, social isolation, changes in appetite, mood swing, or difficulty sleeping.-On 05/14/2026 Trazodone HCl 100 mg. Give 1 tablet by mouth one time a day for insomniaOn 05/20/26 at 9:48 AM, Surveyor reviewed R9's Treatment Administration Record (TAR) that was ordered of documenting the number of targeted behaviors. The TAR was documented using a checkmark instead of the number of episodes.Example 4R45 was admitted to the facility on [DATE] with diagnoses including anxiety disorder.R45's care plan initiated 2/06/2026 states resident uses anti-anxiety medications related to anxiety disorder. Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetiteR45's physician orders state:-On 05/14/2026, Buspirone HCl. Give 1 tablet by mouth three times a day related to generalized anxiety disorder.-On 05/20/2026, R45's care plan states: Resident is prescribed a medication for anxiety. Document number of times the resident exhibits the following behaviors: Nervousness, restlessness, sweating, increased heart rate, difficulty sleeping, or trouble concentrating.On 05/20/2026 at 9:48 AM, Surveyor reviewed R45's Treatment Administration Record (TAR) for documentation of the number of targeted behavior episodes. The TAR documented a checkmark instead of the number of episodesExample 5R11 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder.-R11's care plan initiated 12/18/2025, states resident uses an antipsychotic medication (Seroquel) r/t bipolar disorder with intervention Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change inpsychomotor skills.R11's physician orders state:-On 12/18/25: Seroquel Oral Tablet 50 mg. Give 1 tablet by mouth one time a day related to bipolar disorder.-On 12/19/2025: Antipsychotic - Resident is prescribed a medication for anxiety/bipolar disorder. Document number of times the resident exhibits the following behaviors: Delerium, paranoia, hallucinations, mood swings, or agitation.On 05/20/2026 at 9:48 AM, Surveyor reviewed R45's Treatment Administration Record (TAR) for documentation of targeted behavior episodes. The TAR documented a checkmark instead of the number of episodesOn 05/20/2026 at 10:56 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O regarding documentation expectation of behaviors of residents. CNA O stated all residents have same behavior task with a selection of behaviors they complete during the shift. On 05/21.26 at 11:10 AM, Surveyor interviewed DON B regarding targeted behavior orders recorded on the TAR record showing checkmarks instead of the number of episodes. DON B stated, I don't know what happened there.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 3 of 18 residents (R) (R9, R10, and R15) reviewed for following physician orders. -Facility failed to notify physician on four occasions when R9's fluid restrictions exceeded 2500 cc in 24 hours as per physician ordered parameters. -Facility failed to provide thorough speech therapy services for R10 which contributed to R10's weight loss as R10 did not wear dentures. -R15's hospital discharge orders were omitted when readmitted , following surgical procedure on R15's left thigh requiring a wound vac. Example 1 R9 was admitted to facility on 06/19/2024 with diagnosis of Cor pulmonale, chronic respiratory failure, and chronic kidney disease. R9's care plan initiated on 06/28/2024, states: The resident is on diuretic therapy r/t diuretic use. Administer diuretic medications as ordered by physician. R9's physician orders dated 06/20/2024 state: 2500 milliliters (ML)/day fluid restriction. Add up total of previous day and enter here. Update MD if exceeds fluid restriction. On 05/20/2026 at 10:07 AM, Surveyor reviewed R9's fluid intake record and noted the following dates above physician parameters of 2500 ml and without notification to physician:-04/01/2026 consumed 2700 ml-04/10/2026 consumed 3140 ml-04/12/2026 consumed 2800 ml-04/26/2026 consumed 2600 ml On 05/20/2026 at 2:24 PM, Surveyor interviewed Registered Nurse (RN) Q regarding facility expectation of updating physician when orders state to notify MD when a resident is out of parameters of an order such as intake fluid amounts. RN Q normally will fax the provider or if the resident is symptomatic, the facility will call the 24-hour switchboard. On 05/20/2026 at 3:26 PM, Surveyor interviewed Director of Nursing (DON) B regarding documentation to support R9's provider was notified of fluid intake of more than 2500 ml in 24 hours. DON B stated was unable to find supporting documentation that provider was notified and the expectation would be nursing would follow physician orders. Example 2 Facility policy titled Specialized Rehabilitation Services, last revised 12/2022, states, Facility shall provide services.to assist [residents] attain, maintain or restore their highest practicable level of physical, mental and psychosocial well-being. R10 was admitted to the facility on [DATE] and has diagnosis that include cerebral infarction (stroke of the brain), dysphagia (difficulty swallowing) and aphasia (difficulty speaking). R10 has a brief interview for mental status score (BIMS) of 9/15, which means moderate cognitive impairment. R10 makes own healthcare decisions. Between 05/18/2026 at 9:59 AM and 05/20/2026 at 1:56 PM, R10 was observed in bed with pureed meals on bedside table untouched. R10 did not have dentures in place. On 05/18/2026 at 1:28 PM, Surveyor interviewed R10 on status of dentures. R10 stated dentures do not have enamel on them anymore due to R10's tube feedings eroding them. R10 informed Surveyor the dentures are located in R10's bedside stand. R10 denied facility helping with adjusting dentures or any therapy with use of dentures in place. On 05/19/2026 at 1:00 PM, record review indicates R10 stayed at a rehabilitation facility from 03/25/2026 to 4/16/2026, following a cerebral infarction. R10's discharge Summary from the rehabilitation facility, dated 04/15/2026, includes a speech therapy assessment, education and discharge recommendations. The rehabilitation facility's speech therapy assessment included trials with dentures in place and pureed textured solids. The rehabilitation facility recommended speech therapy services to continue at long term care facility to address speech and swallowing deficits and safe swallowing strategies. R10 has physician orders, dated 04/16/2026, for speech therapy evaluation and treatment. On 05/19/2026 at 1:30 PM, record review of speech language and pathology evaluation and plan of treatment done on 04/17/2026 and 05/08/2026 by speech therapists (ST) P, did not reference use of dentures for R10 during or following evaluations. On 05/19/2026 at 1:30 PM, record review of speech therapy encounters for R10, dated 04/27/2026, 04/28/2026 and 04/30/2026 by ST P, did not reference use of dentures during therapy sessions. On 05/20/2026 at 7:36 AM, Surveyor interviewed ST P on the plan for treatment for R10's speech and swallowing deficits. ST P stated R10 has issues with pocketing food in left cheek and continues to have speech therapy sessions. ST P confirmed all speech therapy sessions for R10 were done without the use of R10's dentures. ST P stated facility did not pursue use of dentures for R10 during meals and other times as recommended by the rehabilitation facility because R10 did not have dentures while at facility. ST P confirmed no further follow up was done by ST to locate dentures. Surveyor informed ST P that R10 stated dentures were in bedside stand, and CNA care plan indicated R10 had upper and lower dentures. Surveyor then observed ST P locate R10's dentures in R10's bedside stand. ST P stated was not aware R10 had dentures available. ST P confirmed the rehabilitation facility's speech assessment of R10 with use of dentures and R10 should continue speech therapy sessions at facility trying to eat with dentures. ST P was aware R10 refused pureed diets, chose to eat in room, and had a weight loss of 10% since R10's admission on [DATE]. ST P confirmed speech therapy sessions with use of dentures may assist in R10's compliance with therapeutic diets and/or lessen chances of continued weight loss. Example 3 Findings include: Facility policy titled, Physician Orders, last revised January 2026, includes a purpose of: To ensure Physician orders are implemented timely and accurately and a procedure that includes: The licensed nurse receiving the order and the second licensed nurse verifying the order must ensure it is complete and that it includes.other information as may be necessary to carry out the order accurately and completely. On 05/19/26 at 6:45 AM, Surveyor reviewed R15's medical record. R15 was readmitted to the facility on [DATE] after surgical procedure. On 05/19/26 at 7:00 AM, Surveyor reviewed the hospital discharge summary from 05/12/26 which indicated R15 had a laceration to the 5th toe on the left foot with a treatment to be completed by nursing. The summary also indicated R15 was to have a follow up appointment with podiatry in relation to fractures of the 4th and 5th left toes. Upcoming appointments on the After Visit Summary (AVS), dated 05/12/26, only listed scheduled appointments for radiology and orthopedic surgery related to the left thigh fracture/fixation. On 05/19/26 at 7:10 AM, Surveyor reviewed R15's orders and care plan and noted no treatment orders for or care plan related to the left foot laceration. On 05/19/26 at 7:37 AM, Surveyor reviewed R15's admission skin assessment, dated 05/12/26, and weekly skin assessment dated [DATE] and noted both indicated no skin impairments to the left foot. On05/19/26 at 7:48 AM, Surveyor reviewed provider notes from 05/15/26 which did not mention the left foot laceration. On 05/20/26 at 8:57 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G about R15's left foot. When asked if R15 had any kind of wound or bandage on the left foot, CNA G stated, I'm not sure. R15 had a sock on. On 05/20/26 at 9:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E about R15's left foot and admission orders. LPN E stated LPN E was not sure about a treatment or wound to R15's left foot but knows there is a treatment to the left leg. LPN E told Surveyor LPN E would have to look into it. LPN E stated that admission orders are put in by the house supervisor. On 05/20/26 at 11:33 AM, Surveyor observed R15's left foot. Surveyor was unable to get a close enough look to see the laceration area clearly but did observe a very darkened area to the inner aspect of the 5th left toe. There was no treatment/bandage in place. Bruising was present on the top of the left foot just off the 4th and 5th toes. On 05/20/26 at 12:00 PM, Surveyor reviewed R15's therapy notes which indicated R15 has plateaued, cannot tolerate toe-touch weight bearing, and therapy services would be coming to an end on 06/02/26. On 05/20/26 at 1:13 PM, Surveyor interviewed Director of Nursing (DON) B about admission orders and R15. DON B indicated admission orders are entered by the charge nurse on duty or the floor nurse if after hours or charge nurse is unable. DON B stated the orders are obtained from the hospital AVS and usually the hospital will fax the summary prior to admission. DON B stated that if the discharge summary or an updated AVS indicated a discrepancy or new orders, they will clarify and update. DON B stated the social workers make follow-up appointments. DON B was made aware that R15 had orders for treatment to the left foot as well as a recommendation for follow up appointment with podiatry and neither had been addressed. DON B acknowledged the treatment orders had been omitted and the appointment had not been scheduled.

Based on observation, interview and record review, the facility did not ensure that 1 resident (R) of 18 residents reviewed for residents' rights can exercise their rights without interference, coercion, discrimination, or reprisal from the facility in a sample of 18 residents (R10). The facility did not allow R10 an advanced diet unless R10 ate meals in a common dining area instead of in R10's room per R10's preference resulting in R10 refusing puree consistency meals, which in turn contributed to weight loss. The facility did not provide R10 and R10's family education on risks and benefits of R10 consuming regular texture meals brought in by R10's family which could result in R10 suffering physical harm due to R10 having dysphagia (difficulty swallowing).Findings include: Facility policy, last revised 2/2026, states, Facility staff will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes the maintenance or enhancement.R10 was admitted to the facility on [DATE] and has diagnoses including cerebral infarction (stroke of the brain), dysphagia (difficulty swallowing) and aphasia (difficulty speaking).R10 has a brief interview for mental status score (BIMS) of 9/15, which means moderate cognitive impairment. R10 makes own healthcare decisions. On 05/19/2026 at 6:59 AM, record review on R10 indicated the following: R10 had a significant weight loss of 10.05% since admission on [DATE]. On 04/20/2026, registered dietician (RD) S documented a mini nutrition score of 6.0, which means malnourished. RD S' notes state, Resident is able to get out of bed/chair but does not go out.resident has moderate decrease in food intake. On 04/29/26, nursing documentation stated, Fax sent regarding resident refusing tube feedings. On 04/30/2026, provider aware of weight loss, refusal of tube feedings, and decreased meal intake. On 05/11/2026, resident care conference note states, .[RD S] asked if the resident can be graduated to a different diet. ST stated that resident should be going to the dining room.ST stated that due to safety, resident would need to eat in the cafeteria so that staff can monitor.resident then can eat small, chopped textures and hot have to eat the pureed. Resident didn't like that idea, but family encouraged. Review of certified nursing assistant (CNA) task charting indicated R10 refused meals 51 times in a 30 day look back period. R10 ate less than 50% of meals 17 times. Between 05/18/2026 at 9:59 AM and 05/20/2026 at 1:56 PM, R10 was observed in bed with pureed meals on bedside table untouched. On 05/19/2026 at 7:11 AM, Surveyor asked registered nurse (RN) Q what R10's eating pattern was. RN Q stated R10 often declines tube feedings and meals. RN Q stated R10 can eat. However, Speech Therapist (ST) P encouraged R10 go out to the main dining room to be supervised and then they will advance R10's diet to minced, but for now R10 must be pureed if R10 chooses to stay in room to eat.On 05/19/2026 at 8:47 AM, Surveyor asked R10 the reason for not eating pureed breakfast meal. R10 stated, I don't like the food, look at that. I cannot eat that. It looks terrible. R10 stated she asked for 2 slices of toast with jelly, but it was not provided. R10 showed Surveyor dietary request form on meal tray, and it indicated toast was requested by R10. There was no toast on R10's meal tray. On 05/20/2026 at 11:57 AM, during interview with CNA O about R10's meal preferences, CNA O stated R10 did not like pureed food. CNA O stated R10's family brings in regular food for her such as hamburgers and donuts and R10 eats them. CNA O denied witnessing R10 choking while eating regular foods. On 05/20/2026 at 7:36 AM, Surveyor interviewed ST P about R10's refusal to eat pureed foods. ST P stated a speech therapy evaluation found R10 pockets food on the left side of mouth and R10 does not know it is there. ST P confirmed R10 does not like pureed diet and is able to have advanced diet, but R10 needs supervision during meals because of risk of choking. ST P stated, We don't have the staff to sit in the room with her. ST P acknowledged R10 has the right to eat meals in her room and the facility should have someone there to assist R10. ST P stated, We should be coming up with something so she can eat in her room and have a different diet. ST P denied being aware of R10's family bringing regular food for R10 to eat. ST P stated staff did not make her aware and both R10 and family need to be educated on how to do a finger sweep of pocketed foods in R10's cheek, as well as risks of R10's choking hazard. ST P stated no education was done for R10 and family of risks/benefits of R10 not complying with pureed diet. ST P confirmed no risk/benefit consent was obtained by R10 when choosing to eat regular texture foods in room and/or without staff supervision.

Based on interview and record review, the facility did not ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 3 residents (R) reviewed for foot care (R15).-R15's physician discharge orders from hospital were omitted for treatment to the left foot/toes and a follow-up appointment with podiatry was not made for R15. Findings include:Facility policy titled, Physician Orders, last revised January 2026, includes .Physician orders are obtained to provide clear direction regarding the care of the resident .to ensure physician orders are implemented timely and accurately. On 05/19/26 at 6:45 AM, Surveyor reviewed R15's medical record. R15 was readmitted to the facility on [DATE] after surgical procedure on left thigh requiring a wound vac.On 05/19/26 at 7:00 AM, Surveyor reviewed the hospital discharge summary from 05/12/26, which indicated R15 had a laceration to the 5th toe on the left foot with a treatment to be completed by nursing. The summary also indicated R15 was to have a follow up appointment with podiatry in relation to fractures of the 4th and 5th left toes. Upcoming appointments on the After Visit Summary (AVS), dated 05/12/26, only listed scheduled appointments for radiology and orthopedic surgery related to the left thigh fracture/fixation.R15's orders and care plan noted no treatment orders or care plan related to the left foot laceration. On 05/20/26 at 8:57 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G about R15's left foot. When asked if R15 had any kind of wound or bandage on the left foot, CNA G stated, I'm not sure. R15 had a sock on.On 05/20/26 at 9:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E about R15's left foot and admission orders. LPN E stated LPN E was not sure about a treatment or wound to R15's left foot but knows there is a treatment to the left leg. LPN E told Surveyor LPN E would have to look into it. LPN E stated admission orders are put in by the house supervisor.On 05/20/26 at 11:33 AM, Surveyor observed R15's left foot. Surveyor observed a darkened area to the inner aspect of the 5th left toe. There was no treatment/bandage in place. Bruising was present 4th and 5th toes of the left foot.On 05/20/26 at 1:13 PM, Surveyor interviewed Director of Nursing (DON) B about admission orders and R15. DON B indicated admission orders are entered by the charge nurse on duty or the floor nurse if after hours or if charge nurse is unable. DON B stated the orders are obtained from the hospital AVS and usually the hospital will fax the summary prior to admission. DON B stated if the discharge summary or an updated AVS indicated a discrepancy or new orders, they will clarify and update. DON B stated the social workers make follow-up appointments. DON B was made aware R15 had orders for treatment to the left foot and a recommendation for a follow up appointment with podiatry and neither had been addressed. DON B acknowledged the treatment orders had been omitted and the appointment had not been scheduled. On 05/21/26 at 9:30 AM, Surveyor interviewed Nursing Home Administrator (NHA) A in relation to policy/procedure for podiatry. NHA A stated the facility does not have one due to no direct facility podiatry services.

Based on observation, interview, and record review, the facility did not ensure residents with an indwelling catheter receive the appropriate care and services to prevent urinary tract infections to the extent possible for 3 of 7 residents reviewed for indwelling catheters (R1, R6, R80).-R1 was observed with R1's catheter drainage bag in the wheelchair seat beside R1.-R6 was observed with R6's catheter drainage bag in the wheelchair seat beside R6 with staff present and no intervention.-R80 was observed with R80's catheter drainage bag and privacy bag wrapped around front wheelchair wheel for 24 minutes without intervention by 4 staff, who were present.Findings include:Facility policy titled, Catheter Care, last revised July 2025, includes.It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.Ensure drainage bag is located below the level of the bladder to discourage backflow of urine.Example 1R1 was admitted to the facility on [DATE]. R1 has a Foley catheter in relation to benign prostatic hyperplasia (BPH), obstructive and reflux uropathy, and chronic kidney disease.R1's care plan which includes a focus of the resident has a catheter related to BPH with obstructive uropathy, and interventions including position catheter bag and tubing below the level of the bladder at all times.On 05/19/26 at 7:49 AM, Surveyor observed R1 transfer from a stationary chair to R1's wheelchair. Certified Nursing Assistant (CNA) J assisted. R1's catheter bag was located in the seat of the wheelchair next to R1 on the right side. Surveyor observed CNA J clip the bag to the sheet in the wheelchair and push the catheter bag back a little before walking away. The catheter bag was not covered and was hanging out of the opening of the wheelchair arm rest and rubbing up against the right wheel. Surveyor was unable to interview R1 due to R1's inability to answer questions. Example 2R6 was admitted to the facility on [DATE]. R6 has a suprapubic urinary catheter related to history of urinary tract infections, calculus of kidney, chronic kidney disease, hydronephrosis, neurogenic bladder, and history of sepsis.On 05/19/26 at 3:10 PM, Surveyor reviewed R6's care plan which includes a focus of resident has a suprapubic catheter.with interventions including position catheter bag and tubing below the level of the bladder at all times.On 05/18/26 at 10:21 AM, Surveyor observed R6 with R6's suprapubic catheter bag sitting in the seat of the wheelchair next to R6 on the left side while in the dining room. CNA H was present in the room and spoke with R6. Surveyor observed CNA H did not acknowledge the location of the catheter bag and left the room.On 05/18/26 at 10:31 AM, Surveyor observed CNA H assisting another resident in the dining room. R6 was sitting to the left of CNA H with the catheter bag still sitting in the wheelchair seat. No intervention by CNA H.Surveyor was unable to interview R6 related to R6's inability to answer questions. Surveyor was unable to interview CNA H.Example 3R80 was admitted to the facility on [DATE]. R80 has a Foley catheter related to BPH and obstructive and reflux uropathy.R80's care plan includes a focus of the resident has a catheter relation to BPH with obstructive uropathy with interventions including position catheter bag and tubing below the level of the bladder at all times.On 05/18/26 at 10:07 AM, Surveyor observed R80 with R80's Foley catheter drainage bag and cover bag entangled in the left front wheel of R80's wheelchair. On 05/18/26 at 10:08 AM, Surveyor observed Activity Aide (AA) K, CNA T, CNA H, and Licensed Practical Nurse (LPN) E, all passing by the R80 with no intervention. On 05/20/26 at 1:13 PM, Surveyor interviewed Director of Nursing (DON) B about catheter tubing and drainage bag placement. DON B stated the drainage bags for catheters should be placed below the bladder, so the urine flows down. DON B stated the expectation would be if a nursing staff member noticed one in the wrong location, they should move it to an appropriate location. DON B was made aware of Surveyor's observations of catheter drainage bags in wheelchair seats and DON B agreed this was not standard of practice.On 05/21/26 at 8:38 AM, Surveyor interviewed CNA G and asked where urinary drainage bags should be placed. CNA G stated urinary drainage bags should be hung under the wheelchair in a bag or on the frame of the bed when the resident is in bed. CNA G stated that if CNA G saw a drainage bag in the seat of a wheelchair, CNA G would ask the resident if it was ok to move it to an appropriate place. CNA G stated if CNA G noticed one tangled in the wheel, CNA G would move them to a more private area and fix it.

Based on observation, interview, and record review, the facility did not ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice for 1 of 2 residents (R) reviewed for nephrostomies (R6).-R6's nephrostomy tubes were placed up and over the back of the wheelchair and placed in a pouch above the kidneys.Findings include:Facility policy titled, Nephrostomy and Cystostomy Tube Care and Maintenance, last revised May 2026 includes.Residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice.Keep the drainage bag below the level of the kidneys at all times.On 05/18/26 at 10:21 AM, Surveyor observed R6's nephrostomy tubes placed up and over the back of the wheelchair and placed in a pouch on the back of the chair above kidney level.On 05/19/26 at 3:05 PM, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE]. R6 has bilateral nephrostomy tubes related to history of urinary tract infections, calculus of kidney, chronic kidney disease, hydronephrosis, neurogenic bladder, and history of sepsis.On 05/19/26 at 3:10 PM, Surveyor reviewed R6's care plan which includes a focus of resident has bilateral nephrostomy tubes, with interventions including position catheter bag and tubing below the level of the bladder at all times.On 05/20/26 at 1:13 PM, Surveyor interviewed Director of Nursing (DON) B about nephrostomy tubing and drainage bag placement. DON B stated the drainage bags for nephrostomies should be placed below the kidneys, so the urine flows down. DON B stated the expectation would be if a nursing staff member noticed one in the wrong location, they should move it to an appropriate location. When asked if it is appropriate for nephrostomy tubes to run up and over the back of a wheelchair and into a pouch on the back of the wheelchair, DON B stated no, because it wouldn't drain correctly. DON made aware of Surveyor's observations of the nephrostomy tubes of one resident up and over the back of the wheelchair with the bag tucked in the pouch behind the wheelchair above kidney level, and DON B agreed this was not standard of practice.On 05/21/26 at 8:38 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G about nephrostomy tubing and drainage bags. CNA G reported that nephrostomy tubing should be beside the resident and it would not be appropriate to hang them over the wheelchair back.

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident, including services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 18 residents (R) reviewed for care planning (R15).-R15 has an open surgical wound with a wound vac present, and a laceration to 5th left toe with no care plan related to Enhanced Barrier Precautions (EBP).Findings include:On 05/19/26 at 1:30 PM, Surveyor reviewed R15's medical record. R15 was readmitted to the facility on [DATE] after a surgical procedure to the left hip/thigh. R15 has an open wound with a wound vac in place to the left thigh, and a laceration to the left 5th toe which would warrant the use of enhanced barrier precautions (EBP).On 05/19/26 at 1:35 PM, Surveyor reviewed R15's care plan and noted no implementation of an EBP care plan to prevent infection.On 05/20/26 at 1:04 PM, Surveyor interviewed Infection Preventionist (IP) L about EBP. IP L stated that IP L is the main person that places the signage and Personal Protective Equipment (PPE) bins out when indicated. IP L stated IP L and Director of Nursing (DON) B usually discuss who requires EBP. IP L stated things such as wounds, catheters, feeding tubes, history of MDROs and Nephrostomies would warrant EBP. IP L stated that they get their information from the county health department and that the health department gives them guidelines and websites to look at. Sometimes they go by the CDC guidelines. IP L stated staff is educated on precautions at monthly meetings, at orientation, and there is a packet available at the nurse's station. When asked if a resident with a laceration that needed treatment, and a surgical wound with a wound vac, would require EBP, IP L stated, That's a tricky one. And when asked specifically about R15, IP L stated they should have put R15 on EBP and that it was missed. IP L acknowledged this information should be placed in the care plan.On 05/20/26 at 1:13 PM, Surveyor interviewed DON B about EBP. DON B stated the Interdisciplinary Team (IDT) team discusses daily at morning meeting who should be on precautions and as referrals come in they discuss it ahead of time. DON B stated IP L places the signage and PPE bins, but the floor nurses can after hours. When asked what kind of things might warrant use of EBP, DON B stated catheters, peg tubes, wounds, chronic/open wounds. When asked about R15 with a surgical wound and wound vac, and a laceration requiring treatment, DON B stated, We were just all talking about this, and indicated that yes, R15 should be on EBP. On 05/21/26 at 8:38 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F. LPN F stated R15's wound vac is to be removed on 05/25/26 and that a new order will begin for gauze and paper tape to the surgical site. LPN F stated that if LPN F were the one to remove the wound vac, LPN F would use standard precautions, EBP, and would wear a gown and gloves for sure.

Based on observation, interview and record review, the facility did not ensure the comprehensive care plan was reviewed and revised for one resident (R) of 18 residents reviewed for care plan timing and revisions in a sample of 18 residents (R10). R10's comprehensive care plan did not:- Include interventions for R10's refusal to wear dentures and how that affects R10's nutritional status which could contribute to R10's weight loss.- Include interventions for R10 refusing to eat meals and alternative meal options provided to R10 which could contribute to R10's weight loss. - Include interventions for R10 refusing tube feedings which could be contributing to R10's weight loss.Findings include: Facility policy titled Comprehensive Care Plan, last revised 01/2026, states, The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition.R10 was admitted to the facility on [DATE] and has diagnoses including cerebral infarction (stroke of the brain), dysphagia (difficulty swallowing) and aphasia (difficulty speaking).R10 has a Brief Interview for Mental Status score (BIMS) of 9/15, which means moderate cognitive impairment. R10 makes own healthcare decisions. On 04/16/2026, R10 has physician orders for tube feedings to be given via a gastric tube 2 times a day. Between 05/18/2026 at 10:09 AM and 05/21/2026 at 9:33 AM, Surveyor made several observations of R10 not wearing dentures during or in between meals. Surveyor observed R10 in bed during all meals, at times with untouched pureed meal. An emesis bag was in place next to R10. On 05/18/2026 at 10:09 AM, Surveyor interviewed R10 on how the scheduled tube feedings were being tolerated. R10 stated tube feedings made her nauseous, therefore R10 often refused them. On 05/18/2026 at 1:28 PM, Surveyor interviewed R10 on status of dentures. R10 stated dentures do not have enamel on them anymore due to tube feedings eroding them. R10 informed Surveyor the dentures are in bedside stand. R10 stated she did not like eating a pureed diet. R10 stated R10 did not want to get out of bed to go to dining room to eat. On 05/19/2026 at 7:11 AM, Surveyor interviewed Registered Nurse (RN) Q on status of R10's tube feedings. RN Q stated R10 often declines tube feedings as they make R10 feel nauseous. Surveyor asked what interventions are in place to alleviate R10's nausea and promote compliance with tube feedings, and RN Q stated R10 receives scheduled Ondansetron (antinausea medication) prior to all meals/feedings. RN Q stated the only other intervention in place for promoting oral intake is R10 should go to the main dining area to receive an advanced diet and have close supervision during meals. On 05/20/2026 at 7:36 AM, Surveyor interviewed certified nursing assistant (CNA) O on the status of R10 not wearing dentures. CNA O stated R10 only wears dentures when family is present for the grandchildren. On 05/20/2026 at 8:08 AM, Surveyor asked CNA O about R10 refusing to eat meals. CNA O stated R10 does not like pureed diet and will refuse to eat it. R10's record review indicated R10 had experienced a 10.05% weight loss since admission on [DATE]. On 05/11/2026, a care conference was held with R10 and R10's family addressing concerns surrounding R10's refusal to eat meals in dining room in order to have an advanced diet and promote food intake. R10's record review showed documentation by Registered Dietician (RD) S in which R10 refused most meals and tube feedings. RD S stated R10's weight loss is due to poor intake and tube feeding refusal.resident does not enjoy pureed diet. A mini nutrition assessment done by RD S on 04/20/2026 indicated R10 had moderate decrease in food intake and did not go out of room to eat. R10's comprehensive care plan did not have interventions and/or alternative approaches in place for R10's refusal to wear dentures, eat pureed meals, go to dining room for meals, or tolerate scheduled tube feedings. CNA care plan did address R10 having dentures, but no indication R10 refused to wear them. CNA care plan did not address R10's refusal to eat meals at times. On 05/20/2026 at 9:33 AM, Surveyor interviewed director of nursing (DON) B what staff expectations were for reviewing and revising resident care plans. DON B stated all nurses can revise care plans. DON B stated staff inform nurses of any changes in residents cares/needs and changes should be made immediately with new interventions in place. An interdisciplinary team (IDT) meets weekly and assesses residents' needs and makes changes according to their plan of care. DON B confirmed there were no interventions in place on R10's comprehensive care plan addressing R10's refusal to wear dentures, eat in dining room, eat pureed meals, and remain compliant with scheduled tube feedings.

Based on observation, interview, and record reviews, the facility did not ensure services provided met professional standards for 2 of 4 residents (R) reviewed for medication pass. (R72 and R10).- Registered Nurse (RN) Q did not cue or assist R72 to blow nose prior to administration of nasal inhalant medication.- Licensed Practical Nurse (LPN) M did not properly check for gastrostomy tube placement prior to administering medications to R10. Example 1 Cleveland Clinic article dated February 18, 2026, under the heading, How To Correctly Use Nasal Spray, indicates, . Shake the nasal spray well. Wash your hands. Scrub your hands thoroughly with soap and water. Before applying, gently blow your nose. This will empty your nasal passages and clear the way for the medicine. R72 was admitted on [DATE] with diagnoses of congestion, nasal crusting, and rhinorrhea. On 05/19/2026 at 7:34 AM, Surveyor observed Registered Nurse (RN) Q administer saline nasal 3% to R72. RN Q did not ask R72 to blow nose prior to administration. At 7:33 AM, Surveyor observed RN Q administer Ipratropium Bromide Nasal solution 0.03% to R72. Again, RN Q did not ask R72 to clear nasal passage prior to administering the nasal spray. On 05/19/2026 at 10:33 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation is for staff to cue or assist residents prior to administering nasal sprays. DON B said staff should ask residents to blow nose prior to administering nasal sprays. Example 2 Facility policy titled Verifying Placement of Feeding Tube, last revised 12/2025, states, Verifying tube placement: for gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by.taking note of the marking on the tube.check and record length of the tube prior to feeding. R10 was admitted to the facility on [DATE] and has diagnoses inclduing cerebral infarction (stroke of the brain), dysphagia (difficulty swallowing) and aphasia (difficulty speaking). R10 has physician orders for Jevity tube feedings to be administered via a gastric tube twice daily. R10 has physician orders for Fluticasone Propionate Nasal Suspension: 2 sprays in both nostrils one time a day On 05/19/2026 at 7:13 AM, Surveyor observed licensed practical nurse (LPN) M prep for administration of R10's medications via a gastric (PEG) tube placed in R10's abdomen. Surveyor observed LPN M unclamp R10's PEG tube, inject approximately 30cc of air using a piston tip syringe, and auscultate using a stethoscope over R10's epigastrium for air bubbling. LPN M did not check measurement of PEG placement at insertion site, or aspirate for gastric contents prior to administering R10's medications via the PEG tube. On 05/19/2026 at 7:20 AM, Surveyor observed LPN M administer 2 sprays of Fluticasone nasal suspension in each of R10's nostrils. LPN M did not have R10 blow nose prior to administration of Fluticasone nasal sprays. On 05/21/2026 at 9:33 AM, Surveyor interviewed director of nursing (DON) B about what the expectations were for staff when determining proper PEG tube placement prior to administering medications. DON B stated the practice changed a few years ago to check measurement of PEG tube at insertion site and if needed, aspirating gastric contents. DON B stated nurses should not be using auscultation for gastric air bubbling as only means for checking PEG tube placement.

Based on interview and record review the facility did not ensure that a system is in place to ensure that residents are free of any significant medication error for 6 of 9 residents (R) (R1, R3, R5, R7, R8, and R9) reviewed for medication errors.R1 is cited at a scope and severity level of G (actual harm that is not immediate jeopardy/isolated). R1 was administered R2's medications, which required R1 to receive Narcan and hospitalization. R3 was administered incorrect pain medication.R5 was administered medication that was discontinued and wrong dosage form.Pharmacy found that R7 had the wrong dose in the medical record for R7's Tacrolimus.R8 received a different resident's 40 mg tab of Atorvastatin. R9 received another resident's medications consisting of gabapentin, clonidine, and Vitamin D.This is evidenced by:The facility's policy, titled Medication Administration last revised on 12/2025, states: Resident medications are administered in an accurate, safe, timely and sanitary manner.Under section labeled Procedure states in part the following: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. If the label and medication sheet are different .or any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Never administer medications from an unmarked container.Example 1R1 was admitted to the facility on [DATE] with diagnoses that include orthostatic hypotension (condition is defined as low blood pressure (hypotension) that occurs upon standing) and neurocognitive disorder with Lewy bodies.R1's admission Minimum Data Set (MDS) dated [DATE] indicates R1 had a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating R1 is cognitively intact. R1 has an Activated Power of Attorney for Health Care (APOAHC). On 07/04/25, per facility investigation report, Registered Nurse (RN) F placed med cart between rooms of R1 and R2 and was setting up medications meant for R2. RN F heard a scream down hallway and left medication cart to see what was happening. RN F returned to the cart when R1 asked RN F some questions, and RN F handed R1 medications that were meant for R2. Medications of R2 that R1 received included an Opioid of Oxycontin ER 20 mg and Amlodipine 5mg (can cause serious side effects of low blood pressure).R1's physician was contacted immediately, and orders were received to administer Narcan and send R1 to emergency department (ED).On 07/04/25, R1 was sent to ED for evaluation of medication error and was originally found to be stable and plan was to return back to facility. On 07/05/25, R1's hospital records indicate R1 was being evaluated by therapy department and was found to be markedly orthostatic (sudden drop in blood pressure). Blood pressure was documented to drop 75/34 after standing and when placed back into bed noted to improve to 131/61. The decision was made to transfer R1 to another hospital for admission due to no current hospital beds being available. R1 required intravenous (IV) electrolytes and hydration with plan to discharge back to facility.On 07/06/25, R1 was transferred back to facility with no further concerns.Example 2R3 was admitted to facility on 06/23/25 with a diagnosis of multiple rib fractures.On 06/23/25, R3 was prescribed Oxycodone HCL (an Opioid) 5mg 1 tablet every 6 hours for pain, which was discontinued On 06/26/25, R3's order for Oxycodone was discontinued and physician prescribed Hydrocodone 5-325 mg 1 tablet every 6 hours for pain.On 07/02/25, R3 received the wrong opioid medication that was previously discontinued and not removed from circulation.Example 3R5 was admitted to facility on 03/21/25 with diagnoses that include chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder.On 06/02/25, R5 was placed on hospice care.On 06/02/25, R5 was prescribed Lorazepam (anti-anxiety) oral concentrate (liquid) 0.25 ml every 4 hours as needed for terminal anxiety but was dispensed/administered in pill form.On 06/19/25, R5's Lorazepam medication was discontinued and not removed from circulation which resulted in R5 receiving a dose on 07/06/25.The facility's log for controlled substance initiated on 06/02/25 is labeled with Lorazepam 0.5 mg tablet with documentation indicating that R5 received wrong form of medication on 06/04/25, 06/05/25, 06/06/25, 06/09/25 and 06/10/25.On 07/06/25, the facility's log indicated that R5 received wrong form of medication and was administered after medication was discontinued.Example 4Surveyor reviewed facility's medication errors from July 2025-present and found three medication errors as stated, .-On 11/26/25 upon pharmacy review of [R7's] medications, pharmacy found that [R7] had the wrong dose in the medical record for [R7's] Tacrolimus. It was transcribed as Tacrolimus 5mg give 2 tablets twice a day. [R7's] original physician order was Tacrolimus 0.5 mg give two tablets twice a day. Immediate action: Order was immediately taken out of medical record but [R7] received the wrong dose in the morning time medication administration. Call was placed to the transplant center, update to RN, update the MD, [R7] updated, monitored for overdose, and DON notified as well.-On 12/15/25 Nurse accidentally gave [R8] a different resident's 40 mg tab of atorvastatin. Immediate action: Provider was called, DON notified, [R8] was monitored for muscle aches or pain. Monitoring in place for 3 days every shift. Medication Administration competency was completed for the nurse who gave wrong medication to [R8].-On 01/22/26 Both residents in room have the same initials. Medication cups were set on each of the residents' bedside tables for them to take. [R9] took medications right away without looking at the cup while the other resident looked at her cup realizing that the medications in the cup were not hers. Nurse had administered the other residents' medications of gabapentin, clonidine, and vitamin D. Provider notified, DON notified, 15-minute checks on affected resident until further orders from Provider.On 02/03/26 at 2:26 PM, Surveyor interviewed Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C regarding medication errors. DON B and ADON C were aware of medication errors and conducted education on 07/07/25 to licensed nursing staff on the 5 medication rights as expected.On 02/03/26 at 2:46 PM, Surveyor interviewed DON B who stated the errors should not have occurred and expectation would be to ensure residents are receiving the correct medication and form. On 02/03/26 at 3:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, DON B and Director of Clinical Services D regarding significant medication error that occurred on 07/02/25 wherein licensed nurse who made the error, was educated on Medication 5 Rights and expectation, but all licensed nurses were not educated prior to their next shift, resulting in 2 significant medication errors to occur (07/04/25 and 07/06/25) before all licensed staff were properly educated. NHA A further indicated that a Performance Improvement Project was initiated on 07/07/25 and facility conducted 3 weeks of medication audits that concluded on 07/22/25 and was reviewed monthly with Quality Assurance Process Improvement process until determined facility was in compliance and stated the project was closed out on 11/25/25 with no further medication errors identified.

Based on interview, observation and record review, the facility did not ensure that a system was in place to ensure residents receive medications that are properly labeled and administered accordingly for 2 of 8 residents (R5, R6) reviewed for medication errors. R5 was administered medication that was discontinued and incorrect dosage form. R6 was administered medication without proper labeling.The facility's policy, titled Medication Administration last revised on 12/2025, states: Resident medications are administered in an accurate, safe, timely and sanitary manner.Under section labeled Procedure states in part the following: If the label and medication sheet are different .or any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Never administer medications from an unmarked container.Example 1R5 was admitted to facility on 03/21/25 with diagnoses that include chronic obstructive pulmonary disease, chronic pancreatitis and generalized anxiety disorder.On 06/02/25, R5 was placed on hospice care. On 06/02/25, R5 was prescribed Lorazepam (anti-anxiety) oral concentrate (liquid) 0.25 ml every 4 hours as needed for terminal anxiety but was dispensed/administered in pill form.On 06/19/25, R5's Lorazepam medication was discontinued and not removed from circulation and received a dose on 07/06/25.The facility's log for controlled substance initiated on 06/02/25 is labeled with Lorazepam 0.5 mg tablet with documentation indicating that R5 received wrong medication form on 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25 and a dose without physician order on 07/06/25.Example 2On 02/03/26 at 2:29 PM, Surveyor observed Registered Nurse (RN) E at the medication cart. Surveyor asked RN E to explain process for narcotic administration. RN E reported that RN E checks physician order against the medication bottle or container before administering medications. RN E showed Surveyor the narcotic box on medication cart. Surveyor observed a morphine bottle with no label of a resident identifier or what the correct dose was to be given to whoever the morphine bottle belonged to. Surveyor observed a handwritten #36 on the unlabeled bottle in permanent marker. Surveyor asked RN E if RN E knew whose morphine concentration was in the bottle that had #36 written on the bottle. RN E started searching through narcotic books and found that the bottle belonged to R6. RN E confirmed that R6's morphine oral concentration bottle was not labeled correctly with R6's identifying information such as name, date of birth , when pharmacy dispersed medication to meet residents' rights for proper medication administration. RN E viewed R6's narcotic sheet and stated, This morphine has been administrated 13 times and is not properly labeled. RN E reported to Surveyor that RN E didn't even know R6's name was not on the bottle as it should be. Surveyor asked RN E about medication destruction. RN reported always have two nurses signing off and verifying destruction.On 02/03/26 at 2:26 PM, Surveyor interviewed Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C regarding medication errors of R5 and R6. DON B and ADON C were aware of medication errors and conducted education on 07/07/25 to licensed nursing staff on the 5 medication rights as expected.On 02/03/26 at 2:46 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectation for liquid narcotics, such as morphine, being labeled and properly identifiable for whose medication the liquid bottle of morphine should be in medication cart. DON B reported that all liquid medications, especially liquid morphine, should be labeled correctly with correct resident identifier, date of birth , pharmacy date dispersed and a date when liquid morphine was opened so staff know when it expires. DON B's expectation is that whoever stocked R6's liquid morphine that the label should have been placed on it before administering. DON B reported that if a staff member observes no label on the liquid morphine, the nurse is not supposed to administer the medication but contact DON B and destruct the morphine accordingly with two nurses as verification and reorder a new bottle of liquid morphine from pharmacy for correct administration. DON B further stated the errors should not have occurred and expectation would be to ensure residents are receiving the correct medication and form.

Based on interview and record review, the facility did not ensure a system was in place to establish disposition of destroying controlled drugs for 2 of 6 residents (R) (R2 and R5) reviewed for medication errors.R2's Lyrica was not destroyed in a timely fashion and by 2 licensed nurses.R5's Lorazepam medication was discontinued and not removed from circulation.The facility policy titled, Destruction of Unused Drugs, revised [DATE], states: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations. This includes having a witness to medications being destroyed.Example 1On [DATE] at 1:25 PM, Surveyor reviewed R2's Narcotic sheet that states, .[R2] is to be given Pregabalin (Lyrica) 50 mg capsule by mouth two times a day ordered on [DATE]. Surveyor observed R2's narcotic sheet to have a crossed of X over top the whole sheet with Destroyed RN on [DATE] with one signature at the bottom.On [DATE] at 3:44 PM, Surveyor interviewed DON B about destruction of the Pregabalin (Lyrica) 50 mg capsule by mouth two times a day ordered on [DATE] but was not given to R2. Surveyor asked DON B the time frame on how quickly narcotics or controlled substances should be destructed and the process for destruction. DON B reported to Surveyor that all controlled substances should be discarded right away once it is known that residents will not be using the controlled substance or by provider's orders to discontinue. DON B reported that R2's order for the Pregabalin (Lyrica) 50 mg capsule by mouth two times a day ordered on [DATE] was discontinued and changed to Pregabalin (Lyrica) 75 mg capsule by mouth two times a day and should have been destroyed right away and was not. DON B reported there should have been 2 licensed staff destroying the controlled substance, but DON B only sees that one licensed nurse destroyed R2's Pregabalin (Lyrica).Example 2On [DATE], R5 was prescribed Lorazepam (anti-anxiety) oral concentrate (liquid) 0.25 ml every 4 hours as needed for terminal anxiety.The facility's log for controlled substance initiated on [DATE] is labeled with Lorazepam 0.5 mg tablet with documentation indicating that R5 received medication after being discontinued on [DATE]. On [DATE] at 2:26 PM, Surveyor interviewed Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C regarding medication errors. DON B and ADON C indicated they were aware of medication errors and conducted education on [DATE] to licensed nursing staff on the 5 medication rights as expected and destruction of medications.On [DATE] at 2:29 PM, Surveyor observed Registered Nurse (RN) E at the medication cart. Surveyor asked RN E to explain process for controlled substance destruction. RN E reported that RN E destroys controlled substance with the drug buster located in the medication storage room and that RN E always has two nurses signing off and verifying the destruction correctly.

Based on record review and interviews, the facility failed to conduct a thorough investigation and implement corrective action in a timely manner for 1 of 8 residents (R) R3, resulting in 2 additional significant errors to occur for R1 and R5.R3 was administered incorrect opioid pain medication on 07/02/25.R1 was administered medications for R2, which required receiving Narcan and hospitalization on 07/04/25.R5 was administered medication that was discontinued and wrong dosage form on 07/06/25.The facility's policy, titled Medication Administration last revised on 12/2025, states: Resident medications are administered in an accurate, safe, timely and sanitary manner.Under section labeled Procedure states in part the following: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. If the label and medication sheet are different .or any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.Example 1R3 was admitted to facility on 06/23/25 with diagnoses that include multiple rib fractures.On 06/23/25, R3 was prescribed Oxycodone HCL (an Opioid) 5mg 1 tablet every 6 hours for pain which was discontinued On 06/26/25, R3's order for Oxycodone was discontinued and physician prescribed Hydrocodone 5-325 mg 1 tablet every 6 hours for pain.On 07/02/25, R3 received the wrong opioid medication that was previously discontinued and not removed from circulation.Example 2R1 was admitted to the facility on [DATE], with diagnoses that include orthostatic hypotension (condition is defined as low blood pressure (hypotension) that occurs upon standing) and neurocognitive disorder with Lewy bodies.R1's admission Minimum Data Set (MDS) dated [DATE], indicates R1 had a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating R1 is cognitively intact. R1 has an Activated Power of Attorney for Health Care (APOAHC). On 07/04/25, a licensed nurse administered medications to R1 meant for R2. Medications received included an opioid of Oxycontin ER 20 mg and Amlodipine 5mg (can cause serious side effects of low blood pressure).R1's physician was contacted immediately, and orders were received to administer Narcan and send R1 to emergency department (ED).On 07/04/25, R1 was taken to ED for observation of medication error and was evaluated by physical therapy and was found to be markedly orthostatic (sudden drop in blood pressure) and was administered IV electrolytes and hydration with plan to discharge back to facility.On 07/05/25, R1's hospital records indicate R1's blood pressure was noted to start trending low and decision was made to transfer to another hospital for admission.Example 3R5 was admitted to facility on 03/21/25, with diagnoses that include chronic obstructive pulmonary disease, chronic pancreatitis and generalized anxiety disorder.On 06/02/25, R5 was placed on hospice care. R5's Significant Change MDS dated [DATE] indicated R5 had a BIMS of 15/15, which indicates intact cognition.On 06/02/25, R5 was prescribed Lorazepam (anti-anxiety) oral concentrate (liquid) 0.25 ml every 4 hours as needed for terminal anxiety.On 06/19/25, R5's Lorazepam medication was discontinued and not removed from circulation. The facility's log for controlled substance initiated on 06/02/25 is labeled with Lorazepam 0.5 mg tablet with documentation indicating that R5 received wrong medication form on 06/04/25, 06/05/25, 06/06/25, 06/09/25 and 06/10/25.On 07/06/25, the facility's log indicated that R5 received wrong medication form and administered after medication was discontinued.On 02/03/26 at 2:26 PM, Surveyor interviewed Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C regarding medication errors. DON B and ADON C were aware of medication errors and conducted education on 07/07/25 to licensed nursing staff on the 5 medication rights as expected.On 02/03/26 at 2:46 PM, Surveyor interviewed DON B who stated the errors should not have occurred and expectation would be to ensure residents are receiving the correct medication and form. DON B further stated that it was a holiday weekend and nurse management were working on the floor and conducting education to all licensed staff on 07/07/25.On 02/03/26 at 3:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, DON B and Director of Clinical Services D regarding significant medication error that occurred on 07/02/25 wherein licensed nurse who made the error was educated on Medication 5 Rights and expectation, but all licensed nurses were not educated prior to their next shift, resulting in 2 significant medication errors to occur (07/04/25 and 07/06/25) before all licensed staff were properly educated.

Based on interview and record review, the facility did not report an incident of potential neglect to the state agency immediately upon learning of an incident wherein resident (R) received the wrong medication which required administration of Narcan and hospitalization, nor did the facility submit the 5-day investigation within 5 days as required. The facility practice had the potential to affect 1 of 8 residents (R1). The facility policy titled Abuse prevention program facility procedures training program and staff materials undated, states under Option 5: Possible Neglect: Means the failure to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress or could be reasonably expected to cause, pain, injury or deathR1 was admitted to the facility on [DATE], with diagnoses that include orthostatic hypotension (condition, which is defined as low blood pressure (hypotension) that occurs upon standing) and neurocognitive disorder with Lewy bodies.R1's admission Minimum Data Set (MDS) dated [DATE] indicates R1 had a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating R1 is cognitively intact. R1 has an Activated Power of Attorney for Health Care (APOAHC ). On 07/04/25, a licensed nurse administered medications to R1 meant for R3. Medications received included an Opioid of Oxycontin ER 20 mg and Amlodipine 5mg (can cause serious side effects of low blood pressure).R1's physician was contacted immediately, and orders were received to administer Narcan and send R1 to emergency department (ED).On 07/04/25, R1 was taken to ED for observation of medication error and was evaluated by physical therapy and was found to be markedly orthostatic (sudden drop in blood pressure) and was administered intravenous (IV) electrolytes and hydration with plan to discharge back to facility.On 07/05/25, R1's hospital records indicate R1's blood pressure was noted to start trending low and decision was made to transfer to another hospital for admission.On 07/06/25, R1 was transferred back to the facility with no further concerns.On 02/03/26 at 12:39 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B regarding if incident of R1 receiving wrong medications was reported to State Survey Agency. Per DON B, who stated it was not reported due to it being the licensed nurse's first medication error, information was relayed to corporate office, and an internal investigation and education was provided. When Surveyor asked if Narcan and hospitalization would qualify for being reported, DON B stated there were no noted signs or symptom effects of receiving wrong medication.

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they have excessively low weekend staffing. This has the potential to affect all 71 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: 1 October 1 - December 31, (quarter 1) 2 January 1 - March 31, (quarter 2) 3 April 1 - June 30, (quarter 3) 4 July 1 - September 30 (quarter 4) . PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal year Quarter 3 2024 (April 1- June 30). Quarter 4 2024 (July 1-September 30), and Quarter 1 2025 (October 1-December 31) all indicate the following: Submitted Weekend Staffing data is excessively low. On 03/18/25 at 1:05 PM, Surveyor interviewed Director of Nursing (DON) B. When asked if the facility staffs any differently on the weekend than during the week, responded No not floor staff. DON B stated, If they are short staffed, due to call in's, management staff or others come in on the weekend. On 03/18/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor asked why the facility triggers for low weekend staffing. NHA A stated they cannot figure out why they trigger for the low weekend staffing, as they schedule the same on the weekends as they do during the week. NHA A stated that they don't have a difference in call in's on the weekends as the facility has a policy in place, that if you call in on your weekend to work, you are then required to work the very next weekend. Human Resources (HR) D joined the interview, and added that she doesn't notice any difference in call in's on the weekends vs week days. HR D confirmed the number of direct care staff scheduled does not change on the weekends versus during the week. HR D enters hours worked into the system, and makes sure they accurately reflect real time data, but does not do PBJ reporting. PBJ data is entered by Corporate HR E who prints out reports from the system and enters the data into the PBJ system. On 03/18/25 at 4:30 PM, Surveyor requested PBJ data reports for the weekend hours entered for Quarter 1 2025, the corresponding schedules and staff postings. On 03/19/25 at 8:50 AM, Surveyor interviewed NHA A who provided the above requested data and informed the Surveyor upon reviewing the data it was discovered that when Corporate HR E pulled data to enter it into the PBJ system, not all hours worked were included, and therefore were not reported accurately. NHA A stated if a staff person had left employment with the facility prior to the data being pulled, that person's name and corresponding hours worked were deleted from the report which resulted in under reporting errors which triggered low weekend staffing to be triggered. Surveyor reviewed the reported data and corresponding information on 03/19/25. Review of the information revealed that multiple staff hours worked went unreported into the PBJ system which triggered low weekend staffing.

Example 4 R32 was admitted to the facility on [DATE]. R32's current diagnoses include in part, sepsis, acute pyelonephritis, anxiety, muscle wasting and atrophy, weakness, chronic obstructive pulmonary disease, type 2 diabetes mellitus, major depressive disorder, and chronic pain syndrome. Review of the MDS dated [DATE] a quarterly assessment documented R32's brief interview of mental status score of 14/15, meaning R32 is cognitively intact. The mood assessment was completed with a score of 0, meaning R32 has non to minimal depression. Review of physician orders documented on [DATE] Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, recurrent. On [DATE] an order for Bupropion HCl ER (XL) Oral Tablet Extended Release 24 Hour 300 MG (Bupropion HCl) Give 1 tablet by mouth one time a day for anxiousness associated with depression. Surveyor's review of R32's physician orders history identified the orders for sertraline and bupropion with the same dosage were the same orders since admission on [DATE]. Review of R32's care plans documented, in part, The resident has depression r/t prolonged grief disorder, Major Depressive Disorder, Date Initiated: [DATE] The resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Discuss with the resident/family/caregivers any concerns, fears, issues regarding health or other subjects. Encourage expression of feelings Monitor/document/report every shift any s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Pharmacy review monthly or per protocol. Provide the resident with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity as tolerated. The resident uses antidepressant medication (Wellbutrin and Sertraline) r/t Depression, Grief. Date Initiated: [DATE] Administer ANTIDEPRESSANT medications as ordered by physician. Monitor side effects and effectiveness Q-SHIFT. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant medications ordered. Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, The care plans do not address resident specific non-pharmacological interventions for depressive episodes. Review of behavior monitoring identified none documented in the last 30 days. Review of nursing progress notes: [DATE] at 11:25 PM, .Crying when nurse approached her . Talked with nurse about being upset that her friends have passed away. Talked with her and consoled her until she felt better. [DATE] at 12:57 PM, Resident refused to have weight obtained this shift. Became upset with staff and got tearful stating she has too much going on right now and her friend just died . [DATE] at 9:30 PM, Writer went in resident room to do her wound care and she started crying. Writer asked what was going on and resident stated that she feels sad after [resident] who was her friend passed away couple hours ago. Writer asked if there is anything that we can do for her at this time and she stated not at this moment but well (sic) let us know. Review of the IDT weekly summary document that was completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The weekly summaries documented R32 as having no behaviors and no changes to behavior patterns. Review of R32's medical record did not identify a pharmacist request for a gradual dose reduction (GDR) of the sertraline or bupropion anti-depressant medication. On [DATE] at 8:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J about R32's behaviors. CNA J indicated R32 sometimes she gets depressed just like anyone and R32's mood will cycle. Surveyor asked if CNA J documents R32's behaviors. CNA J indicated will report to the nurse. On [DATE] at 2:00 PM, Surveyor interviewed DON B about behavior monitoring and assessing the number of behaviors, what non-pharmacological interventions were used, and the outcome. DON B indicated the facility does Unity rounds and talk with resident about concerns and personal conversation. They do at risk reviews and go over behaviors. Surveyor reviewed with DON B about R32's care plans having no resident specific non-pharmacological interventions. On [DATE] at 12:09 PM, Surveyor interviewed DON B about a GDR being completed and the behavior monitoring indicating R32 is having no behaviors. DON B indicated the GDRs were missed since R32 was admitted to the hospital and the date of the orders were changed when she returned to the facility on [DATE]. The medication did not trigger for a GDR. We are going to look at her GDR next month. DON B indicated the GDR should have been done sooner. Surveyor asked if the pharmacist requested a GDR prior. DON B indicated the pharmacist also missed requesting a GDR. Based on interview and record review, the facility did not ensure residents (R) who were prescribed psychotropic medication were comprehensively assessed for qualitative and quantitative data for individualized targeted behaviors, no gradual dose reductions (GDR) for the first year were completed, and non-pharmacological interventions were implemented, for use of the medications for 5 of 7 residents (R6, R21, R32, R53 and R261) reviewed. R6 receives psychotropic medications. R6 does not have a care plan identifying individualized targeted behaviors, tracking of behaviors, or non-pharmacological interventions in place for anti-psychotic and anti-anxiety medications use. R21 receives psychotropic medications. R21 does not have a care plan for individualized targeted behaviors, tracking of behaviors, or non-pharmacological interventions in place for anti-psychotic medication use. R53 receives psychotropic medications. R53 does not have a care plan for individualized targeted behaviors, tracking of behaviors, or non-pharmacological interventions in place for anti-psychotic, anti-anxiety and anti-depressant medication use. R32 is taking two anti-depressant medication of sertraline and bupropion without adequate indications for continued use. R261 is using a psychotropic medication with no stop date after 14 days of use, or physician rationale to continue beyond the 14 days. Findings: The facility policy, titled Psychotropic Management, revised [DATE], states: The psychotropic medication therapy only when clinically indicated to enhance the quality of life, while maximizing functional potential and well-being of the resident. Psychotropic Medications are not administered unless they are necessary to treat a specific condition as diagnosed and documented in the resident medical record. Gradual dose reductions of psychotropic medications and behavioral or non-pharmacological interventions are attempted, unless clinically contraindicated, in an effort to discontinue the medications, if appropriate. Under the policy section titled Practice Guidelines states in part: Upon receipt of new orders for psychotropic medication. The licensed nurse will implement the following: a. Physician order for the medication, including the appropriate diagnosis or targeted behavior. Licensed nurse will institute the appropriate behavior monitoring form associated with the medication category a. Identify and document objective and quantifiable specific behaviors. b. Document the number of episodes of behaviors. c. Document interventions and outcomes. The Interdisciplinary Team (IDT) documentation on the Psychoactive Medication Evaluation and care plan includes. a. Ruling out medical causes (e.g., pain, constipation, fever. b. Ruling out of environmental causes (e.g., noise, heat, crowding); c. addressing the documented behaviors; and d. Monitoring and evaluating for potential reduction of psychotropic medications on an ongoing basis. Example 1 R6 was admitted to the facility on [DATE]. R6's diagnoses include frontotemporal neurocognitive disorder, dementia in other diseases classified elsewhere severe with agitation, memory deficit; dementia in other diseases classified elsewhere severe, with psychotic disturbance. R6's Significant Change in Condition Minimum Data Set (MDS) assessment, dated [DATE], indicated that R6 has both short term and long-term memory problems with cognitive skills severely impaired-never/rarely made decisions. R6's MDS Section E: Behavior indicated R6 did not have any psychosis behavior or behavioral symptoms exhibited present. R6 has a physician order documented on [DATE] for Lorazepam Oral Tablet 0.5 mg. Give 0.5 tablet by mouth one time a day for anxiety. R6 has a physician order most recently documented on [DATE] for Olanzapine Oral Tablet 5.0 mg. give 1 tablet by mouth one time a day related to Other Frontotemporal Neurocognitive Disorder. Surveyor reviewed R6's At Risk IDT Weekly Summary assessment dated [DATE] indicated under the section titled Baseline behaviors: Check all that apply indicated R6 has verbal output specified as yelling/screaming and changes in behavior pattern documented at No. Surveyor reviewed R6's care plan and Certified Nursing Assistant (CNA) Kardex for Antianxiety medication use with Target date of [DATE], which did not identify individualized targeted behaviors or include non-pharmacological interventions related to anxiety. Surveyor reviewed R6's care plan and CNA Kardex for Antipsychotic medication use which was initiated on [DATE], revised on [DATE] and resolved on [DATE] related to dementia with psychotic disorder and agitation, insomnia. R6 did not have a care plan reinitiated related to current antipsychotic medication regimen identifying individualized targeted behaviors or include non-pharmacological interventions related to agitation and insomnia. Surveyor reviewed R6's care plan and CNA Kardex for Antianxiety medication use Surveyor reviewed R6's medical record for behavior monitoring. No documentation of individualized targeted behaviors was noted. Surveyor was unable to identify that an assessment or monitoring was completed to determine R6's behavior patterns and the effectiveness of non-pharmacological interventions. Example 2 R21 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, traumatic hemorrhage of right cerebrum, unspecified dementia with agitation. R21 had a quarterly MDS completed with a target date of [DATE], which indicated that R21 has a BIMS score of 06 indicating moderately impaired. Under MDS E: Behavior indicated R21 has Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Had Behavioral Symptoms of Physical symptoms of 1-3 days; Verbal behavioral symptoms of 1-3 days; other behavioral symptoms not directed toward others not exhibited. R21 has a physician order dated [DATE] for an antipsychotic, Quetiapine Fumarate Oral Tablet 25 MG. Give 1 tablet by mouth two times a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH AGITATION. Surveyor reviewed R21's At Risk IDT Weekly Summary assessment dated [DATE] which indicated under the section titled Baseline behaviors: Check all that apply indicated R21 has anger outbursts, demonstrates obsessive/repetitive behaviors, noncompliant with cares, resistance to cares, hitting, wandering, abusive language and threatening behavior and noted an increase in these behavior patterns. Surveyor reviewed R21's care plan and CNA Kardex for Antipsychotic and Antianxiety medication use related to dementia with psychotic disorder and agitation, insomnia. R21 did not have a care plan related to current antipsychotic and Antianxiety medication regimen identifying individualized targeted behaviors or include non-pharmacological interventions related to agitation and insomnia in CNA Kardex. Surveyor reviewed R21's medical record for behavior monitoring. No documentation of individualized targeted behaviors was noted. Surveyor was unable to identify that an assessment or monitoring was completed to determine R21's behavior patterns and the effectiveness of non-pharmacological interventions. Example 3 R53 was admitted to the facility on [DATE]. R53's diagnoses include unspecified dementia, moderate, with agitation and unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R53's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated a BIMS of 07 indicating moderately impaired cognition. Under MDS Section E: Behavior, indicated R53 had no psychosis and had behavioral symptoms of physical symptoms of 1-3 days; verbal behavioral symptoms daily; other behavioral symptoms not directed toward others 1 to 3 days. R53 has a physician order for an antipsychotic dated [DATE]: Olanzapine Oral Tablet 2.5 MG. Give 2.5 mg by mouth two times a day for dementia with agitation related to dementia in other diseases classified elsewhere, mild, with anxiety. R53 has a physician order for an antianxiety dated [DATE]: Clonazepam Oral Tablet 0.5 MG. Give 0.5 mg by mouth two times a day for anxiety disorder. R53 has a physician order for an antidepressant dated [DATE]: Fluoxetine HCl Oral Tablet 20 MG. Give 40 mg by mouth one time a day for depression Surveyor reviewed R53's At Risk IDT Weekly Summary assessment dated [DATE] indicated under the section titled Baseline behaviors: Check all that apply indicated R53 has verbal output, demonstrates obsessive/repetitive behaviors, threatening behavior, abusive language, kicking and hitting. Surveyor reviewed R53's care plan and CNA Kardex for antianxiety medication use with which was initiated on [DATE] and target date of [DATE], which did not identify individualized targeted behaviors related to medication regimen. Surveyor reviewed R53's care plans and CNA Kardex for antipsychotic medication use which was initiated on [DATE] and with a target date of [DATE]. R53 did not have individualized targeted behaviors related to medication regimen. Surveyor reviewed R53's care plans and CNA Kardex for antidepressant medication use which was initiated on [DATE] and with a target date of [DATE]. R53 did not have individualized targeted behaviors related to medication regimen. Surveyor reviewed R53's medical record for behavior monitoring. No documentation of individualized targeted behaviors was noted. Surveyor was unable to identify that an assessment or monitoring was completed to determine R53's behavior patterns. On [DATE] at 9:50 AM, Surveyor interviewed CNA H, regarding dementia care and documentation of behaviors. CNA H stated CNAs do not do target behavior documentation but are able to put in alerts for behaviors a resident may have for the nurse to follow up on as needed. On [DATE] at 1:44 PM, Surveyor interviewed Director of Nursing (DON) B regarding behavior monitoring and focus on targeted behaviors and non-pharmacological interventions. DON B stated that the IDT meet weekly to discuss behaviors, nutrition, infections, etc. DON B stated that staff do not document individualized targeted behaviors, but have a blanket behavior record that CNAs are able to document for all residents as applicable. (Of note, the record is able to be completed for all residents and includes 16 behaviors.) Surveyor interviewed DON B about how facility determines effectiveness or potential need for GDR of medication regimen or behavioral changes on medication and which behavior they are focusing on. DON B was unable to provide documentation to support that the facility comprehensively assessed for qualitative and quantitative data for individualized targeted behaviors, non-pharmacological interventions or potential need for a GDR. Example 5 R261 was admitted to the facility on [DATE] with pertinent diagnoses of major depressive disorder and generalized anxiety disorder. Review of R261's medication orders on [DATE] documented, Clonazepam oral tablet 0.5mg (Clonazepam) Give 0.25mg by mouth every 12 hours as needed for anxiety no stop date per PCP. Review of the Medication Administration Record (MAR) documented R261 received the PRN clonazepam on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], nursing communication with provider requested a stop date for ordered clonazepam. Physician response documented, No stop date. Seen on rounds. On [DATE] at 10:30 AM, Surveyor interviewed Director of Nursing (DON) B regarding the absence of a stop date for R261's PRN lorazepam. DON B provided a copy of R261's hospital discharge summary and MAR and stated that was the only information she had. No further information was given to Surveyor for an end date of use of the PRN clonazepam.

Based on observation, interview and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards, to prevent pressure injuries (PI) from developing infection and promote healing for 1 of 1 resident (R) R20, reviewed for PIs. R20 was not provided PI treatment as ordered, and staff did not perform hand hygiene during PI treatment to prevent infection. This is evidenced by: R20 was admitted to the facility on [DATE]. R20's current diagnoses include in part, sepsis, surgical aftercare, muscle weakness, end stage renal disease, dependence on renal dialysis, diabetic mellitus type 2, peripheral vascular, infection of skin and subcutaneous tissue, acquired absence of right leg below knee, and venous insufficiency chronic peripheral. Minimum Data Set (MDS), dated [DATE], a 5 day assessment documented R20 having a brief interview of mental status score of 13/15 meaning R20 is cognitively intact. R20 is dependent on staff for toileting hygiene, lower body dressing and transfers. R20 requires maximum assistance of staff for upper body dressing, personal hygiene, and bed mobility. R20 is at risk for pressure injury. R20 was admitted to the facility with one stage 1 PI, one stage 3 PI, three unstageable PI and diabetic foot ulcers. Physician orders are as followed. On 03/04/25: Apply thick layer of zinc oxide to bilateral gluteal folds and right buttock BID and PRN for protection/prevention. two times a day for wound care and as needed. On 03/04/25: Left Buttock - Cleanse w/NS, pat dry, skin prep to peri wound, apply Santyl and Ca Alginate (plain) to wound bed, cover with bordered foam dressing. Daily and PRN. one time a day for wound care AND as needed for wound care. On 03/04/25: Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Left Buttock topically one time a day for wound care apply to slough on wound bed. AND Apply to Left buttock topically as needed for wound care apply to slough on wound bed. On 03/18/25 at 8:53 AM, Surveyor observed Registered Nurse (RN) F complete R20's PI care. RN F entered R20's room without sanitizing hands and applied gloves. R20 rolled to right side. RN F applied wound wash to gauze and washed buttocks and wound. The buttocks were covered with zinc and the wound bed appeared to be covered with slough. RN F did not remove gloves and did not perform hand hygiene before treatment. RN F, with the same contaminated gloved hands, picked up the calcium alginate and placed into the wound and applied an ABD pad. RN F removed gloves and did not perform hand hygiene and proceeded to provide care. RN exited room and sanitized hands. RN F did not complete dressing change as ordered by the physician, to apply skin prep to the peri wound and apply Santyl ointment 250 units/GM to the wound bed prior to applying calcium alginate. On 03/18/25 at 10:45 AM, Surveyor interviewed Assistant Director of Nursing (ADON) G about infection control practices with wound care. Surveyor reviewed observation of RN F completing R20's wound care and hand hygiene practices. ADON G indicated hand hygiene should have been completed and orders followed. ADON G indicated wound care audits will be completed, and education will be provided.

Based on observation, interview and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 18 residents (R) (R34) reviewed. R34's call light was observed to be out of reach. This is evidenced by: Facility policy titled, Fall Management, with a revised date of October 2024, states in part: The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive device, and/or functional programs, as appropriate, to minimize the risk for falls. R34 was admitted to the facility on [DATE] with pertinent diagnoses of monoplegia of upper limb affecting left non-dominant side (paralysis/weakness of one limb) and chronic obstructive pulmonary disorder (COPD). R34's most recent Minimum Data Set (MDS) quarterly assessment completed on 01/18/25 noted a Brief Interview of Mental Status (BIMS) score of 15/15, indicated cognition intact. R34 required partial to moderate assistance with rolling side to side, sit to stand, and chair to bed transfers. R34's care plan with a revised date of 03/29/24 noted the resident is at risk for falls related to activity intolerance and history of falls with interventions to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 03/17/25 at 8:24 AM, Surveyor entered R34's room after hearing R34 yell for help and observed R34 sitting in wheelchair with her bed to her left. R34's call light was wrapped around the far-left bedside rail closest to the wall and out of reach of R34. On 03/17/25 at 8:46 AM, Surveyor interviewed R34 regarding accessibility of call light. R34 stated having to yell out for help to get assistance for roommate who had just fallen in the bathroom. R34 stated she could not reach her call light to get assistance. R34 stated that staff frequently forget to place call light in reach after transferring her from bed to wheelchair. On 03/19/25 at 11:26 AM, Surveyor interviewed Director of Nursing (DON) B regarding accessibility of call light. DON B stated that all staff are educated to ensure safety of residents before leaving a resident's room, which includes ensuring call light is within reach. Surveyor informed DON B of observation of R34's call light being wrapped around bedside rail out of R34's reach. DON B stated frustration of this as staff are aware of R34's limitations in mobility. DON B stated recognition that this had the potential to put the resident at risk for harm or injury by not being able to reach the call light for assistance.

Based on interview and record review, the facility did not promptly notify and consult with the resident's physician when there was deterioration in a resident's clinical condition. This occurred for 3 of 20 residents (R) (R22, R50, R48) reviewed for physician notification and consultation. R22 has a history of urinary tract infections [MEDICAL CONDITION] with multidrug resistant organisms. R22 was empirically treated with an antibiotic. When the culture returned on 12/08/19 the facility did not consult with the physician to address the resistance of this antibiotic and change treatment to an effective antibiotic until 12/10/19. R22 was hosptalized on [DATE] with E. coli urinary tract infection [MEDICAL CONDITION]. R50 has a history of [MEDICAL CONDITION] and [MEDICAL CONDITION] Hypertension. R50 exhibited respiratory symptoms 01/25/20 - 01/27/20. The physician was not consulted prior to R50 being sent to the emergency room and treated with two antibiotics and a steroid on 01/27/20. R48's physician was not consulted with, or consulted with timely, according to the physician's orders [REDACTED]. This is evidenced by: On 02/19/20 at 11:00 a.m., Surveyor received the policy that reads in part, Policy and Procedure Change in Condition, revision date 12/19/18: Procedure: 1. The physician .will be notified when there has been a change that is sudden in onset, a change that is a marked difference in usual sign/symptoms and or the signs/symptoms are unrelieved by measures already prescribed. 2. Specific information that requires prompt notification include, but is not limited to: l. A significant change in the resident's physical .condition. 1. R22 was admitted on [DATE] having [DIAGNOSES REDACTED]. R22's Significant Change in Status Minimum Data Set (MDS) documents the staff assessment was completed, documenting R22 has moderate cognitive impairment with poor decision making. Care plan for urinary: The resident has bladder/bowel incontinence and/or requires assistance with toileting Dementia, History of UTI , Impaired Mobility, Physical limitations . The resident's risk for [MEDICAL CONDITION] will be minimized/prevented via prompt recognition and treatment of [REDACTED]. Monitor for s/s of [MEDICAL CONDITION] .Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. toileting-has catheter. Surveyor reviewed the medical record noting a hospital admission 10/24/19. The history and physical documents a [DIAGNOSES REDACTED]. The nurses' notes in part: 12/4/2019 10:08 a.m. COMMUNICATION - with Physician/medical provider Situation: Fax sent to Dr. regarding resident noted to have thick green drainage from penis and in incontinent padding. Temp 97.7/oral. Blood sugars noted to be elevated as well. Awaiting response. Response 12/4/19 from physician .start [MEDICATION NAME] 500 mg po (by mouth) 500 mg bid (twice a day) x 7 days. 12/4/2019 17:00 (5:00 p.m.) Order Note: Note Text: Dr. responded to update from today re: urine - UA/UC. Begin [MEDICATION NAME] ( a Cephalosporin classified medication) 500 mg p/o BID x 7 days. Order noted and processed. Guardian updated. On 02/19/20 at 2:00 p.m., Surveyor interviewed Director of Nursing (DON) B and asked why R22 was started on an antibiotic prior to the culture. DON B indicated R22 had a history of [REDACTED]. DON B indicates education has been done with this physician and provided that information with physician rationale for initiating the antibiotic on 12/5/19. 12/5/2019 15:48 (3:48 p.m.) Order Note: Note Text: New order received from Dr. : Insert Foley, leave indwelling due to chronic incontinence, skin breakdown, and frequent UTI. Order noted and processed. Guardian updated. 12/5/2019 07:58 a.m. Nursing Note: Narrative: Straight cath urine sample obtained for UA/UC. Urine return noted to the [MEDICATION NAME] and yellow/green in color. Sample will be sent to lab. 12/7/2019 01:28 a.m. Nursing Note: Narrative: Fax returned from .PA . D/C foley placement until consult with Urologist on Monday December 9th. Straight cath as needed. Noted and processed. 12/8/2019 15:12 (3:12 p.m.) Nursing Note: Narrative: Writer received phone call from Mayo lab stating that they needed to report a critical value to the nurse. The resident's UA/culture results were noted to have E Coli present >100,000 cfu/ml. Writer thanked them for the update, resident is already receiving abx treatment and is noted to have a urology appointment tomorrow morning. Surveyor reviewed the lab results that were finalized on 12/8/19 that states in part, Escherichia Coli > 100,000 cfu/ml, Cephalosporin Resistant [MEDICATION NAME]. Semi-urgent result. The lab report identifies the [MEDICATION NAME] is a cephalosporin that is not effective for the organism found in the culture. 12/9/2019 14:12 (2:12 p.m.) Nursing Note: Narrative: Resident has been taking [MEDICATION NAME] 500 mg bid since 12/5. Has been afebrile. Taking thickened liquids. Fluids encouraged. 12/9/2019 23:59 (11:59 p.m.) Nursing Note: Narrative: Resident returned from his apt with Dr., cysto, foley placed. New orders: F/U (follow up) 1 month for foley cath change. Urine sent for culture. Noted and processed. The urologist consult information sent does not communicate the lab results that were finalized on 12/8/19. The return consult report makes no changes to the current antibiotic therapy. 12/9/2019 21:39 (9:39 p.m.) Nursing Note: Narrative: Resident noted to be lethargic. Refused supper. Had eaten lunch at PM after return from clinic. Taking thickened fluids and ate pudding. Urine remains bloody with clots noted. 700 output this shift. Remains afebrile. Continuing to monitor. 12/10/2019 13:26 (1:26 p.m.} Nursing Note: Narrative: Resident has had 300 ml dark brown, blood tinged, urine out in foley this shift. Urine flowing freely in tubing. Continues on antibiotic for UTI. Will continue to monitor. 12/10/2019 16:57 (4:57 p.m.) Order Note: Note Text: New orders received from Dr : D/C [MEDICATION NAME]. Begin Bactrim DS 1 tab p/o BID x 10 days for UTI. Orders noted and processed . Surveyor reviewed the Medication Administration Record [REDACTED]. R22 received [MEDICATION NAME] antibiotic from 12/5/19 until 12/10/19. The culture was finalized on 12/8/19 identifying the [MEDICATION NAME] antibiotic was not effective. The medical record does not document consultation with the physician about the lab result. On 12/10/19, the physician faxes a change in the antibiotic to an effective antibiotic Bactrim DS ([MEDICATION NAME]). This antibiotic is identified as effective against the Escherichia coli found in the culture 12/08/19. On 02/20/20 at 7:00 a.m., Surveyor interviewed DON B and asked how the communication of the lab results were given to the physician. DON B indicated the physician works at Marshfield Clinic and all labs are done through Mayo Clinic, meaning the nurses at this facility faxed the results to R22's physician. DON B verified that the physician did not review the results until 12/10/19, then faxed the new order for R22 late in the day. 12/11/2019 12:42 p.m. Nursing Note: Narrative: At 1130, resident c/o SOB. Stated he couldn't catch his breath. SpO2 92% on room air. [MEDICATION NAME] neb tx given. Resident brought to dining room for lunch. Resident began panting. SpO2 99%. Temp 97.6/temporal. Resident stated he wanted his dessert. While at table, resident began panting again. SpO2 at that time noted to be 83%. O2 placed on resident at 2Lpm via nasal cannula. Charge nurse aware and is going to notify MD. 12/11/2019 13:45 (1:45 p.m.) Nursing Note: Narrative: Call to Dr.to update on resident. Verbal order to send resident to ED. Call to guardian to update and she is in agreement with eval at ED. Ambulance paged and at facility at 1245. All appropriate paperwork sent with resident . R22 was admitted to the hospital on [DATE]. The hospital discharge summary includes in part, Discharge Diagnoses: [REDACTED]. coli urinary tract infection [MEDICAL CONDITION]. 2. Aspiration [MEDICAL CONDITION] Patient is started on ertapenem in view of cephalosporin resistant E. Coli. On 02/19/20 at 11:00 a.m., Surveyor interviewed DON B asking if R22's admission [DIAGNOSES REDACTED]. DON B reviewed the discharge summary and acknowledged that was the primary diagnosis. 2. R50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R50 has a Brief Interview Score for Mental Status of 15, meaning he is alert and oriented and able to answer questions accurately. Care plan in part, The resident has [MEDICAL CONDITION]/[MEDICAL CONDITION] r/t Exposure to industrial pollutants, Physiological atrophy. The resident will display optimal breathing patterns daily through review date. The resident will be free of s/sx of respiratory infections through review date. Head of bed elevated to 30-60 degrees when in bed or assist out of bed upright in a chair during episodes of difficulty breathing. Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for s/sx of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis, Somnolence. Monitor/document for anxiety. Offer support, encourage resident to vent frustrations, fears. Reassure. Give PRN medications for anxiety as ordered. Monitor/document/report PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. The resident has potential for altered respiratory status/difficulty breathing r/t obstructive sleep Apnea, chronic [MEDICAL CONDITION], hx of [MEDICAL CONDITION] use. The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date . Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for s/sx of respiratory distress and report to MD PRN: Increased respirations; Decreased Pulse oximetry; Increased heart rate ([MEDICAL CONDITION]; Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. Nurses notes in part, 1/21/2020 11:56 a.m. Weekly Pertinent Note. Note text: Resident had the following consultation visits, Urinary-Continent of urine. Uses urinal. Urine clear yellow. No foul odor noted. Digestive-Bowel sounds present in all 4 quadrants. Continent of bowel. Denies any loose stools or constipation Musculoskeletal-Right BKA. Resident had the following medication changes/labs, Endocrine-No endocrine issues noted Skin problems-No skin issues noted. Resident being monitored for the following, Pain-Resident is able to voice pain/discomfort. Denies any at this time 1/25/2020 13:01(1:01 p.m.) Nursing Note: Narrative: Resident short of breath. Resident is pale in color. Yellow tinged sputum. Spo2, 92 RA. Wheezes heard in upper L airway LL airway diminished. Congestion heard in upper R airway when coughing. R lower airway diminished. Resident complaining of diaphragm and ribs hurting due to coughing. Resident is taking cough drops periodically and states his cough has subsided some. BP 116/81 P.58 T.98.4 oral. Notified charge nurse of residents condition. This nurse asked if he would like to be seen at the hospital and Resident stated he would like to wait to see how he feels tomorrow. Will continue to monitor. 1/25/2020 22:00 (11:00 p.m.) Nursing Note: Narrative: Resident continues to have wheezy respirations. 1/26/2020 15:02 (3:02 p.m.) Nursing Note: Narrative: Resident stayed in bed this shift by choice. States he just doesn't feel good. Poor appetite. Wheezes and congestion noted in upper bilateral lobes. Lower bilateral lobes dim. Spo2, 92%RA. Gave PRN updraft. No improvement noted. R 24. T 98.9 oral. Reported changes to charge nurse. 1/26/2020 15:13 (3:13 p.m.) Nursing Note: Narrative: Resident also complaining of tightness in chest and pain in ribs and upper abdominal area with cough. Yellow sputum noted with cough. Encouraging resident to drink plenty of fluids and deep breathing exercises. Continuing to monitor. 1/26/2020 23:22 (11:22 p.m.) Nursing Note: Narrative: Resident has been in his bed throughout the shift. Ate very little for dinner. Taking fluids and voiding adequately. Remains afibrile. Updraft given at 2000. SP02 91% prior to updraft and 94% after updraft. Resident slept for a short time and awake at 2300 stating that he has SOB and resp. were wheezy. SP02 89% at that time. Updraft repeated and charge nurse notified. Some relief noted after updraft and SP02 92% with pulse rate 89 Resp.22.Lung sounds are wheezy with a tight nonproductive cough. Resident requesting 02 for the night. 02 on at 2L per nasal cannula for comfort. Will continue to monitor. 1/27/2020 06:27 a.m. Nursing Note: Late Entry: Narrative: resident c/o sob, skin is dusky in color, lungs sounds congested bilaterally. resident would like to be seen by provider. phoned on call and received verbal order to send resident via ambulance to ED for evaluate and treat. resident in agreement with plan. 1/27/2020 07:00 a.m. Orders - Administration Note: Note Text: Transport to ER by ambulance for evaluate and treat. one time only for respiratory symptoms for 1 Day Resident complaining of SOB. SPo2 97 on 2L. BP 150/102 P 84 R 28 T 98.4. Wheezes heard in upper bilateral lobes. No sound heard in lower bilateral lobes. Resident states his ribs and diaphragm hurt due to continuous cough. Sputum is yellowish in color. States he feels like he's dying. Requesting to be sent to the hospital via ambulance. Reported to charge nurse. Surveyor reviewed the emergency room admission note. R50 had a chest x-ray that states, [MEDICAL CONDITION] vascular congestion, perihilar opacities, suggesting [MEDICAL CONDITION], bibasilar atelectasis, and increased patchy opacity of the left lung. This could represent developing infection;. Small left pleural effusion . Diagnoses: [REDACTED]. R50 was started on antibiotic Cefidnir and [MEDICATION NAME] (antibiotics). R50 was also started on [MEDICATION NAME] (steroid medication) to help the inflammation in his lungs. R50 returned to the facility from the emergency room at 1:54 a.m. on 01/28/20. 1/28/2020 13:54 (1:54 p.m.) Nursing Note Narrative: Resident returned yesterday via . Mayo with dx of [MEDICAL CONDITION] exacerbation and possible pneumonia with new orders for [MEDICATION NAME] and [MEDICATION NAME] taper. All orders sent to .pharmacy. On 02/19/20 at 8:45 a.m., Surveyor interviewed DON B to ask if the physician had been notified about the change in condition in R50's respiratory status prior to being sent to the emergency roiagnom on [DATE]. DON B indicated it was a weekend so it is possible the physician was not contacted. DON B stated she would look for additional information. Surveyor requested the Change in Condition Policy. On 02/19/20 at 10:15 a.m., Surveyor interviewed Registered Nurse (RN) C who had assessed R50 on 01/26/20. Surveyor asked how they obtain oxygen order. RN C stated it was on the standing orders. Surveyor asked for the standing order protocol. Surveyor asked if the physician had been called. RN C indicated the physician was not called as the resident had declined to go to the emergency roiagnom on [DATE]. Surveyor reviewed the physician orders [REDACTED]. R50 did not have an order for [REDACTED]. R50 had a change in his lung sounds, change in skin color, shortness of breath, change in the color of sputum with diaphragm and rib pain on 01/25/20 that meet the above criteria for a change in condition. Those symptoms continued until the morning of 01/27/20 when R50 was sent out to the emergency room at 7:00 a.m. On 02/19/20 at 11:15 a.m., Surveyor interviewed DON B and asked if any additional information was located for R50. DON B indicated it was a weekend and the physician was not notified. DON B stated R50 had declined to be sent to the hospital at one point, so that is most likely why the physician was not notified. 3. The facility policy entitled Blood Pressure, Blood Sugar, Pulse Parameters, effective date 9/1/99 states in part: A. If reading is out of parameter set by the resident's physician, follow physicians directions on p.o. (physician's orders [REDACTED]. R48 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Review of R48's physician's orders [REDACTED]. Check blood sugar 4 x day. Notify MD if less than 60 or greater than 400. Review of R48's blood sugar readings and corresponding physician's notification information revealed the following times when R48's physician was not notified or not notified timely. On 01/05/20, R48's a.m. blood sugar was 408. No information was located in the medical record or provided by the facility, to indicate physician consultation regarding this high blood sugar occurred. On 1/17/2020 at 7:58 a.m., a nursing note (written by RN C) states in part: Resident's blood sugar reading at 7:00a.m. was 551. Resident symptomatic. Slurring speech, falling asleep quickly. Woke resident up and asked her to drink water. She did sit up and drink 500 ml water. Blood sugar at 8:00a.m. is 500. Numerous candy and sweet snack wrappers noted to be in trash can next to bed. Primary care physician in house this AM for routine rounds. Will discuss readings with MD when he arrives. Interview with RN C on 02/19/20 at 1:18 p.m. revealed R48's physician is usually here for rounds at 9:30a.m., and if for some reason he doesn't come until 10:30 he is running late. On 02/04/20, R48's p.m. blood sugar was 415. No information was located in the medical record, or provided by the facility to indicate physician consultation regarding this high blood sugar occurred. On 02/18/20, R48's p.m. blood sugar was 434. No information was located in the medical record, or provided by the facility, to indicate physician consultation regarding this high blood sugar occurred. Interview with NHA A and DON B on 02/19/20 at 4:30 p.m., Surveyor expressed concerns over R48's blood sugars being outside the parameters the physician established for notification and not being able to locate information that notification had occurred, and requested further information. On 02/20/20 at 9:38 AM, DON B provided some more information, and stated that she did see that some blood sugars were not communicated with the physician when 400 or greater. When asked if other information was available, DON B stated she has no further information regarding notifying the physician in relation to the blood sugars. On 1/17/2020 at 1:24 p.m., an order note indicates R48's physician saw the resident at facility, on routine rounds. Current orders, weights, vitals, and blood sugars were reviewed. The following orders were received: 1. Increase [MEDICATION NAME] to 10 units with each meal. 2. Increase [MEDICATION NAME] to 30 units at night. In an interview with RN C on 02/20/20 at 11:40 a.m. regarding R48's blood sugar taken on 01/17/20, RN C stated she first took the a.m. blood sugar around 7:00 a.m. and it read 551. RN C stated R48 was slurring speech, but sat up and had some water. RN C said sometimes R48 slurs speech when speaking. RN C stated she knew R48's doctor would be in house that morning at about 9:00 a.m. Surveyor asked RN C when she gave R48 her insulin that morning. RN C stated she gave it earlier than after breakfast, because the reading was high. RN C stated she spoke with the physician, when he walked in the door. RN C stated she told him right away and he came down to see R48. When asked when RN C should notify the physician regarding blood sugars readings, RN C responded I'm sure it is if less than 60 or over 400 notify the physician prior to the next Blood Sugar check. When asked where she got the prior to next blood sugar part, RN C stated she thought the facility policy states prior to the next blood sugar check. When asked to review the facility policy, RN C did and then stated she used nursing judgement in deciding to wait for the physician to arrive. RN C stated she knew he (the physician) would be in house that morning and knew that he comes from home straight to the facility, and he would be in house before next blood sugar check. RN C stated she checked the blood sugar twice to verify the reading that morning. When R48 woke, her speech was a little slurry but she always has a slur to her speech. The slur was just a bit more that day. RN C said R48 sat up and drank water, got dressed and then laid down until breakfast. R48 also got herself up and went down to the dining room for breakfast, as she does every day. R48 was still in the dining room when the physician came. The physician said to give her the scheduled dose of insulin. RN C stated she told him that she had already. The physician spoke to R48 a bit then and then saw her again after breakfast. RN C stated again she felt it was ok to wait for the physician to see R48 until he got there because she could rouse R48. R48 sat up drank water, was alert and oriented. RN C stated, When I started to talk to her about all of the candy wrappers in the trash can .she jokingly said, 'I should have had housekeeping in to empty that before you got in here.' RN C stated she has worked with R48 as long as she has been here, and one time R48 had a morning blood sugar of 301. R48 had her morning insulin and then ate breakfast and she felt shaky before lunch, so she had me check her blood sugar and it was 88. Due to this, RN C stated she felt it would be better to have her primary care physician address this in house and not an on call physician who would order some fast acting insulin and then R48 would crash (have another low blood sugar). In an interview with DON B on 02/20/20 at 12:06p.m., Surveyor asked DON B to review the 01/17/20 nurses charting. Surveyor then relayed the details of the interview with RN C, and asked what the facility expected the nurse should have done according to their policies and procedures. DON B states she should have called a physician right away as a blood sugar over 500 is critical, and required immediate action instead of waiting until the primary physician came in. DON B stated she would expect the nurses to contact a physician immediately after a blood sugar is taken if it is out of parameters set by the physician.

Based on observation, interview and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychocosocial well being for 2 of 10 sampled residents who were reviewed for pain control. 1. Resident #12 complained of pain during wound care(s). The facility did not notify the physician that the resident was having pain during wound care, or provide the resident with pain relief interventions during wound care. 2. Resident #6 had sudden and significant pain in the left leg, which occurred from an unknown origin. The facility did not promptly consult with the physician after the pain started, and did not immediately investigate the possible root cause of the pain. Staff did not pre-medicate the resident prior to movement with personal cares and transfers. This is evidenced by: 1. Resident #12's [DIAGNOSES REDACTED]. On 09/21/15 at 7:50 a.m., Surveyor reviewed Resident #12's clinical record. The record indicated the resident was admitted to the facility on [DATE]. The abdominal/groin wound measurements obtained on that day at 10:17 p.m. stated the resident had .numerous wounds superior to the umbilicus and extending around the left lateral aspect of the umbilicus. There were five open areas in this region: 1. 3cm (centimeters) x 5 cm. 2. 3 cm x 5 cm. 3. 1.1 cm x 1.3 cm 4. 4 mm x 1 cm 5. 5 mm (millimeters) x 1 cm The documentation related to the right abdomen/groin read: Large wound noted beneath right abdomen .estimate wound to be 15 x 18 inches. Wound bed dark pink with moderate amount of white slough .unable to obtain measurements due to intolerance Resident cooperative with procedure, however; did not tolerate procedure related to severe pain. The documentation did not show the physician was notified of the resident's complaints of pain or any as needed or scheduled pain medication orders had been obtained. On 08/28/15, the facility documented the wounds in the abdominal folds were painful. There is no evidence the physician was notified the resident was having pain, or the facility obtained orders from the physician for pre-treatment pain medication or as needed pain medication. On 08/29/15, the facility documentation stated, Resident was in severe pain during dressing change. This nurse suggested premedication with pain med. No standing orders were signed and there are no prn (as needed) pain meds (sic) listed. Charge RN was updated and will contact physician regarding the possibility of premedicating resident for future dressing changes. Resident complained of 8-10 pain during the cleansing and drying procedure especially on the right side. The writer had to stop and allow the resident to rest several times during the procedure . The documentation did not show the physician was notified of the resident's complaints of pain or that any as needed or scheduled pain medication orders had been obtained. On 08/31/15, the facility documented, .Skin problems: Resident did experience discomfort throughout treatment. Resident does have a wound care appointment this afternoon. will continue to monitor. A faxed order, written on 08/31/15, stated in part, Resident wishes to take naporsyn ([MEDICATION NAME]) (a nonsteroidal anti-inflamatory) for pain, can we have an order? The physician responded that the resident may take and store her own [MEDICATION NAME]; however, no specific communication with the physician was noted regarding pain during wound cares. Surveyor interviewed Licensed Practical Nurse (LPN) H. LPN H stated that Registered Nurse (RN) I assisted her with performing the wound cares on 08/29/15. LPN H stated the resident was in severe pain during wound care, and that RN I was to notify the physician, since RN I was the charge nurse. LPN H stated she did not delay or stop the wound care to wait for a premedication to assist the resident with pain control. Surveyor interviewed RN I. RN I stated she did not notify the physician that Resident #12 was experiencing pain during wound cares because it was a Sunday. RN I did acknowledge that there were physicians she could have contacted but stated to Surveyor , .I didn't call the doctor (to get orders for pain medication). Surveyor interviewed Resident #12. When asked about pain during wound care, Resident #12 stated, Oh! It hurt so bad during the first few days here! I told that nurse, too. And they knew when they (the staff) were doing it (the wound care). Surveyor asked Resident #12 what actions were taken when the facility was aware that she was having pain during wound care. Resident #12 stated, I don't think they did anything. I had [MEDICATION NAME] in my purse, so I took some of that .I told them after a few days or a week that I was taking the [MEDICATION NAME] that I had in my purse. After that, the pain was not so bad since I began going to the wound clinic and it was healing I don't have pain now. Surveyor interviewed the Director of Nursing (DON). The DON stated the facility staff should have obtained orders for premedication prior to wound care, and the physician should have been notified of the resident's high pain level during wound care. The DON also told Surveyor that the facility uses on call physician services during the weekends and holidays, and staff are expected to contact a physician when a resident is having pain. 2. On 09/16/15 at 2:00 p.m., Surveyor reviewed Resident #6's medical record. The resident is dependent on staff for transfers, ambulation, dressing, bathing, toileting and eating. Resident #6 has short and long term memory deficits, and has severely impaired decision making abilities. The resident currently has an activated Power of Attorney for Healthcare (POAHC). Surveyor reviewed the resident's medications, to which the resident is taking the following, in part: -[MEDICATION NAME] (Tylenol) 325 milligrams (mg), one tablet every six hours, as needed (PRN) for pain, fever. -[MEDICATION NAME] 325 mg, two tablets every six hours, PRN for pain, fever exceeding 102 degrees. -Tylenol PM Extra Strength-[MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]), 500 mg-25 mg, one tablet at bedtime, PRN for [MEDICAL CONDITION]. -Tylenol PM Extra Strength-[MEDICATION NAME][MEDICATION NAME], 500 mg-25 mg, two tablets at bedtime, PRN for [MEDICAL CONDITION]. The resident does not have any scheduled pain medications. Resident #6's comprehensive care plan states the following, in part: 09/02/2015. Problem: Self Care Deficit Related To: Dementia Manifested By: Decreased ADL (Activities of Daily Living) participation . Approach .Nurse Aide--Transferring: Extensive assist, 2 (person) assist. At times becomes more agitated when being touched, monitor position of extremities during transfer for safety .use the green colored, high back chair at the dining room table . 09/02/15. Problem Impaired Verbal Communication Related To: [MEDICAL CONDITION] (unable to produce spoken or written language) Manifested By: Unable to make decisions, unintelligible speech, has difficulty finding words or finishing thoughts . Approach .Nurses .Ask questions which can be answered with yes or no, use gestures, offer limited choices . The resident does not have a care plan identifying the presence of pain, or concerns related to pain management. Resident #6's meal intake documentation, from 09/14/15 to 09/20/15, were reviewed. The documentation identifies the resident ate 100% of all breakfast, lunch and supper meals during these dates. Surveyor reviewed Resident #6's nursing notes, from 06/16/15 to 09/18/15. The resident did not have any acute or significant pain during this time. The resident's most recent fall occurred out of bed on 08/23/15 and there were no injuries. Resident #6's most recent Minimum Data Set (MDS), dated [DATE], indicates the resident displayed signs and symptoms of pain, by non-vocal sounds (crying, moaning), as well as vocally (saying ouch or stop). The MDS indicates these signs of pain occurred one to two days, within the previous five days of 08/26/15. On 09/17/15 at 6:58 a.m., Surveyor observed two Certified Nursing Assistants (CNAs) performing personal morning cares for Resident #6. At this time, Surveyor observed the resident lying on his back in bed. The resident bent his right knee up to his chest, and touched his toes with his hands. The resident did not display any signs or symptoms of pain. During the continued observation, Surveyor observed Resident #6 stand up from the bed, and pivot transfer into the wheelchair with the assistance of the two CNAs. The resident did not display any signs or symptoms of pain during the transfer. At 8:39 a.m., Surveyor observed two CNAs assist the resident with a pivot transfer from a wheelchair to the high back chair at a dining room table. The resident did not display any signs or symptoms of pain during the transfer. On 09/21/15 at 7:49 a.m., Surveyor 4 observed the breakfast meal in the dementia unit dining room. At this time, staff brought Resident #6 to a dining room table in a wheelchair. Staff did not attempt to transfer the resident into the high back dining room chair. Surveyor observed the resident display facial grimacing. Resident #6 was completely dressed in a shirt, pants, and socks. During the continued observation, a CNA sat next to Resident #6, and assisted the resident with eating the breakfast meal. The resident was moaning and continued to display facial grimacing. At approximately 8:05 a.m., Resident #6's buttocks began sliding forward in the wheelchair. The resident continued to slightly moan and display facial grimacing. At approximately 8:06 a.m., two CNAs stood on each side of the resident's wheelchair, reached under the resident's arms, and boosted the resident up and back into the wheelchair. At this time, Resident #6 yelled out and continued to moan and display facial grimacing after he was repositioned in the wheelchair. A CNA continued to assist the resident with breakfast. At approximately 8:15 a.m., Resident #6's buttocks began sliding forward in the wheelchair. At this time, two CNAs stood on each side of the resident's wheelchair, and a third CNA stood behind the chair. All three CNAs boosted the resident up and back into the wheelchair. At this time, Resident #6 yelled out, and continued to moan and display facial grimacing after he was repositioned in the wheelchair. A CNA continued to assist the resident with eating breakfast after the repositioning. At approximately 8:45 a.m., RN H pushed Resident #6 in the wheelchair to a small, open room, adjacent to the dining room. Surveyor observed RN H remove a white-colored tube from a medication cart and approach Resident #6. Surveyor was unable to view the treatment RN H was administering to the resident. At this time, Surveyor heard the resident scream two separate times. At 8:53 a.m., Surveyor heard RN H say to a CNA, I'm going to give him some Tylenol. RN H placed a pill in a small cup, which the resident then swallowed. At 8:55 a.m., Surveyor observed two CNAs, one on each side of the resident's wheelchair, holding up Resident #6's knees, so the resident's feet were not touching the floor. A third CNA pushed the resident's wheelchair, from the dining room to the resident's room. The resident was moaning and displayed facial grimacing. At this time, a hoyer lift (a full body sling used for transfers) was brought into Resident #6's room, along with three CNAs. The resident's room door was then closed. At 8:59 a.m., Surveyor heard Resident #6 screaming, two times, behind the closed door. Surveyor was in the dining room, approximately 20 to 25 feet away from the resident's room. At approximately 9:02 a.m., Resident #6 was lying in bed. It is noted, it takes approximately 30 minutes for Tylenol to be effective against pain. At 9:54 a.m., Surveyor interviewed RN H. RN H stated, this morning, she received a report (from the night shift nurse) regarding Resident #6's pain in the left leg. RN H stated Resident #6 has not had any recent falls, and is not sure why the resident was having significant pain. Surveyor asked what medication was given to Resident #6, before the resident was transferred into bed this morning. RN H stated since the resident seemed to be in a significant amount of pain, the resident was given two tablets of Tylenol, 325 mg. Surveyor asked if Resident #6's physician had been contacted regarding the new onset of left leg pain. RN H replied she will look into calling the resident's physician today, since it was on her list of things to do. At 10:12 a.m., RN H approached Surveyor , and stated Resident #6's physician has not been contacted. RN H explained Resident #6's POAHC was notified on 09/20/15, by RN I, of the resident's acute leg pain. The POAHC instructed RN I to have the resident's physician assess the resident's leg during facility rounds. RN H stated Resident #6's physician is not due to complete facility rounds until 09/29/15, in eight days. RN H further stated she will speak with RN I today, and call the POAHC to discuss how much pain the resident is currently experiencing. Surveyor reviewed Resident #6's nurses' notes, from 09/18/15 to 09/21/15. The notes state the following, in part: -09/20/15 at 11:10 a.m.: PRN Med (medication) given: [MEDICATION NAME] 325MG Tablet (1 tablet/325mg) pain. PAIN LEVEL BEFORE MED: 4. Location: in leg(s) left. -11:45 a.m.: PRN MED RESULT: 11:45 Med effective. -7:05 p.m.: PRN MED GIVEN: (Tylenol PM Extra Strength)[MEDICATION NAME][MEDICATION NAME]-APAP (sleep) 500MG-25MG Tablet (2 tablet) Given for pain in L (left) hip and leg area and also to promote sleep. PAIN LEVEL BEFORE MED: N/A -8:17 p.m.: PRN MED RESULT: 8:13PM Med effective sleeping. Resident appears comfortable while lying still. When L leg lifted, bends or moves, he cries out in pain and when leg is still no complaints. Will continue to monitor. PAIN LEVEL AFTER MED: N/A Unable to stage pain. -10:15 p.m.: .Called by SCU (Special Care Unit or Dementia Unit) nurse to assess resident due to pain with transfers r/t (related to) movement of left leg. Resident does cry out with transfer or if leg is bent. Assessed further while resident was in bed. He is able to put pressure against writers hand with left foot without difficulty. No complaints with palpation of hips or knees. Writer placed call to DPOA-HC .and updated. She states that he has had sciatica (radiating pain from the low back to the hips and legs) difficulty for much of his adult life and would react in this same manner when it would flare up on him. Inquired how she would like us to proceed and if she would like resident to see PCP (Primary Care Physician). (POAHC) states that she would like muscle rub to be placed to area and Tylenol PM to be administered and for resident's symptoms to be treated conservatively. She would like resident to see PCP when he does rounds and to keep her updated as needed. SCU nurse updated regarding (POAHC's) wishes . -09/21/15 at 9:00 a.m.: PRN MED GIVEN: [MEDICATION NAME] 325MG Tablet (2 tablet/650MG) given for exclamations from resident of left leg pain. PAIN LEVEL BEFORE MED .(left blank) .Occasional labored breathing. Short period of hyperventilation .Repeated troubled calling out. Loud moaning or groaning. Crying .Facial grimacing .BODY LANGUAGE: Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out .Unable to console, distract, or reassure .TOTAL PAIN SCORE 9 . -10:58 a.m.: .Resident was in severe pain in his left leg. Resident was crying out in pain when staff tried to move his left leg in any way. Pain was rated 9/10 .Resident kept sliding down in his wheelchair during breakfast. May be d/t (due to) increased pain. This nurse will send a note to therapy department to have him evaluated for possible Broda/Geri-chair. -11:04 a.m.: .Resident received a skin tear on the back of his right hand .He was combative at the breakfast table and hit the table with his hand, causing a 1.5 X (0).6 cm (centimeter) skin tear . -11:13 a.m.: .Resident's .DPOA-HC, was notified of resident's increased pain in left leg. Charge nurse was updated and physician will be faxed concerning increased pain . Resident #6's intake documentation, dated 09/21/15, indicates the resident only ate 25% of the breakfast meal. It is noted, Resident #6 does not have a [DIAGNOSES REDACTED]. There is no history of sciatica in the resident's History and Physical assessment, dated October 2014. Surveyor reviewed the Resident #6's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] -09/20/15 at 11:10 a.m.: Tylenol 325 mg -09/20/15 at 7:04 p.m.: Tylenol PM Extra Strength-[MEDICATION NAME][MEDICATION NAME], 1000 mg-50 mg -09/21/15 at 8:55 a.m.: Tylenol 650 mg Resident #6 was not pre-medicated for pain management, prior to being toileted, dressed and transferred out of bed and into the wheelchair the morning of 09/21/15. On 09/21/15 at 12:40 p.m., Surveyor discussed the above observations with the Director of Nursing (DON), as well as the MDS Coordinator (MDS-C) M. The DON and MDS-C M both confirmed Resident #6's left leg pain is acute, and something new since the weekend. MDS-C M was not sure if a nurse called and consulted with the resident's physician, regarding the acute leg pain. MDS-C M further stated nursing staff usually calls the resident's POAHC first, since this person is very involved in Resident #6's care, and gets upset with the facility if the physician is called first. Surveyor stated this notification process is not identified in Resident #6's care plan. During the continued interview, MDS-C M stated the POAHC believes the resident is having a flare-up of sciatic pain. The DON indicated the resident's POAHC has a wait and see attitude, and gets upset when we jump on it. Surveyor stated the resident does not have a history of, or current [DIAGNOSES REDACTED]. Surveyor discussed Resident #6's pain management as it relates to pre-medicating for pain with movement. The DON and MDS-C M confirmed the resident was not given an adequate length of time to be moved before the Tylenol was effective. MDS-C M indicated nursing staff likely wanted the resident to get into bed immediately, due to the amount of pain Resident #6 was experiencing. At approximately 2:30 p.m., Surveyor received and reviewed three facility faxes, which were sent to Resident #6's physician. The faxes state the following, in part: -09/21/15 at 11:00 a.m.: .Comments/Requests: Resident indicating (increase) left leg pain. How do you wish to proceed? Please read nsg (nursing) notes .Orders: (To be filled out by MD) [MEDICATION NAME] 400 mg .(three times a day) PRN x 7 days, for pain not relieved with Tylenol. -09/21/15 at 1:30 p.m.: .Comments/Requests: (POAHC) has been updated and is aware of resident's continued pain (with) any movement of L leg. *Requesting an order for [REDACTED]. -09/21/15 at 2:00 p.m.: .Comments/Requests: Requesting OT (Occupational Therapy) for wheelchair positioning. On 09/21/15 at 2:45 p.m., MDS-C M informed Surveyor that Resident #6 was up in the wheelchair, and out to the dining room for the noon meal. MDS-C M stated the resident did have pain during the transfers at lunch time. At 3:38 p.m., Surveyor asked MDS-C M if the facility initiated an investigation related to Resident #6's unknown origin of acute leg pain. MDS-C M replied the facility has not started an investigation, and will wait to investigate the pain until the x-ray results are received. At 3:55 p.m., MDS-C M stated RN I just called the resident's physician, and received an order for [REDACTED]. On 09/22/15 at 1:02 p.m., the facility faxed a copy of Resident #6's x-ray results, along with a new physician's orders [REDACTED]. .Date of Service: 09/21/2015 Findings .Bones: Deformities seen of the left hip with superior displacement of the femoral diaphysis (fractures which result in high-energy trauma). In addition, there is suggestion of subcapital lucency suspicious for a subcapital fracture . Impressions: 1. Left [MEDICAL CONDITION], most likely subcapital fracture (neck of the femur) . A physician's orders [REDACTED].ER (emergency room ) for further x-rays; possible ortho (orthopedic) consult, and possible (hospital) admit--transport per ambulance. On 09/21/15 at 1:10 p.m., Surveyor received and reviewed two facility policies. The first undated policy is entitled, Acute Health Problems, and states the following, in part: POLICY: Good geriatric nusing care must include constant monitoring for the development of new health problems. It is expected that significant changes in a resident's condition will be promptly reported to the resident's physician for medical record will contain documentation of adequate nursing evaluation and nursing care as the course of the acute health problem progresses. PROCEDURE: 1. All nursing personnel are expected to notify the nurse when they notice any change in a resident's condition . 2. The nurse will thoroughly assess the health problem using the nursing process and document subjective and objective data. For a significant change, the RN will make and initial nursing assessment and chart a plan of appropriate nursing action that should include notifying the resident's physician and the responsible party. 3. The RN will notify the resident's physician if available, or the on-call physician at the appropriate hospital. The RN will report to the MD observed subjective and objective data as well as nursing actions. The MD will make a medical assessment of the acute health problem and give appropriate medical orders to treat that problem. If the physician cannot make an adequate medical assessment with data obtained by the RN and given over the phone, the resident should be sent to the physician's office or hospital emergency room for medical evaluation. 4. The nurse will write a temporary care plan that addresses the acute health problem and place this in front of the interdisciplinary care plan . The second undated policy is entitled, Standards for Pain Management. The policy states, in part: I. GOAL: The goal of pain management is to relive (sic) the physical and psychosocial symptoms associated with pain while maintaining the resident's highest level of functioning. II. PAIN ASSESSMENT .A. Pain is an extremely subjective experience and as such, the resident's is the best judge of the intensity and relief of pain .C. Ongoing pain assessment is necessary to evaluate the changing nature of pain as well as the effectiveness of treatments. Pain should be assessed before and after each intervention. (E.G. 2 hours after medication administration) . IV. PAIN SCORES GREATER OR EQUAL TO 5 ARE NOT ACCEPTABLE OUTCOMES OF PAIN MANAGEMENT: A. The attending physician should be notified if subsequent assessments of 5 or greater after interventions on a scale of 1-10 are documented unless the resident's requests no further interventions. If pain continues at 5 or more, a Pain Flow Sheet to evaluate effectiveness of various treatments .

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free from accidents as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 17 residents reviewed. Resident #6 had four falls within five months as a result of the care plan not being followed. The facility did not educate all caregivers on following the care plan to prevent falls or determine any other root causes for the falls. Resident #7 had a history of [REDACTED]. Observation during survey revealed there was no motion sensor alarm, and Resident #7 self transferred into the bathroom two times, without staff being aware of the independent transfer. Resident #3 requires extensive assist of one with transfers. Resident #3 has a history of falls and is assessed to be a fall risk. The resident was observed being transferred without a gait belt. This is evidenced by: 1. Resident #6 has dementia and resides on the special care unit of the facility. Resident #6's most recent Minimum Data Set (MDS) documents she has a history of falls. The care plan titled, "Potential for Injury," includes in part: Approaches dated 10/01/14 1. Nurses--Sensor alarm Pressure alarm while in bed, seat pressure alarm in chairs, floor mat at bedside. 2. monitor appropriate positioning of alarms...Nurse Aide-- 4. Sensor alarm; pressure alarm while in bed, seat pressure alarm in chairs...8. monitor for unsafe situations 9. Keep located near staff when restless or agitated. Surveyor reviewed previous care plans to determine the start of the seated pressure alarms. The care plan dated 01/03/11 states in part: 6. Seat alarm in chair at all times The intervention dated 02/23/13 in part: Monitor 1:1 when in close quarters of furniture/residents. The Self Care Deficit Care plan includes in part: Approaches dated, 10/01/14 Nurses--Assure safety Nurse Aide--transferring: extensive assist, 1 assist, use gait belt...locomotion: extensive assist, 1 assist, Use w/c for distances -do not sit in w/c in day room. Other special Directions: pressure alarm (Bed), pressure alarm (seat), ... Surveyor reviewed recent falls for Resident #6. The nurses' notes in part: 02/28/14 "Time of incident: 3:54 p.m. Location: SCU (special care unit) lounge...equipment involved: wheelchair...describe event: resident was sitting in wheelchair related to poor ambulation prior to incident. CNA (Certified Nursing Assistant) turned his back to resident and resident attempted to stand independently. Wheelchair started to roll away from resident, staff member was able to catch resident...Interventions: Lock wheelchair wheels prior to transferring resident and do not leave resident alone in wheelchair..." The Falls incident report in part contains the same information as above. The incident investigation includes in part: 3. Who was in the area at the time of the incident, who reported to you? (CNA name) CNA Q. 6. What measures were in place and did they work? (bed alarm, chair alarm) N/A. (The investigation does not state if the seat alarm was in place or turned on; the care plan instructs "Seat alarm in chair at all times.") Witness statement : "I turned my back (Resident #6's name) stood up without an alarm but I did catch her..." Nurses' notes 05/15/14 1:56 a.m. "Incident type: fall location: resident's room resident position: lying right, in partial sitting position...possible cause: slid from bed Actions/interventions: continue to observe...time of incident: 12:50 a.m." The incident report dated 05/15/15 includes the above information. Incident investigation form in part: "6. What measures were in place and did they work? (bed alarm, chair alarm) Bed alarm. Not turned on. 8. Was there any staff neglect? Rounds not done on unit with PM and NOCs (nights). No report sheet signed off. Both aides counseled. 9. Were there other factors? No" Witness statement CNA R: "Heard loud noise and followed fell ow CNA into room where noise was heard. Found resident on floor and I left CNA with resident and went and called nurse. Note: rounds were done on starting of noc (night shift)." Witness statement CNA S: " I heard a noise and went to find resident on floor. Reported it to nurse." Nurses' notes in part: 07/10/14 "Time: 05:35 p.m. Incident type: found on floor Location: day room Activity at time: in chair Equipment involved: none Possible cause: without staff assist, found down Injury: moves all extremities, laceration First Aid: immediately applied, transferred to emergency room , stitches to lower lip...Transferred to: Acute care hospital time: 6:30 p.m. Reason for transfer: Fall related injury: deep laceration to lower lip...Return time: 8:15 p.m. Physician contact: spoke with Dr...fall will need stitches to lower lip...family/guardian contact: fall will need to go to ER for stitches...writer informed husband that resident had bitten through her lip and did need stitches both internal and external..." Incident Investigation form in part: "6. What measures were in place and did they work? (Bed alarm, chair alarm) Seat alarm in place. Not on. 8. Was there staff neglect? Alarm not activated. 10. If unknown what do feel may have happened-what can we do to prevent reoccurrence? Resident attempted to stand on own. No sounding alarm. Unsteady. fell to floor. Bite lip. Probable (sp) head hit." Discussed incident with CNA T aware of importance to recheck alarms. CNA T counseled... Witness statement: "I was feeding (Resident #6). She fell asleep I got up to feed another resident and I did not check to see if the alarm was on." Counseling Statement in part: Comments of employee: "I as a CNA for 8 years should have known to have checked the alarm before leaving the resident. I will most definitely check all alarms." Nurses' notes in part: 07/14/14 "Time: 09:15 p.m. Incident type: fall Location: hallway Activity at time: transferring Description of event: Resident was sitting in wheelchair in hallway with CNA when another high fall risk resident was transferring herself. CNA went to assist another resident. Resident attempted stand and wheelchair moved from resident, did not lock wheels..." The incident report contains this information under actions: continue to observe. Do not leave resident unattended in wheelchair. (This is the same intervention as the 02/28/14 fall.) Incident Investigation Form in part: 5. What in the environment may have contributed to the incident?...wheelchair brakes unlocked. CNA (CNA U) sat this resident down in wheelchair to assist the other resident in her room. CNA was counseled regarding safety. Witness statement "Went to answer another resident alarm brought resident with. Came out of resident's room and found other resident on the floor." This investigation does not address if the seat alarm was in place when the CNA U left Resident #6, or if the alarm was turned on. On 10/27/14 at 1:35 p.m., Surveyor interviewed CNA F about the falls interventions in place for Resident #6 and her use of alarms. CNA F stated that all alarms are to be turned on when residents are in the day room area, except for one resident. Surveyor asked what they do for Resident #6. CNA F said, "Her alarm is always to be on because if she is awake she will try to get up. It has been that way for a long time. We are 1:1 with her when she is awake." On 10/27/14 at 3:35 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) G. LPN G stated, "The alarm is always to be turned on when she is sitting. It has been that way a long time. She is 1:1 when she is up moving." Surveyor asked how long she has been 1:1. LPN G stated, "I would say at least two years." On 10/27/14 at 4:10 p.m., Surveyor interviewed the MDS coordinator, Registered Nurse (RN) A, about the falls interventions for Resident #6. Surveyor reviewed the care plan with RN A asking what interventions were done to prevent future falls. RN A stated, "I believe the CNAs were counseled." Surveyor asked if all the staff that work with Resident #6 were educated about the importance of not leaving her unattended or without alarms being turned on. RN A stated, "No, just the individual involved." Surveyor stated that the same problem was repeating with Resident #6, that she was left without the alarm being turned on, or left unattended in her wheelchair and the result was a fall. Surveyor asked for clarification about the seat alarm being in place or turned on for the 02/28/14 fall and the 07/14/14 fall, since the investigation does not include this information. RN A said, "I do not know, you will just have to go with what is there." On 10/28/14 at 12:40 p.m., Surveyor met with the Director of Nursing (DON) to discuss the above falls and interventions to prevent future falls. The DON said, "I believe we counseled one or more CNAs when the alarm was not turned on." Surveyor asked if they had educated all staff about the importance of not leaving Resident #6 unattended or without the alarms being turned on. The DON stated, "No." Surveyor asked if all staff had been educated with the first fall if they may have been more diligent about checking the alarms and not leaving Resident #6 in an unsafe manner. Surveyor then asked if there were any other root causes determined for the above falls other than caregiver not following the care plan. The DON stated, "Counseling the CNAs was the intervention." 2. Resident #7 has a history of falling; she has dementia and resides in the special care unit. The potential for injury care plan, dated 09/02/14, includes in part: manifested by: high risk per fall assessment, son aware of turning off seat alarm at times 10/02/14. Approaches in part: 09/02/14 Nurses-- 1. Sensor alarm: chair and bed pressure pad alarms and motion sensor...2. Transfer with assistance 5. Falling star posted on room door to alert staff to independent transfers. Nurse Aide-- 3. Assist with ambulating, transferring, toileting. 4. Do not leave unattended when in toilet. 7. Pressure alarm bed, pressure alarm seat, and motion sensor... The medical record review documents a fall on 12/20/13. The nurses' notes include in part: "Incident type: found on floor...describe event: resident stated that she slid off of bed and found sitting on the floor no apparent injury, moves all extremists...need to consider motion monitor as resident turns off bed monitor..." The incident investigation includes in part: "6. What measures were in place and did they work? (bed alarm, chair alarm) Bed alarm in place Resident turns off bed alarm." On 10/23/14, Surveyor observed Resident #7 lying in bed at 6:30 a.m.. The bed alarm was in place; there was no motion alarm observed. At 8:00 a.m., Surveyor could not see Resident #7 in her bed. After knocking on the door, Resident #7 answered from the bathroom that it was alright to come in. Surveyor went in to find Resident #7 was alone in the bathroom. There was no alarm sounding. Surveyor went out into the hall and found CNA M to come to the room. CNA M then came to assist the resident and stated, "She turns the alarm off all the time." At 10:30 a.m., Surveyor went to the DON to ask if a motion alarm was to be in place as the care plan instructed. The DON suggested we speak with RN A who does the care planning. Surveyor asked RN A what alarms should be in place and asked if the DON and RN A would go to the room with Surveyor to observe what alarms were in place. The DON knocked on the door and there was no answer. After entering the room, Surveyor saw Resident #7 alone in the bathroom, and told the DON that the resident was in the bathroom and no alarm was sounding again. The DON determined that the resident had turned off the chair alarm. The DON and RN A verified there was no motion alarm in the room. At 11:00 a.m., RN A came back to Surveyor and said, "There is no motion sensor alarm in the room; it should not have been on the care plan. I think it may be an intervention we should try since the current alarms are not working." 3. A facility policy titled "Transfer/Ambulation" read in part: "Purpose: To develop a consistent and safe transfer and/or ambulation program for the benefit of residents and employees. 2. A transfer/walking belt will be used when indicated for safe transfer and ambulation." On 10/22/14 at 3:10 p.m., Surveyor observed CNA B assist Resident #3 to the restroom. CNA B transferred Resident #3 from the bed to the wheelchair, stating, "(Resident #3) is an assist of one without a gait belt." CNA B then transferred Resident #3 from the wheelchair to the toilet, back to the wheelchair then back to bed, all without using a gait belt. On 10/23/14 at 12:15 p.m., Surveyor interviewed the DON regarding the above observation. The DON stated the facility's policy is that anyone who needs assistance needs a gait belt, unless the resident refuses. The DON was informed Resident #3 never refused the gait belt during this observation as it was never offered/attempted.