Every finding on record at Meadowbrook at Oconto Falls

Based on observation, interview, and record review, the facility did not ensure 2 residents (R) (R64 and R1) of 4 sampled residents received pharmacy services to ensure medications were safely, timely, accurately administered. R64 had Nystatin powder at the bedside. R64 did not have a self-administration of medication assessment that indicated they could safely and accurately self-administer medication or an order to store medication at the bedside. In addition, R64 requested a nicotine lozenge that was not administered in a timely manner.R1's medications were administered orally. R1's physician orders indicated to administer medications via percutaneous endoscopic gastrostomy (PEG) Tube, however, the PEG Tube was removed and the orders were not changed. Findings include: The facility's Self-Administration of Medication policy, revised December 2025, indicates: Each resident has the right to self-administer medication if he or she can do so. The Interdisciplinary Team (IDT) evaluates each resident who expresses a desire to self-administer medication to determine if the resident can safely self-administer medication. If the resident is determined to be capable, the facility provides the education and monitoring necessary to ensure safe administration .2. If a resident desires to participate in self-administration, the IDT will assess the competence of the resident to participate by completing a Medication Self-Administration Assessment .4. Based on the IDT's review, a decision is made as to whether or not the resident is a candidate for self-administration .5. The nurse will obtain a physician's order for each resident self-administering medication .7. Storage of self-administered medications will comply with state and federal requirements .Document the self-administration of medication on the resident's comprehensive plan of care .Mark Medication Administration Records (MARs) to identify medications that are self-administered by each resident . The facility's Medication Administration Policy, dated 12/2025, indicates: Residents' medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician .2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. a. The nurse is responsible to read and follow instructions and prescription labels. b. If the label and medication sheet are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. c. Report any discrepancies to the pharmacy. Do not administer medication until the discrepancy is resolved .Documentation: Record the name, dose, route, and time of medication on the Medication Administration Record (MAR). 1. On 8/18/26, Surveyor reviewed R64's medical record. R64 was admitted to the facility on [DATE] and had diagnoses including morbid obesity, anxiety. and personal history of nicotine dependency. A Minimum Data Set (MDS) assessment, dated 5/25/26, stated R64 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 8/17/26 at 1:29 PM, Surveyor interviewed R64 in their room and observed 2 medications on a nightstand from the doorway. R64 indicated they brought the medications to the facility and always kept them on their nightstand. Surveyor noted the medications were Nystatin powder and contained pharmacy labels with R64's name. One bottle was filled on 8/8/23. The expiration month was worn off but the year was 2024. The other bottle was filled on 4/29/25 and expired on 4/29/26. R64's Medication Administration Record (MAR) contained an order for Nystation power: Apply to affected areas topically every 12 hours as needed for rash (dated 5/21/26). R64's MAR did not contain an order to self-administer Nystatin powder or to store it at the bedside. R64's medical record did not contain a self-administration of medication assessment for Nystatin powder. R64's care plan did not indicate they could store Nystatin powder at the bedside or self-administer the medication. On 8/18/26 at 7:47 AM, Surveyor observed the same two bottles of expired Nystatin powder in R64's bedroom on the nightstand. On 8/18/26, Surveyor requested a self-administration of medication assessment for R64. A self-administration of medication assessment that indicated R64 could self-administer Nystatin powder was not provided. On 8/19/26 at 3:50 PM, Surveyor observed the same two bottles of expired Nystatin powder on R64's nightstand. Surveyor interviewed R64 who was aware the medications were expired but felt they still worked. When asked if staff were aware of or asked about the medications, R64 indicated nurses were aware because they put Nystatin powder on R64 twice daily. When Surveyor asked if nurses use the bottles of Nystatin powder in R64's room or if they bring Nystatin powder from the medication cart, R64 indicated nurses use the expired Nystatin powder they brought from home. R64 indicated the medication is applied under their left breast for a rash and redness. On 8/19/26 at 3:57 PM, Surveyor interviewed Regional Consultant (RC)-C who indicated residents need an order to store medication at the bedside and should be assessed for self-administration of medication in order to have medication in their room. RN-C indicated bedside medications and self-administration of medication should be reflected on a resident's care plan. RN-C verified the expired medications should be removed from R64's room. 2. R64's medical record contained an order for Nicotine Polacrilex mouth/throat lozenge 2 milligrams (mg) give 1 lozenge by mouth every 30 minutes as needed for smoking cessation related to history of nicotine dependency (dated 5/21/26). During a continuous observation on 8/18/26 that began at 8:22 AM, Surveyor observed R64 ask Certified Nursing Assistant (CNA)-DD to ask the nurse come to their room due to a request for medication. CNA-DD left R64's room and informed Licensed Practical Nurse (LPN)-P that R64 requested to see them for medication. At 9:14 AM, Surveyor interviewed R64 who indicated they requested the nurse because they needed a nicotine lozenge. R64 indicated they waited an hour or more at times when requesting medication which made them anxious and have cravings that upset them. R64 indicated they can have a nicotine lozenge every half hour and they need them after meals. R64 indicated they wait a very long time for the medication and the purpose of the medication is to help with cravings before they start. Surveyor noted the medication was administered at 9:24 AM. On 8/19/26 at 9:40 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated an hour is not an acceptable amount of time for a resident to wait for an as needed (PRN) medication. DON-B verified all medications should be administered to residents in a timely manner. 3. Between 8/17/26 and 8/19/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of soft palate, malignant neoplasm of oropharynx, dysphasia, aphagia, severe protein-calorie malnutrition, oral mucositis, and gastrostomy status. An MDS assessment, dated 7/10/26, stated R1 had a BIMS score of 13 out of 15, indicating intact cognition. R1's medical record contained the following orders: ~ Amlodipine besylate oral tablet 5 mg give 1 tablet via PEG Tube once daily for hypertension (dated 3/10/26) ~ Ascorbic acid tablet 500 mg give 1 tablet via gastrostomy (G)-Tube once daily for supplement (dated 4/3/26) ~ Atorvastatin calcium oral tablet 40 mg give 1 tablet via PEG Tube once daily for hyperlipidemia (dated 3/10/26) ~ Cyanocobalamin tablet 1000 micrograms (mcg) give 1 tablet via G-Tube once daily for supplement (dated 4/3/26) ~ Folic acid oral tablet 1 mg give 1 mg via PEG Tube once daily for supplement (dated 3/10/26) ~ Losartan potassium oral tablet 50 mg give 1 tablet via PEG Tube once daily for hypertension (dated 4/27/26) ~ Olanzapine oral tablet 5 mg give 2.5 mg via PEG Tube once daily related to major depressive disorder (dated 6/13/26) ~ Omeprazole oral capsule delayed release 20 mg give 1 capsule via PEG Tube in the morning for gastroenteric reflux disorder (dated 3/10/26) ~ Thiamine mononitrate oral tablet give 100 mg via PEG Tube in the morning for supplement (dated 3/10/26) ~ Apixaban oral tablet 5 mg give 1 tablet via PEG Tube two times daily for blood clot (dated 3/9/26) ~ Enteral feed order once daily for tube feed - flush feeding tube with 60 milliliters of water every 24 hours (dated 5/31/26; discontinued 7/24/26) R1's medical record did not include documentation of a current or discontinued order for removal of their gastrostomy tube. On 8/19/26 at 9:33 AM, Surveyor observed LPN-M administer the following medications to R3 orally: ~ Cholecalciferol 1000 units - 2 tablets ~ Cyanocobalamin 1000 mcg - 1 tablet ~ Thiamine Mononitrate 100 mg - 1 tablet ~ Ascorbic acid 500 mg - 1 tablet ~ Amlodipine 5 mcg - 1 tablet ~ Apixaban 5 mg - 1 tablet ~ Olanzapine 2.5 mg - 1 tablet ~ Folic acid 1 mg - 1 tablet ~ Losartan potassium 50 mg - 1 tablet ~ Omeprazole 20 mg disintegrating - 1 tablet Surveyor reviewed medication administration audit reports for May 2026 through August 2026 and noted R1's medications were administered via PEG Tube from May 2026 through 8/19/26. A progress note on 4/30/26 indicated R1 was upgraded to a regular diet and was being weened from tube feeding. R1's medical record indicated: special instructions: medications crushed in vanilla pudding (dated 8/19/26). 0n 8/18/26 at 12:38 PM, Surveyor interviewed RN-Z who indicated R1's PEG Tube was removed in July 2026. RN-Z indicated R1 had been taking medication orally since May 2026 and they administered oral medications to them on 8/18/26. On 8/19/26 at 9:54 AM, Surveyor interviewed R1 who indicated they do not have a PEG Tube and have been taking all medications orally since June 2026. R1 indicated they do not have trouble swallowing and prefer to take their medications crushed in pudding. On 8/19/26 at 9:56 AM, Surveyor interviewed LPN-M who indicated R1 has been consistently taking medications orally since the end of May 2026. LPN-M verified R1's medication orders indicate the medications should be administered via PEG Tube. LPN-M verified all orders indicating to administer the medication via PEG Tube should have been discontinued when R1 started taking medications orally and new medication orders with the correct route should have been obtained. LPN-M verified R1 has received oral medications since May 2026 and their PEG Tube was removed at the hospital in July 2026. On 8/19/26 at 12:35 PM, Surveyor interviewed RC-C who verified R1 did not currently have a PEG Tube and all medications ordered via PEG Tube should have been discontinued. RC-C verified new orders for oral medications should have been obtained from the provider prior to administering medications orally. RC-C was unable to locate R1's discontinued gastrostomy tube order.

Based on observation, interview, and record review, the facility did not ensure 3 residents (R) (R28, R26, and R3) of 5 sampled residents received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R28's care plan included skin integrity concerns and contained an intervention to offer repositioning every two hours. During a continuous observation, staff did not offer to reposition R28 to prevent pressure injuries from developing. R26 had stage 2 pressure injuries on the sacrum and left heel. R26's care plan contained an intervention for a specialty air mattress to aide in wound healing. R26's air mattress was not set in accordance with manufacturer's recommendations. R3 had a history of pressure injuries on the left foot and had a specialty air mattress. R3's air mattress was not set in accordance with manufacturer's recommendations. Findings include: The facility's Skin Management policy, revised July 2020, indicates: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes .Upon admission or readmission, residents are assessed for skin integrity by completing a head-to-toe physical assessment of skin condition and a Braden Scale For Predicting Pressure Sore Risk User Defined Assessment (UDA) .A care plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address, but is not limited to the following .repositioning requirements . The facility's Use of Support Services policy, revised July 2026, indicates: Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries .Support service refers to a specialized mattress .6. Support surfaces will be utilized in accordance with manufacturer's recommendations .7. For power devices or those requiring air, the licensed nurse will check each shift and as needed (PRN) for proper functioning and or inflation. Based on guidelines followed by major medical organizations and the Centers for Medicare & Medicaid Services (CMS) criteria, which inform clinical practice, pressure-reducing mattresses - Avoid Excessive Firmness: While preventing bottoming out is critical, setting the pressure too high makes the mattress too firm, reducing its ability to conform to the body and increasing rather than reducing interface pressure on bony prominences (e.g., tailbone, heels). 1. On 8/18/26, Surveyor reviewed R28's medical record. R28 had diagnoses including failure to thrive, diabetes type 2, and history of diseases of the skin and subcutaneous tissue. R28's plan of care, dated 7/1/26, indicated R28 will increase level of mobility through the next review date. The care plan contained interventions for the assistance of 2 staff with bed mobility and transfers with a full body lift. The plan of care also indicated R28 had potential/actual impairment to skin integrity, fragile skin, psoriasis, and dermatitis and contained an intervention to offer turning/positioning every two hours. A Braden Scale Assessment (pressure ulcer risk evaluation) completed 7/29/26 indicated R28 was at high risk for the development of pressure injuries and had limited sensory perception which affected their ability to feel pain in half of their body. The assessment indicated their skin was often moist, they were chairfast, unable to bear weight on their own, and had limited mobility (able to change and control body position). During a continuous observation on 8/18/26 that began at 9:23 AM and ended at 12:05 PM, Surveyor observed R28 in a wheelchair in their room. Surveyor observed R28 receive medications from Registered Nurse (RN)-T who left the room and did not offer repositioning. At 11:10 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-Q who indicated when R28 is in bed, repositioning occurs every two hours. CNA-Q was not sure if repositioning should be offered when R28 was in their wheelchair during the day. At 11:42 AM, Surveyor observed Licensed Practical Nurse (LPN)-R enter the room and tell R28 that it was time for lunch. LPN-R wheeled R28 to the dining room and left them in the same position in their wheelchair. LPN-R did not reposition R28 or the wheelchair when they took R28 to the dining room for lunch. On 8/18/26 at 12:33 PM, Surveyor interviewed LPN-R who indicated they were assisting on the wing because most of the residents required a Hoyer lift for transfers. LPN-R was not sure who required assistance with repositioning. On 8/18/26 at 1:38 PM, Surveyor interviewed R28 who was in the same position in their wheelchair as previously observed. R28 indicated staff do not offer repositioning during the day unless they ask for assistance with getting into bed at night. R28 indicated sitting in the wheelchair all day hurts their bottom which was currently hurting from being in their wheelchair all day. On 8/19/26, Surveyor reviewed R28's repositioning documentation which did not indicate they were offered repositioning every two hours. The documentation indicated R28 received repositioning once each shift when personal hygiene was completed. On 8/19/26 at 7:45 AM, Surveyor observed R28 in a wheelchair in the dining room eating breakfast. The back of the wheelchair was slightly reclined. R28 remained in the dining room until staff assisted them into the common area where they remained in the same position in their wheelchair. R28 remained in the same position until 10:43 AM. On 8/19/26 at 1:38 PM, Surveyor interviewed Regional Consultant (RC)-C who confirmed R28's care plan contained an intervention for repositioning to be completed throughout the day either in the wheelchair or in bed in two-hour intervals for the prevention of wounds and pressure injuries. 2. Between 8/17/26 and 8/19/26, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] and had diagnoses including stage 2 pressure ulcer to the sacrum and left heel, Alzheimer's disease, and general weakness. R26's plan of care contained an intervention for a specialty air mattress for wound healing. The plan of care did not specify a setting for the mattress. (R26 had a Proactive Protek Aire specialty air mattress series 3000. According to the operational manual page 7: .Step 6, determine the patient's weight and set the control knob to the weight setting on the control unit.) On 8/19/26 at 9:52 AM, Surveyor observed LPN-CC complete wound care for R26 and noted their air mattress was set at 320 pounds. When Surveyor asked LPN-CC what the setting should be, LPN-CC indicated the air mattress should be set according to R26's weight. LPN-CC verified R26's weight was 180 pounds and set the air mattress accordingly. On 8/19/26 at 10:05 AM, Surveyor interviewed RC-C who indicated the facility follows manufacturers' recommendations to set specialty air mattresses which are based on the resident's weight. RC-C confirmed R26's air mattress was incorrectly set at 320 pounds and should have been set at 180 pounds. 3. Between 8/17/26 and 8/19/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including monoplegia of lower limb, spinal stenosis, lumbar region with neurogenic claudication, and osteoarthritis. A Minimum Data Set (MDS) assessment, dated 6/11/26, stated R3 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. The MDS assessment indicated R3 was at risk for the develoment of pressure injuries but did not have any current pressure injuries. A care plan, revised 5/15/26, indicated R3 had potential for pressure injury development related to decreased mobility. The care plan contained interventions to follow facility policies/protocols for the prevention/treatment of skin breakdown, float and elevate heels, pressure reduction bed (dated 5/16/26), and pressure reduction chair. R3's Kardex (an abbreviated care plan used by nursing staff) contained an intervention for a skin pressure reduction bed. R3's medical record did not contain an order for an air mattress and an air mattress was not listed on their Treatment Administration Record (TAR). On 8/17/26 at 11:23 AM, Surveyor observed R3 asleep in bed with their air mattress set at a weight of [PHONE NUMBER] lbs on a 30- minute alternating cycle, locked. On 8/18/26 at 12:57 PM, Surveyor observed R3 asleep in bed with their air mattress set at a weight of [PHONE NUMBER] lbs on a 30- minute alternating cycle, locked. The mattress alarm was beeping and a low pressure light was flashing on the motor. (The Drive Manufacturer User Manual Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss, indicates: Users can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting .Low pressure indicator: When the air pressure in the system falls below the selected pressure range, a low pressure condition will signal the low pressure indicator. Check if the connections are secure and correctly installed according to the relevant instructions.) On 8/18/26 at 3:39 PM, Surveyor observed R3 asleep in bed with their air mattress set at a weight of [PHONE NUMBER] lbs on a 30- minute alternating cycle, locked. The mattress alarm was beeping and a low pressure light was flashing on the motor. On 8/19/26 at 9:35 AM, Surveyor observed R3 asleep in bed with their air mattress set at a weight of 400 lbs on a 20-minute alternating cycle, locked. R3's most recent documented weight was 222.2 lbs on 8/12/26. A skin sssessment on 6/18/26 indicated R3's left heel stage 3 pressure injury was healed. A skin assessment on 6/4/26 indicated R3's left lateral heel stage 2 pressure injury was healed. On 8/18/26 at 12:44 PM, Surveyor interviewed RN-Z who was not aware of R3's mattress setting. RN-Z verified R3's medical record, care plan, and TAR did not contain an order for an air mattress or specify a mattress setting. RN-Z indicated they check to see if an air mattress is on, but do not check the setting. RN-Z was aware the air mattress could potentially cause pressure if the setting was incorrect. On 8/18/26 at 12:54 PM, Surveyor interviewed R3 who indicated they prefer to stay in bed. R3 indicated they do not currently have any open wounds but did have pressure wounds on their heels that were healed. On 8/19/26 at 10:08 AM, Surveyor interviewed LPN-M who indicated a air mattress setting should be in a resident's TAR and verified R3's TAR did not contain a setting. LPN-M was unsure if an order was needed for an air mattress. LPN-M observeed R3's air mattress setting and indicated they did not know how the air mattress should be set and was not sure who to ask. On 8/19/26 at 11:04 AM, Surveyor interviewed RC-C who verified air mattress settings are based on manufacturer's recommendations. RC-C indicated if an air mattress can be adjusted by weight, staff adjust the setting to match the resident's current weight unless refused by the resident. RC-C verified R3's mattress should be set according to their weight and verified R3 had pressure injuries on the left heel that healed in June 2026.

Based on interview and record review, the facility did not ensure they did not employ an individual with a disciplinary action against their professional license by a state licensure body for 1 staff (Licensed Practical Nurse (LPN)-Y) of 8 sampled staff. The facility did not complete a thorough pre-employment background check for LPN-Y who worked in the facility as a licensed nurse without a valid nursing license. Findings include: The facility's undated Abuse Prevention Program indicates: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment .In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by .conducting pre-employment screening of employees and pre-admission screening of residents .This facility will not knowingly hire any staff with a disciplinary action in effect against their license by a state licensing body that results from a finding of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Prior to a new employee starting a work schedule, this facility will: Initiate a reference check from previous employer(s) in accordance with facility policy; Obtain a copy of the state license and check the website of the licensing agency of any individual being hired for a position requiring a professional license .On 8/18/26, Surveyor conducted a State of Wisconsin Nursing license check for LPN-Y through the Wisconsin Department of Safety and Professional Services (DSP) located at https://license.wi.gov and noted the following:~ LPN-Y's nursing license granted on 10/7/04 was listed as limited and suspended since 8/3/26. ~ An order on 4/7/17 indicated LPN-Y was reprimanded by the State of Wisconsin Nursing Board due to a finding of narcotic diversion during employment as an LPN in a skilled nursing facility. LPN-Y's license was limited to practice only in the state of Wisconsin. LPN-Y was ordered to comply with conditions, terms, and stipulations in order to continue to hold a valid nursing license. ~ LPN-Y's nursing license was suspended by the State of Wisconsin Nursing Board on 1/12/18 for failure to comply with the conditions, terms, and stipulations of the order on 4/7/17. ~ LPN-Y's nursing license was reinstated on 2/27/18 and all limitations were lifted by the State of Wisconsin Nursing Board.~ LPN-Y was reprimanded by the State of Wisconsin Nursing Board on 11/9/23 due to diversion of narcotics during employment as an LPN in multiple skilled nursing facilities. The State of Wisconsin Nursing Board placed limitations and conditions on LPN-Y's nursing license for a period of two years. LPN-Y could only practice in a work setting pre-approved by the licensing board designee and was prohibited from working in any circumstance where their practice would be unsupervised by a licensee with authorized access to controlled substances.~ LPN-Y received further limitations on their nursing license on 5/11/23 due to a finding by the State of Wisconsin Nursing Board that they had administered intravenous (IV) medication without the proper training and certification. LPN-Y was ordered to complete training, provide verification, and was not able to administer IV medication until proper certification was obtained. ~ LPN-Y's license was suspended on 6/27/24 due to failure to adhere to orders, stipulations, conditions, and limitations of the order on 11/9/23 that limited LPN-Y's nursing license. ~ LPN-Y's license suspension was lifted on 10/2/25 and all stipulations and limitations remained in effect from the previous order on 11/9/23.~ LPN-Y's license was suspended by the State of Wisconsin Nursing Board on 12/11/25 due to violating stipulations, limitation, and conditions of the order on 11/9/23. ~ LPN-Y's license was reinstated on 4/4/26 and they were found in compliance with the order and stipulations. LPN's license remained limited and all conditions, stipulations, and limitations remained in effect from the order on 11/9/23.~ LPN-Y's license was suspended until further notice on 8/3/26 due to violating stipulations, limitations, and conditions of the order on 11/9/23.On 8/18/26, Surveyor reviewed timecard punches for LPN-Y and noted they worked on 8/5/26, 8/7/26, and 8/8/26. On 8/18/26, Surveyor reviewed medical records of residents residing on the 200 and 400 wings where LPN-Y was scheduled to work on 8/7/26 and 8/8/26. Surveyor noted LPN-Y worked in the capacity of a licensed nurse and administered medication, including narcotics, to residents on 8/8/26. On 8/18/26 at 2:28 PM, Surveyor interviewed Corporate Human Resources Director (CHRD)-X who indicated LPN-Y was hired directly through an organization with an employment offer extended on 7/28/26. CHRD-X verified they completed a license check for LPN-Y on 7/31/26 and indicated their license was active at that time. CHRD-X indicated LPN-Y completed orientation on 8/5/26 and was training in the facility on 8/7/26 and 8/8/26. CHRD-X was notified on 8/8/26 that LPN-Y's nursing license was suspended. LPN-Y provided a letter from DSPS that indicated their license was reinstated in April 2026. CHRD-X provided Surveyor with a timeline of the hiring and termination of LPN-Y. Surveyor reviewed the timeline and noted the facility completed a background check on LPN-Y, dated 8/18/26, that indicated their license was suspended and they were not eligible to practice as of 8/3/26. On 8/18/26 at 4:05 PM, Surveyor interviewed CHRD-X who indicated the 7/31/26 background check conducted for LPN-Y contained an incorrect spelling of their last name which prompted a complete background check on 8/18/26 with the correct spelling of their last name. CHRD-X confirmed the original background check for LPN-Y indicated no license was noted on their Governmental Findings report. CHRD-X verified a more in-depth review would have discovered that LPN-Y's last name was misspelled. CHRD-X indicated if another background check would have been conducted at that time, the information regarding the limitations and history of LPN-Y's license would have been discovered prior to them working in the capacity of a licensed nurse with a limited license.

Based on interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 5 residents (R) (R1, R3, R4, R6, and R8) of 5 sampled residents in a total sample of 18 residents. R1 was admitted to the facility on [DATE]. Since admission, R1 expressed a desire to leave and attempted to leave on 7/6/26, 7/9/26, and 7/21/26. The facility did not evaluate R1 to ensure all possible safety measures were implemented to prevent harm. In addition, the facility had not begun discharge planning for R1 despite their continued desire to leave. R3, R4, R6, and R8 did not have current smoking assessments. Findings include: The facility's Elopement policy, dated November 2025, indicates: .It is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan. The facility's Safe Smoking/Tobacco use policy, dated January 2026, indicates: .A resident who smokes, uses smokeless tobacco, or uses an e-cigarette is evaluated to determine whether the resident is safe or unsafe to use tobacco products or e-cigarettes using the following forms: a. Upon admission or readmission .Quarterly, annually, with a significant change of condition, and/or an infraction of the facility's smoking policy: The safe smoking/tobacco use evaluation (UDA) is completed for residents who continue to use tobacco or e-cigarettes. 1. R1 was admitted to the facility on [DATE] and had a diagnosis of delusional disorder. An admission Minimum Data Set (MDS) assessment, dated 6/11/26, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating moderately impaired cognition. R1 was responsible for their own healthcare decisions. A care plan, revised 7/9/26, indicated R1 would like to return home to live with family, but was unsure if family would allow them to live there again. R1's family indicated they were not welcome back at home. R1 was aware and stated they had nowhere to go. The care plan contained an intervention to follow R1's wishes as they express them (dated 6/5/26). An Elopement Evaluation on 6/5/26 indicated R1 was not at risk for wandering or elopement. A progress note on 7/6/26 at 2:53 AM indicated R1 wanted to go outside and would not accept redirection. R1 attempted to run over staff with their wheelchair to get to the door. Two staff went outside with R1 who made it to the road and attempted to flag down cars. R1 screamed they would throw themself on the ground if anyone touched their wheelchair. R1 stated staff were holding them captive and attempted to go to a van in the parking lot that they thought was the police. (R1's care plan was not updated with safety measures to prevent harm or interventions for staff redirection following the incident. In addition, R1's medical record did not contain a re-assessment of their wandering/elopement risk.) Progress notes completed by Licensed Practical Nurse (LPN)-I on 7/9/26 indicated at 12:12 AM, R1 was unhappy with multiple things in the facility and wanted to leave against medical advice (AMA). R1 was calm and resting in a chair in the lobby. Director of Nursing (DON)-B was aware. At 2:13 AM, R1 became increasingly agitated. Several staff attempted to keep R1 from leaving the facility. R1 asked to speak to management in person immediately. At 2:30 AM, R1 wanted to leave and signed AMA paperwork which was witnessed by several staff. DON-B asked LPN-I to talk to R1 about staying until morning so they had a safe environment and Social Services could assist them with a safe discharge. R1 wanted to leave and did not want to wait until morning. R1 was alert and oriented to person, place, time and situation and able to make their own medical decisions. LPN-I notified the on-call physician of R1's decision to leave AMA and was awaiting orders. At 3:06 AM, R1 barricaded themself and their roommate in their room. Staff entered the room through the bathroom from the neighboring room. R1 was educated on the importance of allowing staff in the room. R1 stated they understood but was dissatisfied with the current situation and stated they were going to have a stern conversation with management in the morning. At 3:35 AM, the on-call physician ordered a one-time dose of Ativan (antianxiety medication) 0.5 milligrams (mg) and was informed that R1 signed AMA paperwork. R1 refused to take the medication. R1 was in bed with all their belongings, resting comfortably, and chose to stay. LPN-I updated DON-B. A progress note completed by Social Services Director (SSD)-D on 7/9/26 at 8:52 AM indicated R1 stated they did not want to work with Medicaid and would be leaving with their famous significant other as soon as they arrived. On 7/21/26 at 10:49 AM, Surveyor interviewed LPN-I who stated R1 was delusional but continued to be their own decision maker. LPN-I said they had R1 sign an AMA form because R1 had the right to leave. LPN-I stated R1 constantly made statements of wanting to leave and frequently attempted to leave when LPN-I worked the night shift. (R1's care plan was not updated regarding their attempt to leave facility AMA on 7/9/26 and did not contain safety measures to prevent harm or interventions for redirection. In addition, R1's medical record did not contain a reassesment of their wandering/elopement risk.) Progress notes from 7/10/26 indicated R1 went up and down the hallway at 2:45 AM with their pants around their ankles. Staff asked R1 to pull up their pants when out of their room. R1 sat on the couch in the lounge with their pants down. R1 screamed, spit at staff, and threatened physical harm when staff asked them to get dressed. At 5:25 AM, DON-B was notified. At 10:29 AM, staff called the hospital regarding R1's increased confusion, distress, and desire to leave the facility. The hospital advised staff to send R1 to the Emergency Department (ED). At 3:06 PM, the physician agreed to send R1 to the ED for evaluation. A progress note on 7/11/26 at 12:16 AM indicated R1 told LPN-I that SSD-D took their phone and would not give it back because SSD-D and management wanted to keep them from leaving. R1 stated their phone was locked in SSD-D's desk and they needed it to set up transportation. LPN-I called DON-B who stated SSD-D did not have R1's phone. DON-B told LPN-I they would tell Nursing Home Administrator (NHA)-A about the phone. A progress note on 7/14/26 at 2:18 PM indicated staff and R1's physician discussed their increasing delusions and attempts to leave the facility. The physician recommended ED evaluation at a hospital that had psychiatric care. R1 returned from the hospital at 6:10 PM. A physician visit note on 7/16/26 indicated the physician ordered Sertraline (antidepressant medication) 25 mg daily for 7 days and then increase to 50 mg daily. A progress note on 7/20/26 at 3:40 AM indicated R1's physician requested they be referred for a psychiatric consultation. R1 had a referral to be seen in the facility when the psychologist rounded next. A progress note on 7/21/26 at 1:46 AM indicated R1 asked staff for the bubble pack for medications because they were leaving. Staff stated they were not aware that R1 was leaving. R1 raised their voice and asked for the bubble pack again. Staff administered R1's scheduled medications and stated when R1 was ready to leave and staff were aware they would provide the bubble packs. On 7/21/26 at 1:33 PM, Surveyor interviewed LPN-C who stated R1 attempted to leave the facility through the 400 wing exit doors that morning. LPN-C stated R1 often tried to leave the facility and did not wear a WanderGuard. A progress note completed by SSD-D on 7/21/26 at 4:53 PM indicated they spoke with R1 who stated they wanted to leave. When SSD-D asked if R1 wanted assistance with discharge planning and if they had a place to go, R1 stated no and they will just want out of the facility one day. When asked if R1 wanted a referral sent anywhere, R1 stated they did not want anything from SSD-D. The note indicated SSD-D spoke with APS regarding R1 being their own decision maker. (R1's medical record did not indicate APS was notified prior to 7/21/26. In addition, R1's care plan was not updated with their continued desire or attempts to leave the facility.) On 7/21/26 at 3:56 PM, Surveyor interviewed SSD-D who was aware of R1's consistent statements of wanting to leave and attempts to leave. SSD-D stated R1 had never gotten out of the facility without a staff present. SSD-D stated when R1 attempted to leave, staff were able to redirect them. SSD-D made a referral to APS and stated R1 was on the list to be seen by the facility's psychiatric provider, however, the provider did not round until the end of the month. When asked what steps were being taken to ensure R1's safety, SSD-D stated staff manually locked the front entrance at 10:00 PM and unlocked it at 6:00 AM. SSD-D stated when the doors are pushed for 15 seconds from the inside, they release and an alarm sounds. SSD-D confirmed R1 did not wear a WanderGuard and was not asked to wear a WanderGuard. SSD-D did not know when R1's last elopement assessment was completed and confirmed their repeated verbalizations and attempts to leave the facility were not reflected in their care plan. SSD-D verified R1's medical record did not contain safety interventions instructing staff on redirection or how to approach R1 when they were agitated or made statements or attempted to leave. On 7/22/26 at 5:20 AM, Surveyor entered the facility on the night shift without staff noticing. The outside and inside doors to the facility were not locked and the front entrance was not visible from the nurses' station. Surveyor then exited the building and re-entered without staff acknowledgment. On 7/22/26 at 9:14 AM, Surveyor interviewed DON-B who was aware of R1's ED transfers but denied night shift staff called them and stated R1 wanted to or attempted to leave. DON-B stated they are always on-call and if staff had contacted them, they would have told them to encourage R1 to wait until the morning. If that did not work, they would have told staff to contact law enforcement for assistance. DON-B stated a staff member shoould be with R1 if they are outside. DON-B stated they would defer to NHA-A about whether the doors were secured at night. On 7/22/26 at 9:23 AM, Surveyor interviewed NHA-A who stated the night shift nurse manually locks the door around 10:00 PM and unlocks it around 6:00 AM. When Surveyor stated the entrance was unlocked when they entered the facility at 5:20 AM, NHA-A stated the door should have been locked. NHA-A stated there was not a specific nurse assigned to lock the door, however, night shift nurses know how and when to do it. When asked how agency nurses are aware of the procedure, NHA-A stated agency nurses should be trained but did not believe it was being done. 2. R3 was admitted to the facility on [DATE] and had a diagnosis of quadriplegia. A Quarterly MDS assessment, dated 6/4/26, stated R3 had a BIMS score of 15 out of 15, indicating intact cognition. A smoking care plan (revised 3/13/26) indicated R3 chose to vape. On 7/22/26, Surveyor requested R3's most recent smoking assessment which was dated 3/31/26. An updated smoking assessment was not completed following R3's Quarterly MDS assessment on 6/4/26. (See interview under example 5.) 3. R4 was admitted to the facility on [DATE] and had a diagnosis of congestive heart failure (CHF). An admission MDS assessment, dated 7/7/26, stated R4 had a BIMS score of 13 out of 15, indicating intact cognition. A smoking care plan (dated 7/15/26) indicated R4 chose to smoke. The care plan contained an intervention (dated 7/15/26) to determine if R4 is safe to smoke independently (see smoking assessment). On 7/22/26, Surveyor requested R4's most recent smoking assessment. The facility did not have a smoking assessment for R4. (See interview under example 5.) 4. R6 was admitted to the facility on [DATE] and had a diagnosis of personal history of nicotine dependence. A Quarterly MDS assessment, dated 7/10/26, stated R6 had a BIMS score of 13 out of 15, indicating intact cognition. A care plan (revised 3/13/26) indicated R6 chose to smoke but preferred to vape. The care plan contained an intervention (dated 3/13/26) to determine if R6 is safe to smoke independently (see smoking assessment). On 7/22/26, Surveyor requested R6's most recent smoking assessment which was dated 3/10/26. An updated smoking assessment was not completed following R6's Quarterly MDS assessment on 7/10/26. (See interview under example 5.) 5. R8 was admitted to the facility on [DATE] and had a diagnosis of tobacco use. A Quarterly MDS assessment, dated 6/17/26, stated R8 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. R8 had a smoking care plan that was initiated on 3/10/25. On 7/22/26, Surveyor requested R8's most recent smoking assessment which was dated 3/5/26. An updated smoking assessment was not completed following R8's Quarterly MDS assessment on 6/17/26. On 7/22/26 at 1:36 PM, Surveyor interviewed DON-B who confirmed R4 did not have a smoking assessment and R3, R6, and R8's smoking assessments were late. DON-B stated since the facility had an off-site MDS coordinator, nursing leadership should be completing quarterly smoking assessments.

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when they did not ensure allegations of misappropriation and neglect were reported to law enforcement and/or the State Agency (SA) for 2 residents (R) (R1 and R7) of 2 sampled residents. The facility was informed of suspected misappropriation involving R1. The allegation of misappropriation was not reported to local law enforcement or the SA. R7 required the assistance of two staff for mechanical lift transfers. R7 was transferred via sit-to-stand lift by 1 staff, fell to the floor, and sustained a head laceration. The SA wasn't notified of the allegation of neglect. Findings include: The facility's Abuse Prevention Program Policy indicates: .The purpose of this policy is to ensure the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents .External Reporting: 1. Initial reporting of allegations: When an allegation of abuse, neglect .misappropriation .has been made, the Administrator or their designee shall .notify the Division of Quality Assurance (DQA) that an occurrence of potential abuse, neglect .misappropriation .was reported to the Administrator and is being investigated .Informing Local Law Enforcement: .When there is reasonable suspicion that a crime has been committed in the facility by a person other than a resident . 1. R1 was admitted to the facility on [DATE] and had a diagnosis of delusional disorder. An admission Minimum Data Set (MDS) assessment, dated 6/11/26, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating moderately impaired cognition. R1 was responsible for own healthcare and financial decisions. A care plan, dated 7/9/26, indicated R1 had psychosocial well-being concerns related to a risk of being taken advantage of monetarily. The care plan stated R1 believed their significant other was a TV star and country music singer. R1 told staff they had given personal information to another person to assist them with finances. On 7/21/26 at 1:25 PM, Surveyor attempted to interview R1 who refused to speak to Surveyor. A progress note completed by Social Services Director (SSD)-D on 7/9/26 at 8:52 AM stated R1 told SSD-D that they did not want to work with Medicaid and their famous significant other was coming to get them as soon as possible. R1 showed SSD-D text messages in which the individual asked them about money and accounts. The progress note also stated R1 gave a friend personal information, including their date of birth , bank information, and social security number. R1 told SSD-D that they had not received a social security check for some time and the friend was assisting them with it. A progress note on 7/14/26 at 2:18 PM stated R1's physician recommended they be sent to the Emergency Department (ED) for evaluation of increasing delusions. R1 returned to the facility at 6:10 PM. On 7/21/26 at 3:56 PM, Surveyor interviewed SSD-D who stated R1's initial plan was to discharge to a family member's house, however, the family member was no longer willing to allow R1 to live with them. Shortly after learning that, SSD-D became concerned about financial abuse due to statements made by R1 and their family. SSD-D confirmed that R1 believed their significant other was a famous actor and country singer who texted them all the time. SSD-D confirmed they had seen the texts. SSD-D spoke with R1's family who stated the individual had taken between $20,000 and $30,000 of R1's money. SSD-D also stated R1 told them they gave personal information to another friend, however, they were not willing to give SSD-D the friend's name or contact information. SSD-D attempted to have R1 sign a Representative Payee form which would send their social security checks to the facility, however, R1 refused and stated their significant other did not want them to. SSD-D reported the concerns to Adult Protective Services (APS) who stated R1 was their own decision maker and they would not get involved unless R1 was a threat to themself or others. SSD-D stated R1 had not been evaluated for mental capacity or competency to make their own decisions. On 7/22/26 at 8:53 AM, Surveyor completed a follow-up interview with SSD-D who could not recall the exact date they became aware of the financial abuse or when they filed the initial report with APS but thought it was the beginning of July (2026). SSD-D confirmed law enforcement was not notified. (A consultation request, dated 6/24/26, was completed and a referral was sent for psychiatric evaluation due to financial abuse and possible delusions.) On 7/22/26 at 1:08 PM, Surveyor interviewed Adult Protective Services (APS)-H who stated SSD-D called them on 7/14/26 and stated the facility was sending R1 to the ED for evaluation with a potential transfer to psychiatric care. APS-H stated they told SSD-D to let APS know if/when R1 returned to the facility. APS-H stated APS was not informed of R1's return until 7/21/26. APS-H sent an email to SSD-D on 7/21/26 at 3:03 PM to see if R1 had an activated Power of Attorney (POA) document but did not receive a response. APS-H stated APS did not have concerns working with the facility on potential guardianship for R1, but needed more information from the facility before proceeding. On 7/22/26 at 2:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware of suspected misappropriation for R1. NHA-A stated if there was an allegation or suspicion of misappropriation, NHA-A should have been informed and would have filed a report with local law enforcement and the SA. 2. R7 was admitted to the facility on [DATE]. R7 had an indwelling catheter and a diagnosis of a urinary tract infection (UTI). An MDS assessment, dated 4/6/26, stated R7 had a BIMS score of 15 out of 15, indicating intact cognition. A care plan indicated R7 had limited physical mobility. The care plan contained an intervention to transfer R7 with the assistance of two staff (dated 7/8/26). R7's medical record and a fall investigation report indicated R7 was standing in a sit-to-stand lift with one Certified Nursing Assistant (CNA) present on 7/12/26. R7 became weak and slid from the sling while the CNA was providing peri-care. R7 sustained a right forehead laceration with bleeding and was unconscious. Staff called 911 and R7 was transferred to the hospital. Staff did not follow R7's care plan and provide the assistance of two staff for a sit-to-stand transfer. On 7/22/26 at 4:51 PM, Surveyor interviewed NHA-A who stated the facility did not realize staff's neglect to follow R7's care plan which resulted in an injury was a reportable incident.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R7 and R9) of 3 sampled residents. R7 was on enhanced barrier precautions (EBP) due to an indwelling catheter and had a diagnosis of urinary tract infection (UTI). R7's Foley catheter bag was observed on the floor without a barrier to prevent infection. R9 was on EBP due to a feeding tube and indwelling catheter and had diagnoses of sepsis and UTI. Staff did not wear a gown while changing R9's feeding tube dressing. Findings include: The facility's Enhanced Barrier Precautions policy, revised 5/2026, indicates: .Initiation of Enhanced Barrier Precautions: .b. An order for EBP will be obtained for residents with any of the following: i. Wounds .Indwelling medical devices (e.g., .urinary catheters, feeding tubes .) even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO) .High-contact resident care activities include: .g. Device care or use: .urinary catheters, feeding tubes . 1. R7 was admitted to the facility on [DATE]. R7 had an indwelling catheter and a diagnosis of UTI. A Minimum Data Set (MDS) assessment, dated 4/6/26, stated R7 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 7/22/26 at 11:22 AM, Surveyor observed R7's catheter bag on the floor of their room. Medical Records (MR)-G (who was also a Certified Nursing Assistant (CNA)) was leaving the room and verified R7's catheter bag was on the floor. MR-G confirmed the bag should not be on the floor and cleansed and hung the bag from the side of R7's bed. On 7/22/26 at 11:25 AM, Surveyor interviewed CNA-F who was in R7's room just prior to MR-G. CNA-F verified the catheter bag should not be on the floor and stated the bag must have fallen when they repositioned R7. On 7/22/26 at 3:48 PM, Surveyor interviewed Director of Nursing (DON)-B who verified catheter bags should not be on the floor due to infection control concerns. 2. R9 was admitted to the facility on [DATE]. R9 had a feeding tube, indwelling catheter, and a diagnosis of UTI. An MDS assessment, dated 6/29/26, stated R9 had a BIMS score of 14 out of 15, indicating intact cognition. On 7/22/26 at 8:05 AM, Surveyor observed Licensed Practical Nurse (LPN)-E change R9's feeding tube dressing. LPN-E wore gloves but not a gown. Surveyor interviewed LPN-E who verified they should have worn a gown during the dressing change. On 7/22/26 at 3:48 PM, Surveyor interviewed DON-B who stated staff should wear a gown and gloves during high-contact cares for a resident on EBP.

Based on interview and record review, the facility did not ensure medically-related social services were provided to attain or maintain the highest practicable well-being for 1 resident (R) (R1) of 18 sampled residents.R1 was admitted to the facility on [DATE]. The facility did not ensure appropriate and safe discharge planning was implemented and R1's decision-making capacity was assessed.Findings include:R1 was admitted to the facility on [DATE] and had a diagnosis of delusional disorder. An admission Minimum Data Set (MDS) assessment, dated 6/11/26, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating moderately impaired cognition. R1 was responsible for their own healthcare and financial decisions.Discharge Planning:A care plan, revised 7/9/26, indicated R1 wanted to return home to live with family, but was unsure if family would allow them to live there again. R1's family indicated they were not welcome back at home. R1 was aware and stated they had nowhere to go. The care plan contained an intervention to follow R1's wishes as they express them (dated 6/5/26).An admission MDS assessment, dated 6/11/26, indicated R1's discharge plan was to return to the community. The assessment indicated there was no active discharge plan for R1 and they declined county referral for assistance with discharge planning.A care conference note on 6/9/26 indicated R1 stated they were no longer welcome to live with family which was the plan upon admission. The note indicated R1 would continue to work with therapy and the Aging and Disability Resource Center (ADRC) for housing.R1's progress notes indicated they made statements or attempted to leave the facility on the following dates:~ On 7/6/26 at 2:53 AM, R1 stated they wanted to leave and left the facility with staff following.~ On 7/9/26 at 2:30 AM, R1 expressed a desire to leave the facility and attempted to do so.~ On 7/10/26 at 10:29 AM, 7/11/26 at 12:16 AM, and 7/21/26 at 1:46 AM and 4:53 PM, R1 stated they wanted to leave the facility. On 7/21/26 at 10:49 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who stated R1 constantly made statements of wanting to leave and frequently attempted to leave when LPN-I worked the night shift.On 7/21/26 at 1:33 PM, Surveyor interviewed LPN-C who stated R1 often made statements of wanting to leave and often attempted to leave the facility. LPN-C stated earlier that day, R1 attempted to leave through the 400 wing exit doors. On 7/21/26 at 3:56 PM, Surveyor interviewed Social Services Director (SSD)-D who stated R1's initial discharge plan was to move back in with a family member, however, the family member was no longer willing to allow R1 to live with them. SSD-D stated R1 was cut from insurance and they attempted to have R1 sign a Representative Payee form which would send their social security checks to the facility, but R1 refused to sign or apply for Medicaid. SSD-D was aware of R1's consistent statements of wanting to leave and repeated attempts to leave. SSD-D stated staff were able to redirect R1 when they attempted to leave. SSD-D stated there was no active discharge plan for R1 and no referrals had been submitted regarding discharge planning.R1's medical record included several instances in which they stated they wanted to leave the facility as well as documented attempts to leave. The facility did not have documentation to support ongoing discharge planning.Evaluation of Decision Making Capacity:A care conference note on 6/9/26 indicated R1 appeared to have delusional-type thoughts of being in a relationship with a known Hollywood star and county singer.A care plan, dated 7/9/26, indicated R1 had psychosocial well-being concerns related to a risk of being taken advantage of monetarily. The care plan indicated R1 believed ther significant other was a TV star and country music singer. R1 told staff they gave personal information to another person to assist them with finances. A referral was made to the facility's contracted behavioral consulting provider.A progress note on 7/9/26 at 8:52 AM indicated R1 told SSD-D their famous significant other was coming to get them as soon as possible and showed SSD-D text messages from the individual. SSD-D indicated the individual asked R1 about money and bank accounts in the text messages. The progress note also indicated R1 gave a friend personal information, including their date of birth , bank information, and social security number. R1 told SSD-D that they had not received a social security check for some time and the friend was assisting them with it.A progress note on 7/10/26 at 10:29 AM indicated the physician was notified that R1 stated they had no family support and said they were going to be a caretaker in a children's home.A progress note on 7/14/26 at 2:18 PM indicated R1's physician and staff discussed the fact that R1 was increasingly more delusional and altered over the last couple weeks and often attempted to leave the facility. The physician suspected potential underlying dementia and recommended evaluation at a hospital that had psychiatric care. R1 returned to the facility at 6:10 PM.A progress note on 7/16/26 at 11:53 AM indicated SSD-D spoke with the long-term care Ombudsman regarding concerns about financial abuse, competency, safe discharge options, representative payee, and Adult Protective Services (APS) for R1. The Ombudsman encouraged SSD-D to call APS again with an update.A progress note on 7/21/26 at 4:53 PM indicated SSD-D spoke with APS regarding R1 being their own decision maker.On 7/21/26 at 3:56 PM, Surveyor interviewed SSD-D who stated shortly after R1 was admitted to the facility, they became concerned about financial abuse due to statements made by R1 and their family. SSD-D confirmed R1 believed their significant other was a famous actor and country singer who texted them all of the time. SSD-D confirmed they had seen the texts. SSD-D stated R1's family said the individual had taken between $20,000 and $30,000 of R1's money. SSD-D stated R1 also stated they gave personal information to another friend, however, they were not willing to give SSD-D their name or contact information. SSD-D attempted to have R1 sign a Representative Payee form which would send their social security checks to the facility, however, R1 refused and stated their significant other did not want them to. SSD-D reported the concerns to APS who stated R1 was their own decision maker and they would not get involved unless R1 was a threat to themself or others. SSD-D stated R1 had not been evaluated for decision-making capacity and a referral was made to the facility's behavioral consulting provider who did not round until the end of the month. SSD-D confirmed they did not contact the facility's Medical Director or R1's physician to evaluate for incapacity.On 7/22/26, Surveyor reviewed R1's Power of Attorney for Healthcare (POA) document and noted R1's primary agent had signed off as unwilling to act as their agent. R1's secondary agent was a legal guardian. The document indicated the POA agents were not able to admit R1 for long-term nursing home care.On 7/22/26 at 8:53 AM, Surveyor completed a follow-up interview with SSD-D who could not recall the exact date they became aware of the allegation of misappropriation or when they requested assistance from APS to prevent further misappropriation. SSD-D confirmed additional safety interventions to prevent further misappropriation were not implemented and R1 was still in contact with the individual suspected of committing the misappropriation. SSD-D could not recall the exact date the initial report was made to APS and was aware R1's POA document indicated their agent was unwilling to act and was not allowed to admit them to a nursing home. SSD-D stated they were working with APS on getting R1 evaluated for capacity.On 7/22/26, Surveyor requested documentation of the facility's communication with APS. The facility could not provide documentation of communication with APS prior to 7/21/26.On 7/22/26 at 1:08 PM, Surveyor interviewed Adult Protective Services (APS)-H who stated SSD-D notified APS-H on 7/14/26 that R1 was being sent to the hospital. APS-H asked SSD-D to call back if/when R1 returned to the facility. APS-H stated APS was not notified of R1's return to the facility until SSD-D contacted APS again on 7/21/26. APS-H stated they sent an email to SSD-D on 7/21/26 at 3:03 PM to check if R1 had a POA document and if their physician had evaluated them for incapacity but did not receive a response. APS-H acknowledged concerns related to financial abuse, delusions, and discharge safety. APS-H reported no concerns working with the facility on potential guardianship for R1 but stated they needed more information from the facility before they could proceed. APS-H reported previous concerns working with the facility and getting timely and consistent information.Surveyor noted R1's medical record included several incidents of potential misappropriation and delusional episodes. The facility was unable to provide documentation to support ongoing communication with APS and attempts to have R1 evaluated for incapacity.

Based on observation, interview, and record review, the facility did not ensure 1 resident (R) (R7) of 4 sampled residents received care and treatment based on their needs and medical orders. R7 had an order to wear Prevalon boots in bed to prevent skin breakdown. The order was not consistently followed. In addition R7's care plan did not contain an intervention for Prevalon boots. Findings include: The facility's Skin Management Policy, revised 7/2026, indicates: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing .4. Residents admitted with skin impairments will have: a. Interventions implemented to promote healing; b. A physician's order for treatment .5. A care plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown . R7 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, chronic venous insufficiency, and gout. A Minimum Data Set (MDS) assessment, dated 4/6/26, stated R7 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R7's medical record indicated they had limited mobility and wound care orders for the left ischium and right lower extremity. R7 also had an order to wear Prevalon boots at all times while in bed and to be sure the ankle does not rest on the foot pedal of the wheelchair. R7's medical record also indicated staff may free float R7's heels by elevating legs and placing pillows laterally under calves to keep heels and right lateral ankle free from all surfaces (dated 12/12/25). R7's care plan indicated they had the potential for pressure injury developement due to decreased mobility (revised 5/8/26). The goal indicated R7's pressure injury would show signs of healing and remain free from infection. (The care plan did not contain an intervention to wear Prevalon boots at all times while in bed.) On 7/22/26 at 11:15 AM, Surveyor observed R7 in bed without Prevalon boots. R7's feet/heels were in direct contact with the mattress. R7 stated staff only apply the boots at night. R7 stated they are willing to wear boots at all times in bed if that is what is ordered. On 7/22/26 at 11:19 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated R7's Prevalon boots are for comfort and they chose when to wear them. CNA-F did not think R7 needed to wear the boots at all times when in bed. On 7/22/26 at 3:48 PM, Surveyor interviewed Director of Nursing (DON)-B who stated if there is a medical order for Prevalon boots, the boots should be on R7's care plan and staff should follow the order as written.

Based on interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R1) of 1 sampled resident.The facility was informed of suspected misappropriation involving R1. The facility did not thoroughly investigate the allegation and implement safety measures to prevent further misappropriation.Findings include:The facility's undated Abuse Prevention Program indicates: The facility affirms the right of residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment .Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion .Misappropriation of resident property means the deliberate misplacement, exploitation .of a resident's belongings or money without the resident's consent. Additionally, misappropriation of a resident's property means obtaining property of a client by intentionally deceiving the client with a representation which is known to be false, made with the intent to defraud, and which does defraud the person to whom it is made and/or intentionally using or attempting to use personal identifying information .The facility will take steps to prevent potential abuse while the investigation is underway .Accused individuals not employed by the facility will be denied unsupervised access to the resident during the course of the investigation .Any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will result in an investigation.R1 was admitted to the facility on [DATE] and had a diagnosis of delusional disorder. An admission Minimum Data Set (MDS) assessment, dated 6/11/26, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating moderately impaired cognition. R1 was responsible for their own healthcare and financial decisions.A care plan, dated 7/9/26, stated R1 had psychosocial well-being concerns related to a risk of being taken advantage of monetarily. The care plan stated R1 believed their significant other was a TV star and country music singer. R1 told staff they had given personal information to another person to assist them with finances.On 7/21/26 at 1:25 PM, Surveyor attempted to interview R1 who refused to speak to Surveyor.A progress note completed by Social Services Director (SSD)-D on 7/9/26 at 8:52 AM indicated R1 stated they did not want to work with Medicaid and their famous significant other was coming to get them as soon as possible. R1 showed SSD-D text messages in which the individual asked R1 about money and accounts. The progress note also stated R1 gave a friend personal information, including their date of birth , bank information, and social security number. R1 told SSD-D they had not received a social security check for some time and their friend was assisting them with it.A progress note on 7/14/26 at 2:18 PM stated R1's physician recommended they be sent to the Emergency Department (ED) for evaluation of increasing delusions. R1 returned to the facility at 6:10 PM.On 7/21/26 at 3:56 PM, Surveyor interviewed SSD-D who stated R1's initial plan was to discharge home with a family member, however, the family member was no longer willing to allow R1 to live with them. Shortly after learning that, SSD-D became concerned about financial abuse due to statements made by R1 and their family. SSD-D stated R1 believed their significant other was a famous actor and country singer who texted them all the time. SSD-D confirmed they saw the text messages. SSD-D stated R1's family stated the individual had taken between $20,000 and $30,000 of R1's money. R1 also told SSD-D they gave personal information to another friend, however, they were were not willing to provide their name or contact information to SSD-D. SSD-D attempted to have R1 sign a Representative Payee form which would send their social security checks to the facility, but R1 refused and stated their significant other did not want them to. SSD-D reported the concerns to Adult Protective Services (APS) who stated R1 was their own decision maker and they would not get involved unless R1 was a threat to themself or others. SSD-D stated R1 had not been evaluated for mental capacity or competency to make their own decisions.On 7/22/26 at 8:53 AM, Surveyor completed a follow-up interview with SSD-D who could not recall the exact date they became aware of the allegation of misappropriation or when they requested assistance from APS to prevent further misappropriation. SSD-D confirmed safety interventions were not implemented to prevent further misappropriation and confirmed R1 was still in contact with the individual suspected of committing misappropriation.On 7/22/26 at 9:14 AM, Surveyor requested the facility's investigation, including all documentation and interventions implemented to prevent further misappropriation.On 7/22/26 at 1:08 PM, Surveyor interviewed Adult Protective Services (APS)-H who stated SSD-D notified APS on 7/14/26 that the facility was sending R1 to the ED for evaluation with a potential transfer to psychiatric care. APS-H told SSD-D to call APS if/when R1 returned to the facility. APS-H stated APS was not informed of R1's return until 7/21/26. APS-H stated they sent an email to SSD-D on 7/21/26 at 3:03 PM to check if R1 had an activated Power of Attorney (POA) document but did not receive a response. APS-H stated they had no concerns working with the facility on potential guardianship for R1, but they needed more information from the facility before proceeding.On 7/22/26 at 2:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware of suspected misappropriation involving R1. NHA-A stated if there was an allegation or suspicion of misappropriation, NHA-A should have been informed and would have completed an investigation.

Based on interview and record review, the facility did not ensure 1 resident (R) (R1) of 6 sampled residents or their legal representative was informed in advance of the risks and benefits of prescribed medication and provided consent to receive the medication.R1 was prescribed Sertraline (antidepressant medication). R1 was not informed of the risks and benefits and did not consent to receive the medication. Findings include:The facility's Psychotropic Management policy, dated December 2025, indicates: A psychotropic medication is considered a chemical restraint when it is used as the first intervention to control behavior, mood, or mental status. Psychotropic medications can also be considered chemical restraints when they are the only intervention for the treatment of a psychiatric condition .1. Upon receipt of new orders for psychotropic medication, the licensed nurse will implement the following: .b. Complete the appropriate psychotropic medication consent form; .c. Education of the resident and/or the resident representative is conducted to communicate the risks and benefits of the medication .R1 was admitted to the facility on [DATE] and had diagnoses including nonrheumatic aortic (valve) stenosis and post transcatheter aortic valve replacement (TAVR). An admission Minimum Data Set (MDS) assessment, dated 6/11/26, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating moderately impaired cognition. R1 was responsible for their healthcare decisions.Visit orders from R1's provider, dated 7/16/26, recommended starting Sertraline 25 milligrams (mg) once daily for 7 days then increasing to 50 mg daily thereafter.R1's Medication Administration Record (MAR) indicated they received the first dose of Sertraline on 7/18/26 with daily doses administered through 7/21/26 for a total of 4 doses.R1's medical record did not indicate they were notified of the risks and benefits of Sertraline or consented to receive the medication.On 7/22/26 at 1:33 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who confirmed they administered Sertraline to R1. LPN-C stated when they give R1 their medications, R1 does not ask which medications are being administered. LPN-C stated residents should consent to medication before it is administered. LPN-C stated they did not take the initial order and did not know if R1 consented to the medication.On 7/22/26 at 9:14 AM, Surveyor interviewed interim Director of Nursing (DON)-B who confirmed the facility did not have documentation that R1 consented to the administration of Sertraline. DON-B stated R1 refused the medication on 7/21/26 when staff attempted to obtain consent. DON-B acknowledged that R1 received 4 doses of Sertraline without consent and stated consent should have been obtained before Sertraline was administered.

Based on observation and interview, the facility did not ensure the nurse staffing was posted daily. This practice had the potential to affect all of the 71 residents residing in the facility.The facility did not consistently post the required daily nurse staffing.Findings include:On 7/21/26 at 11:39 AM, Surveyor observed the nursing staff posting outside Nursing Home Administrator (NHA)-A's office which was dated 7/2/26.On 7/21/26 at 1:22 PM, Surveyor showed NHA-A the posting that was dated 7/2/26. NHA-A verified the posting had not been updated and confirmed it should be updated daily to reflect the total number of licensed and unlicensed nursing staff directly responsible for resident care per shift and the actual hours worked. NHA-A stated the Human Resources Department was responsible for updating the posting.

Based on interview and record review, the facility did not ensure they accurately acquired and administered medication for 1 resident (R) (R1) of 4 residents in a total sample of 6 residents. R1 was admitted to the facility with orders for Rexulti (an antipsychotic medication), Vyvanse (a central nervous system stimulant), Lyrica (used to treat nerve pain), fentanyl (an opioid medication) and biotin (a vitamin B supplement). The facility did not ensure the medications were acquired or administered as ordered. Findings include:The facility's Medication Administration policy, dated December 2025, indicates: Resident medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician .Verify the medication label against the medication sheet for accuracy of drug, frequency, duration, strength, and route. R1 was admitted to the facility on [DATE] and had diagnoses including infection of deep incisional surgical site, nerve root and plexus disorder, depression, attention-deficit hyperactivity disorder (ADHD) inattentive type, and intervertebral disc degeneration of lumbar region. An admission Minimum Data Set (MDS) assessment, dated 5/22/26, indicated R1 received antidepressant medication, was at risk for pain, and received scheduled pain medication. The assessment did not indicate R1 received antipsychotic medication. A care plan, dated 5/19/26, indicated R1 was prescribed antidepressant, antipsychotic, and pain medication and had the potential for pain.A hospital Discharge summary, dated [DATE], indicated R1 had a postoperative lumbar wound infection at L4-L5 as well as chronic midline low back pain and a history of binge eating disorder. R1 discharged from the facility back to the hospital on 5/22/26. On 7/7/26 at 11:53 AM, Surveyor interviewed R1's Significant Other ((SO)-F) who stated when R1 arrived at the facility on 5/19/26, the facility did not have R1's medications. SO-F stated the nurse told them they had to order the medications from the pharmacy which was located in another city and said some of the medications required a doctor's order which they did not have. SO-F stated all of the orders should have come from the hospital. SO-F stated R1 often cried and complained of pain when SO-F arrived at the facility or talked with R1 via phone. SO-F stated they discharged R1 from the facility on 5/22/26 and brought them to the hospital to be admitted for pain management. A hospital Discharge summary, dated [DATE], included the following orders:~ Rexulti 2 milligrams (mg) daily for depression (last administered 5/19/26 at 9:03 AM).~ Vyvanse 40 mg every morning for eating disorder with an associated diagnosis of ADHD (last administered 5/19/26 at 8:52 AM).~ Lyrica 150 mg three times daily for L4-L5 disc bulge and compression of the spinal nerve root (last administered 5/19/26 at 8:53 AM).~ Fentanyl 25 micrograms/hour (mcg/hr) 1 patch every third day (72 hours) for surgical site infection, chronic midline low back pain, unspecified sciatica, L4-L5 disc bulge (last administered 5/19/26 at 2:38 AM).~ Biotin 10000 mcg daily as supplement (no hospital administration record noted). R1's Medication Administration Record (MAR) indicated from 5/19/26 through 5/22/26, orders for Rexulti, Vyvanse, Lyrica, and biotin were signed out as unavailable for administration. On 7/7/26 at 12:29 PM, Surveyor interviewed Registered Nurse (RN)-D who worked with R1 on their day of admission. RN-D stated some of R1's medications had not arrived and the facility did not have them in contingency. RN-D also stated some of the medications required a written prescription from the physician which did not arrive from the hospital and had to be requested. RN-D could not verify which medications were not available but stated one may have been Lyrica. R1's MAR contained an order for a fentanyl patch (dated 5/20/26) that was administered on 5/20/26 at 7:39 AM by Licensed Practical Nurse (LPN)-E. The patch was administered 29 hours after the previous patch was administered in the hospital and 43 hours before the next patch administration. On 7/7/26 at 1:07 PM, Surveyor interviewed LPN-E who did not recall if they had administered pain medication or a fentanyl patch for R1. LPN-E acknowledged R1's MAR indicated they administered the patch. LPN-E stated they would follow the physician's order for administration. On 7/7/26 at 3:13 PM, Surveyor interviewed interim Director of Nursing (DON)-B who was not the DON when R1 resided in the facility. DON-B stated nurses should administer medications as ordered by the physician. DON-B stated if a medication is unavailable or if the facility is unable to obtain a medication, the physician should be notified. DON-B verified the physician was not updated when R1's medications were not available.

Based on interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents with a non-pressure wound received treatment as ordered. R1 was admitted to the facility on [DATE] with a surgical wound on the lower spine. R1 did not have a treatment order for the wound until 5/22/26. R1's dressing was not changed while they resided at the facility.Findings include:The facility's Skin Management policy, revised July 2026, indicates: Residents receive care to aid in the prevention or worsening of wound and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing, prevent infections. and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes .Residents admitted with skin impairments will have: a physician's order for treatment . The facility's Physician Orders policy, revised January 2026, indicates: Purpose: To ensure physician orders are implemented timely and accurately .Physician orders are obtained to provide clear direction regarding the care of the resident. R1 was admitted to the facility on [DATE] with a diagnosis of L4-L5 transforaminal lumbar interbody fusion with post operation infection methicillin-sensitive Staphylococcus aureus (MSSA) and a surgical wound. R1 was admitted to the facility for wound care and intravenous antibiotic therapy. R1 discharged from the facility on 5/22/26. A hospital discharge record, dated 5/19/26, indicated a wound vac could not be continued at the skilled nursing facility so the discharge plan included frequent dressing changes. (R1's medical record did not contain a wound dressing order upon admission on [DATE].) A wound dressing order (dated 5/22/26) indicated the following: ~ Wound type: post-surgical. Wound location: lower spine. Cover staples with oil emulsion followed by silicone foam border, change every shift and as needed. Every day three times daily. On 7/7/26 at 2:23 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who stated they did not complete a dressing change for R1 and was not aware that R1 had a wound dressing. On 7/7/26 at 2:28 PM, Surveyor interviewed interim Director of Nursing (DON)-B who stated the facility's wound physician completed rounds on 5/21/26 and a new dressing change order was entered into R1's medical record on 5/22/26. DON-B verified R1 did not have a dressing change order at the time of admission and nursing staff did not obtain an order. DON-B verified R1's wound dressing was not changed at the facility prior to their discharge on [DATE].

Based on interview and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R1) of 6 sampled residents.R1 was not provided effective pain management from 5/19/26 through 5/22/26.Findings include:The facility's Pain Management policy, dated July 2026, indicates: The facility will evaluate and identify residents experiencing pain; evaluate their existing pain and the cause(s); determine the type and severity of the pain; and develop a care plan for pain management .3. The Pain Evaluation will be completed in the following circumstances: Resident reports inadequate pain control .4. Following the evaluation, the nurse will notify the physician/licensed practitioner of the findings and document .and implement new orders, if received .12. The licensed nurse, when administering as needed (PRN) pain medication will record the drug administration and the following on the Medication Administration Record (MAR): Pain level using a 0-10 numerical rating scale .as appropriate .Follow-up observations post-intervention to determine the effectiveness of PRN pain interventions. If the resident is asleep or resting, document as an observation in a progress note. R1 was admitted to the facility on [DATE] and had diagnoses including infection of deep incisional surgical site, unspecified abdominal pain, varicose veins of bilateral lower extremities with pain, unspecified chest pain, nerve root and plexus disorder, and intervertebral disc degeneration of lumbar region. An admission Minimum Data Set (MDS) assessment, dated 5/22/26, stated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 had intact cognition. The assessment also indicated R1 was at risk for pain and received scheduled pain medication.A care plan, dated 5/19/26, indicated R1 had pain and the potential for pain due to recent back surgery. The care plan contained interventions to notify the physician if interventions are unsuccessful or if current complaint is a significant change from R1's experience of pain (dated 5/19/26). A hospital Discharge summary, dated [DATE], indicated R1 had a postoperative lumbar wound infection at L4-L5 and chronic midline low back pain. R1 returned to the hospital on 5/22/26. On 7/7/26 at 11:53 AM, Surveyor interviewed R1's Significant Other ((SO)-F) who stated the facility did not administer pain medication as needed to alleviate R1's pain, specifically at night. SO-F stated R1 asked for pain medication one evening and did not receive it for 2 hours. The concern was reported to staff. SO-F stated R1 often cried and complained of pain when they arrived at facility or when they talked with R1 via phone. SO-F stated they discharged R1 from the facility on 5/22/26 and brought R1 to the hospital to be admitted for pain management. R1's physician orders included the following medications for pain:~ Oxycodone-acetaminophen (an opioid medication) 10-325 milligrams (mg) 1 tablet every 4 hours as needed (PRN) for pain (started 5/19/26)~ Tizanidine (a muscle relaxant) 4 mg every 6 hours PRN (started 5/19/26)~ Lyrica (a neuropathic pain agent) 150 mg three times daily for intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain (started 5/19/26)~ Acetaminophen (Tylenol) 650 mg every 8 hours PRN for pain (started 5/19/26)~ Diclofenac sodium external gel 1% (a nonsteroidal anti-inflammatory medication) apply to affected area topically every 6 hours PRN for pain (started 5/19/26)~ Fentanyl transdermal patch (an opioid medication) 72 hour 25 microgram/hour (mcg/hr) apply 25 mcg transdermally every 72 hours related to nerve root and plexus disorder (started 5/20/26) ~ Lidoderm patch 5% (a local anesthetic) apply to affected area topically every 24 hours PRN for pain~ Pain evaluation every shift for pain management (started 5/19/26) R1's MAR indicated oxycodone-acetaminophen was administered on the following dates:~ On 5/19/26 at 9:20 PM for pain at a level 8/10 (with 10 being the worst pain) - a follow-up pain level of 8/10 was documented on 5/20/26 at 7:47 AM. ~ On 5/20/26 at 7:49 AM for pain at a level 8/10; a follow-up pain level of 5/10 was documented at 10:39 AM. ~ On 5/20/26 at 12:41 PM for pain at a level 8/10; a follow-up pain level of 4/10 was documented at 2:40 PM. ~ On 5/20/26 at 7:25 PM for pain at a level 8/10; a follow up pain level of 5/10 was documented at 8:30 PM. ~ On 5/21/26 at 3:23 AM for pain at a level 6/10; a follow-up pain level of 2/10 was documented at 5:20 AM. ~ On 5/21/26 at 7:38 AM for pain at a level 8/10; a follow-up pain level was not documented. ~ On 5/21/26 at 11:38 AM for pain at a level 8/10; a follow-up pain level of 5/10 was documented at 12:54 PM. ~ On 5/21/26 at 3:47 PM for pain at a level 5/10; a follow-up pain level of 3/10 was documented at 7:48 PM. ~ On 5/21/26 at 7:49 PM for pain at a level 3/10; a follow-up pain level of 2/10 was documented at 8:50 PM. ~ On 5/22/26 at 3:55 AM for pain at a level 6/10; a follow-up pain level of 3/10 was documented at 3:56 AM. ~ On 5/22/26 at 9:15 AM for pain at a level 9/10; a follow-up pain level of 8/10 was documented at 10:49 AM. ~ On 5/22/26 at 1:30 PM for pain at a level 7/10; a follow-up pain level of 8/10 was documented at 3:54 PM. R1's MAR indicated a Fentanyl patch was administered on the following date:~ On 5/20/26 at 7:39 AM for pain at a level 8/10.R1's MAR indicated Lyrica was not administered from 5/19/26 through 5/22/26 because the medication was unavailable. R1's MAR indicated they did not receive additional PRN medication between 5/19/26 through 5/22/26 including tizanidine, acetaminophen, diclofenac, or Lidoderm, to assist with break through pain. In addition, R1 did not receive pain medication during the hours of 9:20 PM and 3:55 AM. R1's vital signs from 5/19/26 through 5/22/26 included 34 numerical pain evaluations. Eighteen (53%) of the evaluations indicated R1 had a pain level between 7 and 10.On 7/7/26 at 12:29 PM, Surveyor interviewed Registered Nurse (RN)-D who stated R1 could make their needs known and would call when they wanted pain medication. RN-D was aware that pain was an issue for R1. RN-D stated when a resident reports pain at a level 9 or 10, they should be sent to the hospital. RN-D stated if pain is not controlled, the provider should be updated. On 7/7/26 at 1:07 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who did not recall R1 but acknowledged R1's MAR indicated they administered pain medication to them. LPN-E stated pain medication is administered per the physician's order. LPN-E stated if a resident's pain level is outside their baseline, they check the resident's vital signs to see if there is a trend, or if there is relief with pain medication. If there is a concern, they update the physician. A Grievance Report, dated 5/21/26, indicated R1 requested pain medication at approximately 5:30 PM on 5/20/26 but had to wait almost 2 hours before the medication was provided. The report indicated Nursing Home Administrator (NHA)-A spoke with LPN-G on 5/26/26 who spoke with R1 and SO-F at approximately 4:30 PM on 5/20/26. LPN-G stated R1 did not request pain medication. An attached statement, completed and signed by LPN-G, stated it was reported to LPN-G that R1 and SO-F were concerned about timely administration of pain medication. LPN-G reviewed R1's medication schedule to determine when the next dose could be given which was between 4:30 and 5:30 PM. The statement indicated when LPN-G entered R1's room around that time and asked if it was a good time for medication, R1 and SO-F agreed. LPN-G administered medication at that time. When asked if it was R1's preference to stay ahead of the pain medication or if R1 wanted to request it, R1 stated they wanted to stay on top of the pain. LPN-G informed R1 that the next dose would be available between 8:30 PM and 9:30 PM. The statement indicated LPN-G and another LPN went to R1's room to administer medication at that time. On 7/7/26 at 2:44 PM, Surveyor interviewed LPN-G who stated LPN-G provided R1 with pain medication on 5/20/26 between 4:30 and 5:30 PM and later that evening. Surveyor showed LPN-G R1's MAR that indicated they received pain medication on 5/20/26 at 12:21 PM and 7:25 PM, but did not indicate they received medication between 4:30 and 5:30 PM. LPN-G stated they must not have provided the pain medication. On 7/7/26 at 3:47 PM, Surveyor interviewed interim Director of Nursing (DON)-B who stated the facility did not have documentation that R1's provider was updated on their continued complaints of pain. DON-B did not confirm if R1's provider should have been updated, but stated nurses should monitor a resident's pain and update the provider if pain is not effectively managed.

Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R1 and R2) of 3 sampled residents. R1 was on a facility-provided list of resident who smoke, vape, or use nicotine. R1's safe smoking evaluation and care plan indicated vaping materials should be stored at the nurses' station. R1 kept vaping materials in R1's room and vaped inside the facility. R2 was on a facility-provided list of residents who smoke, vape, or use nicotine. R2's care plan indicated smoking materials should be stored at the nurses' station. R2's smoking materials were observed in R2's room. Findings include: The facility's Safe Smoking/Tobacco Use Policy, revised 1/2026, indicates: Smoking is not permitted in the facility or where oxygen is in use .3. A resident who smokes, uses smokeless tobacco, or uses an e-cigarette is evaluated to determine whether the resident is safe or unsafe to use tobacco products or e-cigarettes .a. Upon admission or re admission .a Safe Smoking/Tobacco Use Evaluation (UDA) is completed. b. Quarterly, annually, with significant change of condition, and/or an infraction of the smoking policy, the Safe Smoking/Tobacco Use Evaluation (UDA) is completed .7. Staff maintain all smoking materials (e.g., cigarettes, cigars, smokeless tobacco, loose tobacco, pipes, lighters, lighter fluid, e-cigarettes, etc) as appropriate for the resident. Staff members may distribute smoking materials to residents at smoking times or may provide a locked container to residents determined to be safe while smoking .8. Residents who use e-cigarettes are required to follow manufacturer's instructions for the use and care of the e-cigarette and any associated equipment .9. Smoking, smokeless tobacco use, and e-cigarette use occurs in designated locations that are environmentally separate from all resident care areas .12. Nursing staff re-evaluate residents who are involved in incidents involving smoking/tobacco use/e-cigarettes .This re-evaluation may result in a greater degree of supervision, use of a protective smoking vest apron while smoking, or discharge from the facility. 13. If it is determined that a policy infraction has occurred: a. The first infraction results in a warning, verbal or written, to the resident and his/her representative. The smoking policy is reviewed with the resident and/or the resident's representative .b. The second infraction results in a notice of involuntary discharge. Discharge procedures are initiated and pursued to completion. The reason for involuntary discharge is endangerment to the health and safety of residents . 1. Between 3/12/26 and 3/13/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, chronic obstructive pulmonary disease (COPD), diabetes, anxiety, and nicotine dependence on cigarettes. R1's Minimum Data Set (MDS) assessment, dated 3/7/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was responsible for R1's medical decisions. R1's plan of care indicated: ~ R1 chooses to vape. Asked to turn in smoking materials when not smoking (Initiated 4/22/21; Revised 3/14/25).~ R1 will vape in designated areas until next review (Initiated 4/22/21; Revised 12/19/25). ~ Encourage all smoking items to be left at the nurses' station (Initiated 3/29/22). ~ Non-compliant with smoking policy. R1 has been observed to vape in R1's room (Initiated 3/18/22; Revised 3/22/22). ~ R1 educated to appropriate smoking areas (Initiated 4/22/21).~ Risk versus benefits form filled out as R1 continues to vape in R1's room (Initiated 4/2/22). A Safe Smoking Evaluation, dated 3/4/26, indicated: R1 was informed of safe smoking evaluation results, safe smoking policies/procedures. and that all smoking materials must be secured in the nurses' station/supply room/designated area when not in use. R1 must request smoking materials from staff. On 3/12/26 at 11:37 PM, Surveyor entered R1's room with Certified Nursing Assistant (CNA)-C who answered R1's call light. R1 was in bed. Surveyor observed a pink and black e-cigarette (vape cartridge) on a blanket on R1's right side and an e-cigarette/vape plugged into a computer on a table next to R1's bed. CNA-C assisted R1 with a room temperature concern and left the room. On 3/12/26 at 11:38 PM, Surveyor interviewed R1 who indicated the items were vaping devices and belonged to R1. R1 stated R1 vapes outside during the day but vapes in the room at night. R1 indicated staff get R1 up to go outside if R1 asks, however, once R1 is in bed, R1 likes to stay in bed. R1 usually goes to bed between 7:00 and 8:00 PM and falls asleep between 2:00 and 3:00 AM. R1 stated R1 keeps the vaping materials and vapes in the room approximately 10 to 20 times or more per hour. R1 stated R1 also vapes in the room in the morning before R1 gets up, but vapes outside when R1 is up. R1 stated staff know R1 vapes in the room and see the vaping devices. R1 stated staff don't ask about the vaping device or tell R1 not to vape inside. R1 stated staff tried to take the vaping devices away over a year ago but don't do so any more. R1 stated the pink and black vape device is disposable and the device plugged into R1's computer is refillable and rechargeable. R1 buys vapes and materials at a gas station near by or orders them online. At 11:53 PM, R1 used one of the devices to show Surveyor that it lit up during use. When asked if management knows R1 vapes in the facility, R1 stated Director of Nursing (DON)-B is aware but was unsure if Nursing Home Administrator (NHA)-A is aware. On 3/13/26 at 12:03 AM, Surveyor interviewed CNA-C who confirmed CNA-C saw two vaping devices in R1's room. CNA-C was unsure if R1 was supposed to have the devices. CNA-C indicated staff and management are aware that R1 has the devices and uses them in R1's room. On 3/13/26 at 1:04 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who was aware that R1 vapes in the room and saw vaping devices in the room. When Surveyor stated R1 said staff are aware that R1 vapes in the room, LPN-D stated DON-B is aware. LPN-D indicated DON-B was part of a previous contract with R1 to store vaping materials at the nurses' station, however, R1 has been openly vaping for a long time. LPN-D indicated R1 turned in R1's smoking materials for a while but eventually staff figured out that R1 only turned in empty devices and kept the useable devices. LPN-D indicated LPN-D is unable to keep R1 from vaping. On 3/13/26 at 1:11 AM, Surveyor interviewed Medication Technician (MT)-E who was aware R1 has vaping devices in the room. MT-E indicated MT-E asked R1 to store the devices at the nurses' station, however, R1 turned in used devices that didn't work and kept the usable ones in R1's room. MT-E stated MT-E heard from others that R1 vapes in R1's room. On 3/13/26 at 1:14 AM, Surveyor and MT-E observed the lock box for smoking materials which did not contain any smoking materials for R1. 2. Between 3/12/26 and 3/13/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including acute kidney failure, diabetes, and nicotine dependence on cigarettes. R2's MDS assessment, dated 10/20/25, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. R2 was responsible for R2's medical decisions. R2's plan of care indicated: ~ R2 chooses to smoke cigarettes. R2 is able to move about the home and get self inside and ring the doorbell to be let back in (Initiated 8/12/24; Revised 3/14/25). ~ R2 will smoke in designated areas until next review (Initiated 8/12/24; Revised 8/8/25).~ R2 will turn smoking materials into nursing staff for safe keeping between smoking (Initiated 8/12/24; Revised 8/8/25).~ If safety becomes a concern, involve Interdisciplinary Team and R2 for re-evaluation of smoking needs (Initiated 8/12/24). ~ R2 educated to appropriate smoking areas (Initiated 8/12/24). A Safe Smoking Evaluation, dated 3/5/26, indicated R2 was informed of safe smoking evaluation results. On 3/12/26 at 11:29 PM, Surveyor observed R2 in R2's room in a wheelchair with a pack of cigarettes in hand. R2 exited the room and put the cigarettes in R2's pocket. R2 went past the nurses' station with three staff present, down the hall, and out the front door. R2 removed a cigarette from R2's pocket and lit the cigarette. On 3/12/26 at 11:33 PM, Surveyor interviewed R2 while R2 was smoking. R2 initially stated R2 did not keep R2's smoking materials in R2's room. When Surveyor stated Surveyor observed R2 in the room with smoking materials, R2 then stated R2 keeps the materials in R2's room. R2 stated when R2 picks up R2's cigarettes in the morning, R2 keeps them. R2 stated staff worry more about flammable stuff than cigarettes. On 3/13/26 at 12:03 AM, Surveyor interviewed CNA-C who stated R2 usually keeps R2's cigarettes and lighter for convenience and doesn't return them to the nurses' station. On 3/13/26 at 1:04 AM, Surveyor interviewed LPN-D who was aware that R2 keeps R2's smoking materials. LPN-D stated the materials are supposed to be stored in a lock box behind the nurses' station, however, there is no follow-up or consistency so R2 and other residents keep their materials. On 3/13/26 at 1:11 AM, Surveyor interviewed MT-E who was aware that R2 keeps R2's smoking materials. MT-E indicated R2 is not a supervised smoker and can keep R2's cigarettes and lighters. MT-E indicated R2 often gets cigarettes from other residents. On 3/13/26 at 1:14 AM, Surveyor and MT-E observed the lock box for smoking materials which did not contain any smoking materials for R2. On 3/13/26 at approximately 1:30 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff and residents should follow the facility's smoking policy. DON-B indicated staff are supposed to keep R1 and R2's smoking materials which should not be kept on their person or in their rooms. DON-B stated DON-B was not aware that R1 keeps vaping materials in R1's room or vapes in the room.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. One of three medication carts was observed unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the * residents residing in the facility. The 300 wing medication cart was unlocked and unattended during medication administration on 5/28/25. Findings include: The facility's Medication Storage policy, revised 1/2023, indicates: .c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 5/28/25 at 9:07 AM, Surveyor observed Licensed Practical Nurse (LPN)-L administer medication to residents. During the observation, LPN-L returned to the medication cart to retrieve a medication for a resident and left the medication cart unlocked and unattended in the hallway after entering the resident's room. The medication cart was left unlocked and unattended for 20 minutes. On 5/28/25 at 9:42 AM, Surveyor interviewed LPN-L who verified LPN-L left the medication cart open and unattended. LPN-L indicated it done on accident and LPN-L's practice was to lock the medication cart when unattended. On 5/29/25 at 11:11 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated medication carts should always be locked when unattended.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 4 residents (R) (R1, R35, R30, and R15) of 6 residents observed during medication administration and the provision of cares. R1 was on enhanced barrier precautions (EBP). Staff did not wear a gown and gloves at all times during a pressure wound dressing change or urostomy and colostomy care. Staff did not complete proper hand hygiene before or after preparing medication and prior to administering medication to R35, R30, and R15. Findings include: The facility's Handwashing/Hand Hygiene policy, dated August 2014, indicates: This facility considers hand hygiene the primary means to prevent the spread of infections .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .c. Before preparing or handling medications . The facility's Enhanced Barrier Precautions policy, revised March 2024, indicates: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident cares .4. High-contact resident cares include: .g. Device care or use: central lines, urinary catheters .h. Wound care: any skin opening requiring a dressing . 1. On 5/28/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, stage 4 pressure ulcer, urostomy, and colostomy. R1's Minimum Data Set (MDS) assessment, dated 3/9/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. On 5/28/25 at 7:49 AM, Surveyor observed an EBP sign posted outside R1's room and observed Licensed Practical Nurse (LPN)-L and Registered Nurse (RN)-M provide a wound dressing change, a urostomy bag/dressing change, and a colostomy bag/dressing change for R1 without wearing gowns. R1 was on EBP which required staff to don a gown during high-contact resident cares, including wound care. During wound care, Surveyor observed RN-M retrieve a scissors from RN-M's pocket with a gloved hand, sanitized the scissors, and continued with wound care without changing gloves. After RN-M changed R1's urostomy and colostomy bags and dressings, RN-M removed gloves. Without cleansing hands and donning clean gloves, RN-M secured the dressing sites with tape. On 5/28/25 at 8:25 AM, Surveyor interviewed RN-M who verified RN-M did not wear a gown during high-contact cares for R1. RN-M verified RN-M retrieved scissors from RN-M's pocket with a gloved hand and removed gloves to apply adhesive tape to R1's dressing sites. RN-M indicated a gown should be worn during dressing changes, gloves should be worn when applying dressings, and gloves should be changed when compromised. On 5/28/25 at 9:43 AM, Surveyor interviewed LPN-L who verified LPN-L did not wear a gown during R1's dressing changes. LPN-L indicated LPN-L should have worn a gown. On 5/28/25 at 11:38 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should follow the facility's EBP policy when completing wound care, urostomy care, and colostomy care. 2. On 5/28/25 at 7:34 AM, Surveyor observed LPN-L prepare medication for R35. LPN-L did not complete hand hygiene before or after medication preparation or prior to administering medication to R35. On 5/28/25 at 7:43 AM, Surveyor observed LPN-L prepare medication for R30. LPN-L did not complete hand hygiene before or after medication preparation or prior to administering medication to R30. On 5/28/25 at 9:07 AM, Surveyor observed LPN-L prepare medication for R15. LPN-L did not complete hand hygiene before or after medication preparation or prior to administering medication to R15. On 5/28/25 at 9:43 AM, Surveyor interviewed LPN-L who indicated hand hygiene should be performed before preparing and administering medication. LPN-L verified LPN-L did not complete hand hygiene but should have. On 5/29/25 at 11:38 AM, Surveyor interviewed DON-B who indicated staff should complete hand hygiene prior to administering medication to residents.

Based on observation, staff interview, and record review, the facility did not ensure adequate assistance to prevent accidents was provided for 1 resident (R) (R43) of 3 sampled residents. R43 was observed without care planned fall prevention interventions on multiple occasions from 5/27/25 to 5/29/25. Findings include: The facility's Fall Reduction Policy, dated October 2020, states residents will be assessed for risk of falling and risk management should monitor to ensure the facility's policies and protocols are followed, including implementation and effectiveness of interventions. On 5/27/25, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) on the left side, dysphagia (difficulty swallowing), type 2 diabetes, anxiety, and depression. R43's most recent Minimum Data Set (MDS) assessment, dated 3/21/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R43 had severe cognitive impairment. The MDS assessment also indicated R43 had functional impairment of the bilateral lower extremities and one upper extremity (left) and required substantial assistance for all activities of daily living (ADLs). R43's comprehensive care plan, revised 6/28/24, indicated R43 was at risk for falls related to deconditioning due to a stroke. The care plan contained interventions for non-skid socks and/or shoes (6/21/24), a door bell call light on the wall next to the bed and on the bedside table (10/14/24), and an air conditioning unit in the window (5/21/25). R43's most recent fall risk assessment, dated 3/29/25, indicated R43 was at risk for falls. R43's medical record indicated R43 fell on 5/25/25, 5/21/25, 3/19/25, 1/15/25, and 12/24/24. On 5/27/25 at 10:06 AM, Surveyor noted R43's door bell call light was out of reach and did not observe a window air conditioning unit in R43's room. On 5/28/25 at 9:03 AM, 10:12 AM, 11:56 AM, 1:23 PM, and 2:02 PM, Surveyor observed R43 in R43's room in a Broda chair in bare feet without non-skid socks or shoes and did not observe a window air conditioning unit in R43's room. On 5/29/25 at 9:04 AM and 10:40 AM, Surveyor noted R43's door bell call light was out of reach on R43's impaired (left) side. Surveyor noted R43's room had a window air conditioning unit at that time. On 5/29/25 at 10:55 AM, Surveyor interviewed Registered Nurse (RN)-D who verified R43 should have non-skid footwear on at all times. RN-D also stated R43's call light should be placed on the right side. RN-D indicated R43 occasionally used the call light to make R43's needs known. RN-D verified the window air conditioning unit was installed sometime between 5/28/25 and 5/29/25. On 5/29/25 at 11:20 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R43's call light should always be within reach on R43's right side which was R43's stronger side. DON-B also confirmed R43 should always have non-skid footwear/socks on. DON-B indicated fall interventions should be put in place immediately (or as soon as possible) after a fall and the resident's care plan should be updated. On 5/29/25 at 1:30 PM, Surveyor interviewed Maintenance Director (MD)-J who indicated DON-B sent a message to MD-J at approximately 4:00 PM on 5/28/25 to install R43's air conditioning unit. MD-J stated MD-J had a few window units in storage and was able to install the unit right away.

Based on staff interview, and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R24) of 3 sampled residents. R24's wound care order was changed following a wound clinic appointment on 5/19/25. The facility did not implement the new order or order the needed supplies in a timely manner. In addition, the facility did not notify R24's physician or obtain an alternate order until the supplies could be obtained. Findings include: The facility's undated Skin Management policy indicates: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. From 5/27/25 to 5/29/25, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis, use of antibiotics, quadriplegia, anoxic brain damage, dysphagia, contractures, and chronic pain syndrome. R24's Minimum Data Set (MDS) assessment, dated 5/15/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R24 had moderately impaired cognition. R24 had a skin integrity care plan that indicated R24 had pressure injuries related to decreased mobility and contractures. R24 had a stage 4 pressure injury on the right 5th metatarsal head and an unstageable pressure injury on the left 5th toe. The care plan was initiated on 5/17/25 and revised on 5/23/25. R24 had a physician order, dated 4/6/25, that indicated: Wound dressing instructions right 5th metatarsal head: Remove dressing. Irrigate wound with saline. Apply small amount of Iodosorb or Iodoflex over the wound. Cover with Mepilex border. Apply rest of foam over Mepilex border if available for offloading. Change every other day and as needed for dressing soilage. One time a day on odd days and as needed. On 5/19/25, R24 went to the wound clinic. R24's treatment order for the right 5th metatarsal head was changed to: Remove dressing. Irrigate wound with saline. Apply small amount of Iodosorb or Iodoflex over the wound. Apply cut out maypad (sic) around the wound on the periwound skin for offloading (these can be obtained through durable medical equipment (DME)). (A phone number was included to order if needed.) Cover with dry dressing. Change every other day (maypad (sic), if not soiled and remains in place, can be left in place for 7 days and changed weekly) and as needed for dressing soilage On 6/4/24, Surveyor interviewed Wound Clinic Nurse (WCN)-K who indicated the maypad referred to in R24's wound care order was a mayo pad which WCN-K described as a felt pad cut out around the wound in order to apply no weight bearing and protect the wound. Surveyor noted the 5/19/25 wound clinic order was not transcribed or added to R24's plan of care and staff were still completing the treatment order from 4/6/25. On 5/29/25 at 8:59 AM, Surveyor interviewed Director of Nursing (DON-B) regarding R24's most recent wound care order. DON-B indicated the facility had to order mayo pads. DON-B indicated the staff who ordered supplies had been off for a while but was back and would order them. On 5/29/25 at 10:44 AM, Surveyor interviewed Materials Management (MM)-H who confirmed MM-H ordered medical supplies for the facility. MM-H indicated MM-H is notified via staff or email when supplies need to be ordered. MM-H confirmed R24's mayo pads were not ordered because MM-H had been off from 5/16/25 to 5/27/25. MM-H indicated MM-H would order the mayo pads on Friday (5/30/25) and they would be delivered on Tuesday (6/3/25). When asked who ordered supplies when MM-H was off, MM-H indicated MM-H did not have a backup. On 5/29/25 at 10:45 AM, Surveyor interviewed Wound Nurse (WN)-I who completed R24's wound care that day and noted R24's wound had improved. WN-I indicated R24's wound care order was not changed yet because the facility did not have mayo pads. WN-I indicated WN-I would call the wound clinic to let them know and find out if they recommended an alternative until the mayo pads arrived. WN-I verified WN-I was not notified that the facility did not have the supplies for R24's new order and confirmed WN-I would have contacted the wound clinic about an alternative until the supplies were received.

Based on staff interview and record review, the facility did not ensure the necessary care and treatment to prevent weight loss and dehydration was provided for 2 residents (R) (R40 and R51) of 5 sampled residents. R40 had significant weight loss. Weekly weights were not implemented per Registered Dietician (RD)-G's recommendation and a nutrition care plan was not implemented timely. R40's quarterly evaluation for nutrition, dated 4/2/25, contained a weight from 1/6/25 and did not indicate a current weight was requested at the quarterly review. In addition, R40's family's request to evaluate R40's stomach issues was not completed timely. R51 had severe weight loss without appropriate follow-up. In addition, R51 had an order for weekly weights which was not implemented or completed. Findings include: The facility's Weight Management policy, revised November 2021, indicates: Residents' nutritional status will be monitored on a regular basis to aid in the maintenance of acceptable parameters, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Accurate weights are obtained by having staff follow a consistent approach to weighing and using an appropriately serviced and functioning scale .The measurement of weight is a guide in determining nutritional status. Therefore, the evaluation of the significance of weight gain or loss is a part of the assessment process. Nutritional status, including weight, is influenced by calories, protein, and fluid. Weight can be a useful indicator of nutritional status when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem .Complete monthly weights in the same week each month .7. Staff members will be assigned to: Obtain weight and re-weight data .b. determine residents that should be re-weighed. The interdisciplinary team (IDT) will update the care plan and communicate with the resident, the resident's representative, and staff regarding interventions to be implemented. 1. From 5/27/25 to 5/29/25, Surveyor reviewed R40's medical record. R40 was admitted to the facility on [DATE] and had diagnoses including gastroesophageal reflux disease (GERD), generalized anxiety disorder, depression, and muscle weakness. R40's Minimum Data Set (MDS) assessment, dated 4/4/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R40 had intact cognition. R40's medical record indicated: ~ R40 did not have a weight completed between 1/6/25 and 5/5/25. ~ R40's Treatment Administration Record (TAR) noted R40 refused to be weighed on 2/3/25, 3/3/25, 5/10/25, and 5/12/25. On 4/28/25, nothing was recorded. On 5/10/25, R40 had an order for daily weights for 5 days. R40 was weighed on 5/11/25, 5/13/25, and 5/14/25. On 5/10/25 and 5/12/25, R40 refused to be weighed. ~ A mini-nutrition assessment, dated 4/2/25, indicated 40 had mild dementia and a body mass index (BMI) of 23 or greater. R40's weight was documented as 160.3 pounds (from 1/6/25). The assessment indicated R40 did not have a decrease in food intake or weight loss in the last 3 months and did not suffer psychological stress or acute disease. R40 was able to get out of R40's bed/chair but did not go out. R40's mini nutrition score was 12.0 which indicated R40 had normal nutritional status. A physician note, dated 4/7/25, indicated R40 complained of stomach pain and pointed to R40's epigastric region. R40's PPI (proton pump inhibitor) (a class of medications used to reduce stomach acid production) dose was previously lowered. R40 requested Tums (an antacid medication used to relieve heartburn and acid indigestion). An increase in R40's PPI would be considered if Tums was ineffective. The note indicated the physician would reduce R40's Depakote (an anticonvulsant and mood stabilizing medication) to see if R40's weakness improved. A progress note, dated 4/8/25 at 10:50 AM, indicated R40's managed care organization (MCO) and power of attorney (POA) notified the writer of some concerns. They were updated on R40's physician visit on 4/7/25. They asked if R40 could try therapy again and stated they were concerned about R40's stomach issues and wanted to pursue further diagnostic testing. R40's physician was updated. Surveyor noted R40's meal intakes decreased around 4/11/25 and went from 50-100% to 0-50%. On 5/2/25, the facility added an order to weigh R40 monthly one time a day every 4 weeks on Friday. Surveyor noted R40 did not have an order for weekly weights. An At-Risk IDT Review, dated 5/9/2025 at 1:12 PM, indicated the IDT team reviewed R40 for weight loss. R40 was on a 5 day weight regimen to determine R40's base weight. R40 often refused weights. R40's current weight was 129.8 pounds. R40's meal intake was 0-25% and fluid intake was an average of 1178 milliliters (ml) over 7 days. RD-G was waiting to find out R40's base weight to determine the best regimen. A nutrition/dietary note, dated 5/11/25 at 7:45 PM, indicated R40's weight had decreased 16% in 5 months. R40 weighed 134 pounds and had a BMI of 19.9 which was near underweight. R40 was on a CC4/regular/thin diet with no chewing/swallowing problems and no signs/symptoms of diet intolerance. R40's meal intake was 0-25% and fluid intake was 1.2 liters. R40 received Mighty Shakes (a supplement drink) three times daily and ice cream twice daily. R40 received as needed (PRN) medication for constipation and drank well during fluid pass. The note contained a recommendation for juice three times daily between meals and at fluid pass to provide 600 kilocalories and 18 grams of protein. Weekly weights were also recommend due poor intake. If weight loss continued, there was a recommendation to switch twice daily ice cream to Magic Cups. The note contained an instruction to continue to monitor weight, labs, and skin and alert RD-G as needed. A note to the physician, dated 5/12/25 at 4:18 PM, indicated R40 had significant weight loss since admission and frequently refused to be weighed. R40 generally ate 0-25% of meals and was offered nutritional drinks. The physician was asked to review and advise. R40's weights were as follows: ~ On 5/11/25, R40 weighed 134.8 pounds. ~ On 5/5/25, R40 weighed 129.8 pounds. ~ On 1/6/25, R40 weighed 160.3 pounds. ~ On 12/29/24, R40 weighed 160.0 pounds. ~ On 12/28/24, R40 weighed 160.2 pounds. ~ On 12/27/24, R40 weighed 161.4 pounds. A progress note, dated 5/12/25, indicated staff asked the physician to see R40 for notable weight loss and poor oral intake. The physician addressed R40's weight loss and indicated orders would likely start with a computed tomography (CT) scan of the chest, abdomen, and pelvis. Labs were ordered. On 5/23/25, R40 had a CT scan. The results indicated R40 had a large colorectal stool burden with distention of the rectum to 8.2 centimeters (cm). There was no evidence of obstruction or perforation. A Nurse Practitioner (NP) note, dated 5/27/25 at 6:42 AM, indicated there was nothing to explain R40's abdominal pain, weight loss, and decline. Miralax 17 grams daily was started. R40 was referred for an esophagogastroduodenoscopy (EGD) that staff should schedule. On 5/28/25 at 11:26 AM, Director of Nursing (DON)-B informed Surveyor that staff could not find paperwork that indicated the physician was notified when R40's POA and MCO requested further evaluation of R40's stomach issues (as indicated in the 4/8/25 progress note). DON-B indicated the family was updated on R40's physician visit the previous day and Tums order. DON-B was not sure if further testing was completed between the family's request on 4/8/25 and R40's identified weight loss on 5/10/25. On 5/28/25, Surveyor noted R40 did not have a care plan related to weight loss. Later on 5/28/25, the facility added a care plan that indicated R40 had a potential nutritional problem and recent hospitalization with goals of no gastrointestinal (GI) complains or significant weight loss. On 5/29/25, Surveyor observed R40's lunch. R40 ate in R40's room and refused lunch but accepted 2 [NAME] bars. On 5/28/25 at 1:40 PM, Surveyor interviewed RD-G who stated employment in November of 2024. RG-D was at the facility twice per month and could be reached via email or phone. RD-G took over nutritional charting approximately 2 months ago when the staff who completed quarterly charting left the facility. RD-G verified R40's medical record did not contain an order for weekly weights. RD also confirmed if a resident refused to be weighed, the refusal should be documented and the resident should be reapproached. RD-G indicated RD-G communicated the order changes for weights to Director of Nursing (DON)-B. RD-G confirmed R40 did not have a nutritional care plan until 5/2/25 and indicated either RD-G or nursing staff complete care plans when concerns are identified. RD-G also confirmed RD-G used a weight from January of 2025 for R40's quarterly nutritional evaluation. RD-G indicated RD-G preferred to have an updated weight but there were none available. 2. On 5/27/25, Surveyor reviewed R51's medical record. R51 was admitted to the facility on [DATE] and had diagnoses including GERD, osteoporosis, history of falls, unsteadiness on feet, overactive bladder, and weakness. R51's MDS assessment, dated 3/15/25, had a BIMS score of 11 out of 15 which indicated R51 had moderately impaired cognition. R51 had an activated Power of Attorney for Healthcare (POAHC). R51 was currently hospitalized (not related to the investigation). R51's plan of care indicated R51 was at risk of malnutrition due to chronic kidney disease. R51's care plan contained a goal that R51 would intake nutrients to meet R51's metabolic needs and have no significant weight change through the review date. R51's medical record indicated R51 had a 9.12% weight loss over the 6 months R51 resided at the facility. Surveyor noted R51's most recent weight was on 3/14/25. Surveyor reviewed R51's weights from admission to the present and noted the following: ~ On 12/6/24, R51 weighed 155.6 pounds. ~ On 12/7/24, R51 weighed 150.5 pounds. ~ On 12/8/24, R51 weighed 149.0 pounds. ~ On 1/16/25, R51 weighed 145.2 pounds. ~ On 1/21/25, R51 weighed 144.4 pounds. ~ On 1/28/25, R51 weighed 144.0 pounds. ~ On 2/4/25, R51 weighed 143.8 pounds. ~ On 3/10/25, R51 weighed 143.8 pounds. ~ On 3/14/25, R51 weighed 142.6 pounds. On 5/28/25 at 10:47 AM, Surveyor interviewed Hospital Registered Nurse (HRN)-F who indicated the hospital weighed R51 that morning and R51's current weight was 141.4 pounds. Surveyor reviewed R51's Medication Administration Record (MAR) and Treatment Administration Record (TAR). Surveyor noted an order that indicated: Weight-monthly. One time a day every 4 weeks on Tuesday. Start date: 2/4/25. Surveyor noted R51's April and May 2025 MAR/TAR did not contain documentation of R51's weights. R51's May 2025 MAR/TAR was marked as not applicable (NA) since R51 was absent from the facility. Surveyor used the following formula to determine percentage of weight loss for R51: Percent of body weight loss = (usual weight - actual weight)/(usual weight) x 100. The following table was used to analyze the results: ~ 1 month = Significant Loss - 5%, Severe Loss - Greater than 5% ~ 3 months = Significant Loss - 7.5%, Severe Loss - Greater than 7.5% ~ 6 months = Significant Loss - 10%, Severe Loss - Greater than 10% Surveyor used R51's admission weight as the usual weight. Surveyor applied the facility weights as documented (using the nearest applicable dates) along with R51's 5/28/25 hospital weight to determine the following percentages of weight loss for R51: ~ 1 month (12/6/24 - 1/16/25): 6.68% weight loss which was considered a severe loss in a one month period. ~ 3 months (12/6/24 - 3/10/25): 7.58% weight loss which was considered a severe loss in a three month period. ~ 6 months (12/6/24 - 5/28/25): 9.12% weight loss which was just under the significant loss criteria of 10%. A nutritional assessment, completed by RD-G and dated 12/13/24 (and was the only nutritional assessment since R51's 12/6/24 admission), indicated R51 did not have edema, was on a regular diet with no restrictions, did not take supplements, and did not have weight loss. The assessment indicated R51's weight was 149 pounds (from 12/8/24). RD-G indicated if significant weight loss occurs, RD-G sends a recommendation for a health shake. Surveyor noted R51 had a 6.6 pound weight loss in two days despite the fact the assessment indicated R51 did not have any weight loss. A mini nutrition note, dated 3/10/25, indicated R51 did not have a decrease in food intake or weight loss in the last 3 months, had not suffered psychological stress or acute disease, and had no psychological problems. R51's BMI was 23 or greater. R51 had a mini nutrition score of 14.0 which indicated R51 had normal nutritional status. A Nutritional Assessment/Screening Summary, dated 3/13/25, indicated R51 was on a regular diet with meal intakes of 51-75% and fluid intakes of 1500 cubic centimeters (cc). R51 was not on any supplements. R51 weighed 143.8 pounds which was an 11 pound weight loss since admission. RD-G and nursing were aware. The note contained an instruction to continue to monitor weights and intakes weekly and consult RD-G as needed. On 5/28/25 at 12:48 PM, Surveyor interviewed DON-B who indicated R51 was not on the facility's list of residents with weight loss. When asked about nutritional documentation on 3/10/25 that indicated R51 did not have weight loss and nutritional documentation on 3/13/25 that indicated R51 had an 11 pound weight loss, DON-B indicated it should have been looked into. DON-B indicated RD-G had access to residents' weights, including R51. DON-B indicated R51 should have had an order for weekly weights. DON-B indicated it was concerning that there were no weights documented for R51 after 3/14/25 considering R51 experienced severe weight loss at the facility, DON-B indicated R51's weight refusals should have been documented and DON-B would follow-up with RD-G on the oversight. On 5/28/25 at 1:39 PM, Surveyor interviewed RD-G who indicated the facility's computer system notified RD-G if a resident had a significant weight loss and RD-G followed up with the IDT. When Surveyor asked if there was a nutritional assessment summary from 3/13/25 that listed weekly weights for R51, RD-G indicated weekly weights should have been obtained. RD-G did not know why weekly weights were not completed and stated the weekly weight note should have been given to DON-B and added to R51's orders. When asked about the nutritional note on 3/10/25 that indicated R51 did not have any weight loss, RD-G indicated RD-G did not enter that note in the system. When asked why R51's weight loss was not addressed, RD-G indicated RD-G reviewed weights with the IDT, however, R51's weight did not trigger. RD-G indicated R51's weight loss should have been addressed and weekly weights should have been completed if that is what the nutritional summary indicated.

Based on observation, staff, resident, resident representative interview, and record review, the facility did not ensure the resident environment remained free of abuse for 1 resident (R) (R2) of 10 sampled residents. R9 had a history of sexually inappropriate behavior toward residents and staff. R2 had a history of wandering in and out of residents' rooms unsupervised. On 10/23/24, R10 reported to R2's Guardian (GDN-O) that R9 had groped R2's breast in the dining room. GDN-O reported the allegation to Nursing Home Administrator (NHA)-A. R2 was not assessed for injury and there were no interventions put in place to supervise R9 and R2. The facility's failure to supervise a resident with a history of sexually inappropriate behavior and a vulnerable resident who wandered in the facility unsupervised created a finding of immediate jeopardy that began on 10/23/24. NHA-A was notified of the immediate jeopardy on 12/6/24 at 11:00 AM. The immediate jeopardy was removed on 12/6/24, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Abuse Prevention Program policy indicates: The purpose of this policy is to assure the facility is doing all that is within its control to prevent occurrences of abuse .This will be done by: .identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse .; implementing systems to promptly and aggressively investigate all reports and allegations of abuse .and making the necessary changes to prevent further occurrences .V. Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway. VI. Internal Investigation: 1. All incidents will be documented whether or not abuse .was alleged or suspected. 2. Any incident or allegation involving abuse .will result in an investigation. Resident Protection Investigation Paths: .If an allegation of physical sexual contact without penetration is involved: Do a full body exam. Check range of motion. Consult with a physician as to the need for further diagnostic examination or X-rays . On 12/4/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Non-Alzheimer's dementia with severe dementia with behavioral disturbances, anxiety, restlessness, and agitation. R2's Minimum Data Set (MDS) assessment, dated 9/3/24, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R2 had severe cognitive impairment. R2 had a Guardian for healthcare decisions. On 12/4/24, Surveyor reviewed R9's medical record. R9 was readmitted to the facility on [DATE]. R9 had diagnoses including vascular disease, cerebral infarction, and diabetes. R9's MDS assessment, dated 9/21/24, had a BIMS score of 13 out of 15 which indicated R9 was not cognitively impaired. R9 was R9's own decision maker. On 12/4/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including acute kidney failure, depression, and diabetes. R10's MDS assessment, dated 10/19/24, had a BIMS score of 15 out of 15 which indicated R10 was not cognitively impaired. R10 was R10's own decision maker. On 12/4/24 at 10:42 AM, Surveyor interviewed GDN-O who indicated R10 approached GDN-O on 10/23/24 and reported that before GDN-O arrived at the facility, R10 witnessed R9 fondle R2's breast in the dining room. R10 informed GDN-O that Registered Nurse (RN)-G moved R9 away from R2 and out of the dining room. When GDN-O asked RN-G why GDN-O was not notified, GDN-O indicated RN-G thought someone else was going to report it. GDN-O asked NHA-A to see footage from the video camera in the dining room but was denied. GDN-O was still upset two days later, asked NHA-A for more follow-up, and was again denied the ability to view video footage of the incident. GDN-O stated NHA-A indicated there was a split second in the video when R9 reached for R2, but R2 brushed R9's hand away. GDN-O asked to see the video a third time and was denied. GDN-O relayed the observations reported by NHA-A to R10. R10 indicated that was not accurate and told GDN-O that R9 had R9's hand on R2's breast for a while and was rubbing it. GDN-O indicated the facility should have reported the incident to the police. GDN-O indicated GDN-O was not happy with R2's care because R2 was often unsupervised and left to roam at will in the facility. R9's medical record contained the following: ~A progress note, dated 10/23/24 at 5:16 PM by RN-G, indicated R9 reached for another resident and the writer pulled R9 away. No contact was made when writer was present. R9 was escorted from the dining room. ~A progress note, dated 10/24/24 at 10:41 AM, indicated R9 has had increased sexual behaviors toward staff and residents. Staff redirected and educated R9 that sexual thoughts were normal but R9 should respect others' space and bodies. The note was sent by RN-H to Primary Physician (PP)-M and Nurse Practitioner (NP)-N and asked them to advise. ~A note, dated 10/24/24 at 3:07 PM, indicated R9 had daily behaviors and redirection was only partially effective and seemed less effective than previously. The note was entered by RN-H in response to PP-M and NP-N and asked them to advise. ~A note, dated 10/25/24 at 3:34 PM, indicated R9 had a new order for finasteride 5 milligrams (mg) daily prescribed by NP-N. R2's medical record did not contain documentation of the alleged sexual assault in the dining room on 10/23/24 or a skin assessment following the allegation of abuse. R10's medical record did not indicate R10 witnessed or reported a sexual assault in the dining room on 10/23/24. On 12/4/24 at 2:10 PM, Surveyor observed R9 in bed with the door open. R9 was not wearing pants and R9's buttock and groin were visible from the hallway. On 12/4/24 at 4:24 PM, Surveyor interviewed R10 who recalled the 10/23/24 incident involving R2 and R9 without being prompted. R10 indicated R9 groped R2 on the chest in the cafeteria for approximately one minute. As R10 made R10's way over to stop the incident, a staff quickly and urgently moved R9 away from R2. R10 was unsure if the staff saw what happened between R9 and R2 but thought they did due to the quick separation of the residents. R10 told GDN-O what R10 witnessed when GDN-O arrived to see R2 that day. R10 also reported the incident to NHA-A in a brief conversation. R10 indicated NHA-A seemed unconcerned. R10 was positive there was physical contact and stated the front of R2's shirt was moving when staff moved R9 away from R2. On 12/4/24 at 4:33 PM, Surveyor interviewed R9 who indicated (through head nods, head shakes, word mouthing, and hand gestures) that R9 did not touch anyone's breast. R9 indicated NHA-A talked to R9 about not touching people. When asked if NHA-A talked to R9 because R9 had touched someone, R9 nodded yes. On 12/4/24, Surveyor attempted to interview R2 who was unable to answer questions. On 12/4/24 at 4:42 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who worked on 10/23/24 but did not witness the incident between R9 and R2. CNA-L was informed that R9 attempted to touch R2's breast by an unknown staff. CNA-L indicated R9 was often naked in R9's room or naked on the bottom half in bed with the door open. CNA-L indicated R9 was handsy, grabbed staffs' butts, and told people they had nice asses. When asked what interventions were in place for R9's sexual behavior, CNA-L stated staff verbally redirected R9 and documented after the behavior occurred. CNA-L indicated R2 was often in other residents' rooms. CNA-L indicated there was no stopping R2. CNA-L felt there was not enough staff to appropriately supervise R2. On 12/4/24 at 4:54 PM, Surveyor interviewed RN- I who worked on 10/23/24 but was not aware of the incident between R9 and R2. When asked if R9 touched R2's breast, RN-I stated the incident rang a bell but RN-I was unsure if there was a touch or an attempt. RN-I indicated coworkers often talked about R9's sexual behavior and how they had to redirect R9. On 12/4/24 at 5:04 PM, Surveyor interviewed Med Tech (MT)-F who was outside the dining room window and saw R9 approach and reach for R2 on 10/23/24. When MT-F knocked on the window, R9 pulled R9's arm back from R2. MT-F indicated a staff then entered the dining room and pulled R9 away from R2. MT-F did not think anything sexual happened, but was later told (by an unknown staff) that R9 had touched R2. When asked what interventions were in place for R9, MT-F indicated R2 was not allowed in the dining room without staff or R2's spouse to protect R2 from being touched by R9. MT-F stated MT-F could not keep R9 out of the dining room but could try to protect R2. MT-F was unsure if the intervention to separate R9 and R2 was care planned and stated NHA-A and Director of Nursing (DON)-B gave the directive several times during daily huddles. On 12/4/24 at 5:08 PM, Surveyor interviewed PP-M who was aware R9 had increased sexual behavior toward residents and staff but was not aware of any specific incidents, including the incident on 10/23/24. PP-M indicated Surveyor should speak with NP-N regarding R9's finasteride order. PP-M indicated finasteride was most likely prescribed to decrease R9's sexual behaviors. On 12/4/24 at 5:12 PM, Surveyor interviewed CNA-K who worked on 10/23/24 but was not aware of the incident between R9 and R2 and was not aware of a directive to keep R9 away from R2. CNA-K heard from coworkers that R9 offered them money to touch their breasts. CNA-K stated R2 was often in other residents' rooms and indicated CNA-K could not keep track of R2 if CNA-K was completing cares. CNA-K indicated it was especially difficult after 6:00 PM and R2 was left to roam the halls. CNA-K indicated if R2 was not in the hall, R2 was probably in another resident's room. CNA-K tried to keep R2 in common areas. On 12/4/24 at 5:27 PM, Surveyor interviewed RN-G who stated R9 offered staff money for sexual favors. RN-G indicated R9's behaviors were often verbal, however, R9 reached for body parts and patted people's bottoms. RN-G verified RN-G removed R9 from the dining room on 10/23/24, directed R9 to R9's room, and told R9 that R9 could not touch or approach people without their permission. RN-G did not see any contact between R9 and R2 which was what RN-G documented. When asked why RN-G separated R9 and R2 if nothing occurred, RN-G indicated RN-G did not think R9 and R2 should be in close proximity to each other. When asked what interventions were in place for R9's sexual behavior, RN-G indicated staff verbally redirected R9 and documented R9's behavior. RN-G indicated R9 was prescribed medication to decrease sexual behavior, but the medication was not as effective as they had hoped. RN-G reported the 10/23/24 incident to NHA-A and DON-B after GDN-O confronted RN-G about the incident. GDN-O would not share who reported the allegation of sexual contact to GDN-O. RN-G could not say R10's report of sexual contact between R9 and R2 was false, however, RN-G did not see any sexual contact when RN-G moved R9 away from R2. RN-G entered R9's order for finasteride on 10/25/24 but did not communicate with the physician about R9's increased sexual behavior. After reading the order and notes in R9's medical record, RN-G stated RN-G believed the medication was started because R9 had behavior toward R2. When asked if R9 had touched other residents, RN-G stated, No. Most of the time it is (R2) or staff. RN-G was aware that R9 had offered money to see staffs' breasts and had asked staff to rub R9 sexually. On 12/4/24 at 7:36 PM, Surveyor interviewed RN-H who worked on 10/23/24. RN-H indicated RN-H heard from other staff that R9 made sexual comments and attempted to grab them. RN-H noted an increase in R9's behavior and messaged the physician who prescribed finasteride. RN-H discussed the medication with another nurse because it was not typically prescribed. RN-H was not familiar with R9's care plan but indicated staff used redirection to address behavior after it occurred. RN-H tried to keep an eye on R9 when R9 was in common areas. RN-H indicated R9 wheeled R9's self toward other residents. RN-H moved R9 if R9 got too close to female residents to foreshadow (R9's) intent. When asked if R9 had touched R2 inappropriately, RN-H stated RN-H did not witness the incident on 10/23/24 but it sounded in line with R9's behavior and things discussed. RN-H indicated R2 could not be alone in the dining room as a result of the incident on 10/23/24. When asked if R9 targeted R2, RN-H indicated R9 targeted females in general. RN-H was not aware of any monitoring interventions for R9 and indicated sexual behavior should be addressed on a resident's care plan. On 12/5/24 at 8:53 AM and at 8:59 AM, Surveyor observed R9 self-propel R9's wheelchair in the 100 wing hall, 200 wing hall, and through a common area without supervision. Surveyor observed R2 in the common area at the same time but not near R9. On 12/5/24 at 11:25 AM, Surveyor interviewed CNA-J who worked on 10/23/24 but was not aware of R9's behavior or of a directive to keep R9 and R2 apart. On 12/5/24 at 12:16 PM, Surveyor interviewed NP-N who indicated staff reported R9's increased sexual behavior toward staff and residents to NP-N. When NP-N asked staff if redirection helped, staff indicated redirection did not work like it used to and indicated R9 had daily behaviors. NP-N prescribed finasteride for R9's sexual behavior, possible prostate issues, and history of urinary retention. NP-N indicated finasteride was the least restrictive medication for R9's behavior. On 12/5/24 at 1:24 PM, Surveyor interviewed DON-B. When asked what interventions were in place for R2 who wandered into other residents' rooms, DON-B indicated staff should redirect R2 with food, drinks, books, a doll, or to lay down and the behavior should be addressed on R2's care plan. DON-B was aware there was a grievance regarding R2's wandering and indicated R2's care plan was not yet updated. DON-B indicated R9 did not have daily sexual behaviors and was unsure why staff indicated that. DON-B confirmed DON-B and NHA-A directed staff to keep R9 and R2 apart following the incident on 10/23/24. DON-B and NHA-A interviewed R9 who told them R9 reached for R2 to stop R2 from ripping pages out of a magazine. DON-B verified R10 stated R9 groped and touched R2's breast. DON-B did not feel there was a reason for R10 to lie. DON-B and NHA spoke with Chief Nurse Officer (CNO)-P and Regional Director of Operations (RDO)-Q and determined the allegation was unsubstantiated. DON-B was unsure if the incident happened or not, but indicated an intervention was added to keep R9 and R2 apart and not allow R2 in the dining room without R2's spouse or staff. DON-B indicated the interventions should be part of R2 and R9's care plans. DON-B indicated R9 was mostly independent and was not monitored for going into other residents' rooms. DON-B indicated R9 and R2 were not on increased supervision. DON-B confirmed R9 was prescribed finasteride for increased sexual behaviors and indicated staff should redirect and document R9's behavior. DON-B reviewed camera footage from the dining room on 10/23/24 and indicated R9 reached toward R2 and R2 moved R9's arm away. DON-B could not definitively tell if R9's hand was or was not touching R2. DON-B indicated there was something in R2's hand but they could not determine what. DON-B and NHA-A interviewed staff and did education during a huddle regarding reporting signs of abuse. DON-B was not aware that GDN-O was not notified and confirmed GDN-O should have been notified. When asked why R9 was determined to be credible but R10 was not, DON-B did not answer. On 12/5/24 at 2:19 PM, Surveyor interviewed NHA-A who indicated R9 was inappropriate with staff, however, NHA-A was not aware that R9 was inappropriate with residents. NHA-A was unsure why notes to R9's physician indicated R9 had increased sexual behavior toward staff and residents. NHA-A indicated R9 was alert and redirectable. When asked why NHA-A directed staff to keep R9 and R2 apart, NHA-A stated there was an incident when R9 reached over R2 and R2 swatted R9's arm away. NHA-A stated there was no harm and R2 was not hurt. NHA-A indicated GDN-O did not want R9 by R2, so NHA-A and DON-B instructed staff to keep R9 and R2 apart. When asked why R10's allegation of abuse and GDN-O's concerns were disregarded, NHA-A indicated there was no intent from R9. NHA-A confirmed residents' concerns should be reported and investigated. When Surveyor indicated a concern regarding R2 entering others' rooms was reported in October 2024, NHA-A stated R2 was redirected when R2 entered others' rooms. NHA-A verified the behavior should be on R2's care plan. NHA-A agreed staff needed to supervise R2 for R2's safety and the safety of others. NHA-A indicated NHA-A viewed camera footage from the 10/23/24 incident and didn't see abuse. When Surveyor stated DON-B indicated the video was unclear, NHA-A indicated R2 quickly put R2's hand up to push R9 away and it did not appear abuse occurred. NHA-A indicated other residents were not interviewed following the incident. When asked why GDN-O was not allowed to see the video from 10/23/24, NHA-A indicated NHA-A had to check with corporate and did not hear back. On 12/5/24 at 3:16 PM, Surveyor interviewed NHA-A and DON-B who indicated the facility no longer had the video from the incident on 10/23/24. On 12/5/24 at 3:51 PM, Surveyor completed a follow-up interview with MT-F. When asked if R9 had touched anyone, MT-F stated no, but R9 was a pervy guy with staff and MT-F did not trust R9 not to do anything to R2 which was why MT-F knocked on the window when R9 reached toward R2. MT-F indicated R9 was like a predator going for the weakest person. On 12/5/24, Surveyor reviewed the facility's soft file regarding the incident. A typed, unsigned, and undated document provided by NHA-A indicated NHA-A was notified of the incident by DON-B via phone on 10/23/24 at 6:30 PM. On 10/24/24, GDN-O arrived at the facility at 8:00 AM and asked NHA-A to investigate the incident. An investigation had not been started before GDN-O's request. Camera footage from the dining room indicated R2 was brought to the dining room at 4:45 PM. R9 entered the dining room at 4:50 PM and sat by R2. At 4:52 PM, R9 reached over and R2 brushed R9 away. NHA-A documented the incident was one to two seconds and it did not appear that R9 groped R2. At 4:55 PM, staff moved R9 away from R2. NHA-A notified GDN-O that there was no abuse. The file included an undated, handwritten note from RN-G stating RN-G saw R9 approach R2 and reach for R2. RN-G entered the dining room and removed R9. RN-G informed R9 that R9 could not touch residents and asked R9 to go to R9's room. A handwritten note from MT-F, dated 10/23/24, indicated MT-F knocked on the window when MT-F saw R9 wheel to R2's table and called the charge nurse who removed R9 immediately. MT-F stated R9 did not touch R2. A handwritten note from RN-I, dated 10/23/24, stated RN-I saw R9 wheel R9's chair close to R2. RN-I yelled at R9 to stop as R9 moved closer to R2. R9 stopped reaching for R2 and RN-I intervened before R9 touched R2. RN-I moved R2 to the other side of the room and away from R9. (Note: Surveyor contacted RN-I to clarify disputing statements provided by RN-I. RN-I stated the incident RN-I referred to in the handwritten statement occurred in the common room by the television and was not the incident that occurred between R9 and R2 in the dining room on 10/23/24.) On 12/6/24 at approximately 8:00 AM, Surveyor interviewed NHA-A who indicated NHA-A began interviewing other residents (primarily female residents) about abuse that morning (12/6/24) to ensure their safety. On 12/6/24, NHA-A presented Surveyor with an unsigned typed note from RN-H, dated 12/5/24, that indicated RN-H mistakenly wrote resident on RN-H's progress note to PP-M and NP-N on 10/24/24 that indicated R9 had increased sexual behavior toward staff and other residents. The typed note indicated RN-H did not know if R9 had sexual behavior toward other residents. On 12/5/24, Surveyor reviewed R9's plan of care which indicated R9 had the potential to be physically and verbally inappropriate due to poor impulse control (initiated 10/29/24). The following interventions were noted: Redirect R9 to spend private time in R9's room should R9 choose to gratify R9's self (dated 10/29/24); Attempt non-pharmacological approaches including redirection, explain what is not acceptable, and encourage R9 to sit at a men's table (dated 12/5/24). Target behaviors (revised 12/5/24) included: talking sexual, asking to see a woman's breast, touching in inappropriate areas, offering items or money for sexual favors. R9's plan of care did not contain any interventions to monitor R9 around other residents or keep R9 separated from R2. On 12/5/24, Surveyor reviewed R9's task documentation which indicated staff should document sexual behaviors each shift. Despite the fact that Surveyor interviewed multiple staff who indicated R9 had repeated and/or daily sexual behaviors, NP-N was notified of R9's increased behaviors, and finasteride was prescribed to help with sexual behavior, only one instance of sexual behavior was documented in October 2024 (not on 10/23/24). There were two entries of sexual behavior in November 2024 and no entries for December as of 12/5/24. On 12/5/24, Surveyor reviewed R2's plan of care which indicated R2 wandered the halls (initiated 7/31/24). Interventions included to monitor and redirect R2 as appropriate. A focus added to R2's plan of care (dated 8/19/24) indicated R2 was aggressive to others. An intervention (dated 12/4/24) indicated to attempt non-pharmacological approaches. A revision (dated 12/4/24) indicated staff should offer alternatives to occupy R2 if R2 wandered into residents' rooms. (Note: R2's plan of care did not indicate R2 wandered into other residents' rooms prior to 12/4/24.) Interventions (dated 12/4/24) indicated to get permission before touching, note changes in behavior, and notify the physician. The failure to supervise a resident with a history of inappropriate sexual behavior following an allegation of abuse involving a resident who wandered unsupervised in the facility created a reasonable likelihood for serious harm for R2 and other residents and led to a finding of immediate jeopardy. The facility removed the jeopardy on 12/6/24 when it completed the following: 1. Initiated one-to-one supervision for R9 who will be at least arms-length from and not seated near female residents. 2. Updated R9's behavior care plan and implemented interventions in accordance with R9's behavior patterns. 3. Consulted with R9's providers for suggestions and interventions. 4. Educated staff on abuse, behavior documentation, and updated care plan interventions.

Based on staff interview and record review, the facility did not ensure the provision of a safe environment that was free of accident hazards for 1 resident (R) (R1) of 5 sampled residents. On 5/17/24, R1 reported to staff that R1 fell out of a Hoyer lift when Certified Nursing Assistant (CNA)-C transferred R1 alone. On 5/18/24, R1 went to the hospital and was diagnosed with a left hip fracture. In addition, staff did not adequately assess R1 following R1's reported fall and had increased pain which delayed R1's diagnosis. Findings include: The facility's Change of Condition policy, with a revision date of October 2020, indicates: To ensure prompt notification of the resident, the attending physician, and durable power of attorney/responsible party of changes in the resident's physical, psychosocial and/or mental condition and/or status .Specific information that requires prompt notification includes, but is not limited to: .l. A significant change in the resident's physical/psychosocial/mental condition; m. A need to alter the resident's medical treatment significantly; .3. Nurse will complete assessment and document findings in resident's record including but not limited to vital signs, pain, respiratory status as applicable, cardiac status as applicable, etc. Notification of medical professional and resident representative will be documented in the medical record . The facility's undated Abuse Prevention Program policy indicates: .2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation .4. Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable . On 5/21/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral vascular accident (also known as a stroke) affecting the left non-dominant side. R1's Minimum Data Set (MDS) assessment, dated 2/25/24, stated R1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R1 had intact cognition. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1 was transferred to the hospital on 5/18/24. R1's care plan indicated R1 required the use of a full mechanical lift with the assistance of two staff for all transfers. A nursing progress note dated 5/18/24, indicated: Between 7:30 AM and 8:00 AM, R1 complained R1's left hip and leg hurt very badly. Writer noted no redness but the area was tender to touch. Writer tried to have R1 straighten R1's legs but R1 started yelling. Writer asked if R1 wanted to go to the emergency room (ER) to be evaluated. R1 stated, Yes. I've been wanting to go. R1 stated R1 was dropped from a Hoyer lift. Writer was confused because there was no documentation of a fall, but R1 was getting Tylenol more often and cold packs. Writer called Director of Nursing (DON)-B and physician. R1 was sent to the ER at 8:12 AM. When the ambulance arrived, Emergency Medical Technicians (EMTs) asked if R1 had any recent falls. Writer stated there were no recent falls documented. A hospital staff called later and asked if R1 was aware of what went on daily. Writer stated R1 knew who writer was that morning, where R1 was, R1's name, the year, and that R1 was in a lot of pain. When the hospital staff asked if R1 was alert and oriented, writer stated yes. The hospital staff stated R1 said R1 was dropped on the floor during a Hoyer lift transfer by a named CNA. Writer called DON-B who stated there was an investigation regarding an episode R1 had with therapy when therapy staff tried to get R1 to stand in a sit-to-stand lift. DON-B indicated R1 let R1's self hang in the lift but was next to R1's bed and didn't end up on the floor. The hospital staff called again and stated R1 had a left hip fracture and was scheduled for surgery the next day. The hospital staff was concerned that R1 kept stating R1 was dropped on the floor during a transfer with a named CNA. Writer told the hospital staff about what DON-B said regarding therapy and the sit-to-stand lift. The hospital staff was convinced differently and stated writer needed to look into it more. On 5/21/24 at 9:37 AM, Surveyor interviewed R1 via phone. R1 stated R1 had a shower earlier in the evening on 5/16/24 and at approximately 8:00 PM, CNA-C transferred R1 via Hoyer lift from wheelchair to bed. During the transfer, R1's nightgown caught on something which caused R1 to slip out of the sling onto the floor. R1 stated R1 fell approximately three feet and landed pretty much on my ass. R1 stated another staff was with CNA-C and provided a physical description and the staff's first name. R1 stated R1 did not experience pain at the time of the fall, but experienced pain later that night. R1 stated, I asked to go to the hospital. They said I wasn't hurt. R1 stated R1's pain that night was a level 8 on a scale of 0-10 with 10 being the worst pain. R1 stated on 5/17/24, R1's pain worsened pretty close to a 9 or 10 and on 5/18/24 a different nurse said I should go to the ER. R1 said R1 wanted to go to the ER and stated, I had wanted to go last night. On 5/21/24 at 9:58 AM, Surveyor interviewed CNA-D who indicated R1 should be transferred with a Hoyer lift and two staff. CNA-D indicated R1 wanted to be transferred with a sit-to-stand lift but that wasn't safe. On 5/21/24 at 10:01 AM, Surveyor interviewed CNA-E who indicated R1 should be transferred with a Hoyer lift and two staff. CNA-E stated CNA-E worked 6:00 AM to 2:00 PM on 5/17/24 and used a Hoyer lift to transfer R1. CNA-E stated CNA-E was told in shift report that R1 complained of pain, but R1 did not complain of pain to CNA-E. On 5/21/24, Surveyor reviewed R1's May 2024 Medication Administration Record (MAR), Treatment Administration Record (TAR), and administration notes. R1 received scheduled Tylenol 650 mg (milligrams) every morning. R1 also had an order for Tylenol 650 mg every four hours as needed (PRN). R1's MAR indicated R1 received one dose of PRN Tylenol on 5/1/24, 5/2/24, 5/3/24, 5/4/24, 5/6/24, 5/9/24, 5/12/24, 5/13/24, and 5/16/24. R1 received two doses of PRN Tylenol on 5/5/24, 5/7/24, 5/11/24, and 5/14/24. R1 received PRN Tylenol on 5/17/24 at 12:00 AM for a pain level of 4, at 5:00 AM for a pain level of 6, at 11:53 AM for a pain level of 6, and at 11:00 PM for a pain level of 3. Administration notes indicated the dose R1 received at 12:00 AM was for body pain, the dose R1 received at 5:00 AM was for right hip pain, the dose R1 received at 11:53 AM was for resident reports left upper leg pain and requested (Tylenol,) provided, cold pack applied and the dose R1 received at 11:00 PM was for left hip pain. A progress note, dated 5/17/24 at 3:00 AM, indicated: R1 complained of hip pain but was unable to receive PRN Tylenol because R1 received it 3 hours prior. R1 was repositioned and provided with an ice pack per R1's request. After repositioning, R1 stated it feels better. Will continue to monitor. R1's MAR indicated the Tylenol doses were effective. R1's TAR indicated R1 had an order for Biofreeze (a topical medication used to relieve mild to moderate pain) PRN for right shoulder pain. R1 received the medication on 5/17/24 at 5:01 AM. An administration note stated, Put on left hip. On 5/21/24, Surveyor reviewed the facility's investigation which indicated: On 5/17/24, Licensed Practical Nurse (LPN)-F told DON-B that R1 stated R1 fell on the evening of 5/16/24 during a Hoyer lift transfer and the sling broke. DON-B interviewed Physical Therapy Assistant (PTA)-G, CNA-C, and Medication Technician (MT)-H. On 5/18/24, R1 went to the ER for leg pain and was diagnosed with a hip fracture. Surgery was scheduled for 5/19/24. R1 reported to hospital staff that R1 fell from a Hoyer lift on 5/15/24 and staff didn't do anything. R1 did not tell facility staff right away because R1 did not want to get CNA-C in trouble. DON-B updated RDO (Regional Director of Operations). DON-B reported during a therapy session with a sit-to-stand lift on 5/15/24, R1 was lowered to the bed when R1's knees buckled. R1 did not fall and the sling was intact. On 5/20/24, the facility's cameras were reviewed. A camera indicated CNA-C used a sit-to-stand lift to transfer R1 and also used a Hoyer lift to transfer R1 alone on the 5/16/24 PM shift. CNA-C was terminated. CNA-I was interviewed and stated CNA-I used a sit-to-stand lift with CNA-C to transfer R1. Education was provided to CNA-I. On 5/20/24, Regional Director of Sales and Marketing (RDSM)-J completed a hospital visit. R1 reported CNA-C and LPN-K used the Hoyer lift to put R1 into bed after R1's shower. R1 said R1's hip did not hurt at that time. An interview with PTA-G, dated 5/17/24, indicated: CNA-C asked PTA-G if PTA-G would help CNA-C transfer R1 with a sit-to-stand lift. PTA-G told CNA-C therapy staff worked on a sit-to-stand transfer with R1 the previous day and R1 had to 'let go' and was hanging with R1's entire weight in the lift and had to be set down. CNA-C stated CNA-C would use a Hoyer lift. An interview with CNA-C, dated 5/17/24, indicated: CNA-C asked PTA-G to help CNA-C transfer R1 with a sit-to-stand lift because staff had been transferring R1 that way. PTA-G said R1 didn't do well with a sit-to-stand lift and told CNA-C to use a Hoyer lift. CNA-C stated CNA-C used a Hoyer lift from then on and never used a Hoyer lift alone with R1. On 5/21/24 at 11:42 AM, Surveyor interviewed DON-B who stated sometime between lunch and 2:00 PM on 5/17/24, LPN-F told DON-B that R1 stated R1 fell out of a lift. DON-B started interviews and notified Nursing Home Administrator (NHA)-A. DON-B was unsure if R1 was interviewed on 5/17/24. On 5/21/24 at 12:02 PM, Surveyor interviewed R1 via phone again. When asked how R1 got off the floor following the fall on 5/16/24, R1 stated, (CNA-C) helped pick me up. (CNA-C) got behind me. (CNA-C) did it by (CNA-C's) self. When asked if there was another staff in the room, R1 gave a physical description and first name of a nurse. R1 stated the nurse watched CNA-C pick R1 up off the floor without a lift. R1's medical record indicated on 5/16/24 at 7:57 PM, staff weighed R1 via Hoyer lift scale. R1's weight was 302 pounds. On 5/21/24 at 12:42 PM, Surveyor interviewed CNA-L via phone. CNA-L stated CNA-L worked the PM shift on 5/16/24 but did not transfer R1. CNA-L stated CNA-M had the name R1 gave Surveyor (as being the second staff in the room when CNA-C picked R1 off the floor. When Surveyor provided CNA-L with the physical description given by R1, CNA-L stated LPN-K fit the description and went by a nickname that was the same first name as CNA-M. On 5/21/24, Surveyor reviewed the facility's staffing schedule for 5/16/24 which indicated neither CNA-M or LPN-K worked the PM shift on 5/16/24. On 5/21/24 at 1:17 PM, Surveyor interviewed PTA-G who stated therapy staff worked with R1 for leg and upper arm strength to allow R1 to be transferred via sit-to-stand lift because R1 did not like the Hoyer lift. PTA-G stated therapy staff were allowed to use the sit-to-stand lift during R1's therapy sessions, but nursing staff were directed to use a Hoyer lift. PTA-G stated R1 showed improvement with strength and tolerance prior to the evening of 5/16/24. When asked if R1 was lowered to the bed during a therapy session on 5/15/24, PTA-G stated therapy staff worked with R1 in the therapy room, not R1's room. PTA-G stated on 5/16/24, a CNA asked if PTA-G would help with a sit-to-stand transfer to get R1 into a shower chair. PTA-G said no. PTA-G stated, I came into work the next day to work with (R1). (R1) told me (R1) had a fall from the Hoyer lift. I followed up with (Director of Rehab (DOR)-N). (DOR-N) looked in (R1's) nursing notes and didn't see anything. I documented in my notes as potential fall. PTA-G stated on 5/17/24, PTA-G only did stretching with R1 because R1 was in a lot of pain and had poor initiation of trunk flexion which was a change from earlier in the week. PTA-G stated R1 wanted to try standing in the sit-to-stand lift on 5/17/24 but couldn't do it as (R1) was very limited with pain. PTA-G stated R1 never had a care plan intervention for use of a sit-to-stand lift and stated staff should have always used a Hoyer lift to transfer R1. R1's PT Daily Treatment Notes indicated the following: ~ 5/15/24: R1 performed pre-standing activity of trunk flexion with minimal assistance provided .R1 completed 10 repetitions to prep for transfers and is able to lift lower extremities onto and off the sit-to-stand platform .R1 is able to maintain standing position for an increased time of 1:30 minutes, then 1:40 minutes. R1 exhibited improved knee extension with standing and has an improved posture in the highest position. R1 has a 'hanging' posture toward the end of duration and will further benefit from standing balance training . ~ 5/16/24: R1 is able to complete with minimal assistance and exhibits improved forward reaching needed for improved standing posture and prepping for sit-to-stand transfers .R1 performed surface-to-surface transition with use of sit-to-stand .R1 completed 3 static standing trials with R1's longest standing time being 1:30 minutes. ~ 5/17/24: R1 seen this morning and stated my legs and back are in a lot of pain due to potential fall with staff. Writer applied passive range of motion (PROM) to bilateral lower extremities in motions of hip flexion and knee flexion/extension. R1 is limited in range of motion (ROM) due to pain and discomfort with passive movement .R1 has increased difficulty with forward reaching. R1 would like to attempt standing with sit-to-stand lift, but is notable hanging prior to initiation of standing and is lowered for safety. Recommended continued use of Hoyer lift due to weakness, poor postural correction, and pain. On 5/21/24 at 2:02 PM, Surveyor interviewed LPN-K who verified LPN-K's nickname was the same name R1 gave Surveyor (as being the second staff in the room when CNA-C picked R1 off the floor). LPN-K verified LPN-K did not work on 5/16/24. LPN-K indicated LPN-K assisted CNA-C with transferring R1 from wheelchair to shower chair via sit-to-stand lift the week prior to 5/16/24. LPN-K indicated the sit-to-stand lift was used because of limited space in the shower area. LPN-K stated R1 stood up pretty good during the transfer. When asked if R1's care plan stated R1 should be transferred with a Hoyer lift, LPN-K stated, Yea. It was a big mistake. LPN-K stated LPN-K did not assist CNA-C with any transfers for R1 from wheelchair to bed in the past couple weeks. When asked if LPN-K saw CNA-C or any staff pick R1 up off the floor without the use of a mechanical lift, LPN-K stated, No, I can't imagine (how it could happen that way due to R1's weight). On 5/21/24 at 2:32 PM, Surveyor interviewed DON-B. When asked what LPN-F reported to DON-B on 5/17/24, DON-B stated, That (R1) reported there was an issue with the lift and (R1) fell with a staff member. DON-B stated R1 initially said the fall occurred on 5/16/24, but hospital notes indicated R1 told hospital staff that R1 fell multiple different times. After LPN-F informed DON-B of the fall, DON-B stated DON-B immediately interviewed staff who worked on 5/16/24 who told DON-B that no fall occurred. DON-B verified R1 wasn't interviewed until 5/20/24. DON-B verified DON-B did not interview R1 on 5/17/24 or ask who was present when R1 allegedly fell from the lift. When asked if LPN-F asked R1 who was present during the transfer, DON-B stated, I do not know. When asked if an assessment should be completed if a resident alleges a fall occurred, DON-B indicated a full pain assessment and a change of condition assessment should be completed. DON-B verified staff did not complete a body check for injuries. DON-B verified DON-B was not aware of a specifically named staff member involved in the alleged fall until DON-B reviewed R1's hospital records on 5/20/24. On 5/21/24 at 2:56 PM, Surveyor interviewed LPN-O who verified LPN-O worked the PM shift on 5/16/24 and assisted CNA-C with transferring R1 from wheelchair to bed via Hoyer lift. LPN-O indicated the transfer went well and R1 had no complaints at the time. LPN-O indicated R1 did not fall out of the lift and R1's nightgown did not get caught during the transfer. When asked if LPN-O saw any staff try to pick R1 off floor without the use of a lift, LPN-O stated, Oh no, (R1)'s too big for anyone to do that. (R1)'s paralyzed on one side. On 5/21/24, Surveyor reviewed additional investigation documents which indicated staff reviewed the facility's camera on 5/21/24 at 9:25 AM and noted on 5/16/24 at 7:21 PM, CNA-C pushed a sit-to-stand lift to the shower room. R1 was in a wheelchair in the hallway. CNA-C put a sling on R1 while R1 was in the wheelchair and was noted to use the sit-to stand lift. On 5/21/24 at 4:10 PM, Surveyor interviewed NHA-A and DON-B who indicated the resident in the video was R1 and stated the camera angle showed the hall in front of the shower room but did not show the shower room itself. NHA-A and DON-B were unsure if another staff member assisted CNA-C with the transfer because the video showed another staff member pass in the hallway; however, NHA-A and DON-B stated they believed CNA-C completed the sit-to-stand transfer alone. On 5/22/24 at 9:14 AM, Surveyor interviewed CNA-C via phone. CNA-C indicated on 5/16/24, R1 wanted CNA-C to use a sit-to-stand lift for the shower transfer. When CNA-C asked PTA-G to assist, PTA-G said, Absolutely not. CNA-C stated CNA-C gave R1 a shower on the evening of 5/16/24 with the help of CNA-P and a Hoyer lift was used for the shower transfer. CNA-C stated CNA-C and CNA-P used a Hoyer lift to transfer R1 from wheelchair to bed. CNA-C and CNA-P undressed R1, changed the lift pad, transferred R1 from bed to wheelchair, and covered R1 for privacy. CNA-C stated R1 was transported to the shower area via wheelchair because R1 was too heavy to push down the hall in the shower chair. CNA-C stated the shower room was too small for transfers so R1 was taken to the tub room where CNA-C and CNA-P transferred R1 via Hoyer lift from wheelchair to shower chair. CNA-C stated CNA-C was aware of the above-mentioned video. When asked to explain the video, CNA-C stated, I don't explain that. That did not happen. CNA-C stated CNA-C did not pick R1 up off the floor after a fall without the use of a mechanical lift and did not recall a time when R1's nightgown got caught during a lift transfer. CNA-C stated staff did not show the video to CNA-C. On 5/22/24 at 1:16 PM, Surveyor interviewed CNA-P via phone. CNA-P verified CNA-P worked the PM shift on 5/16/24. When asked if CNA-P assisted CNA-C with transferring R1 during the shift, CNA-P stated, I did not. CNA-P verified CNA-P did not assist CNA-C with R1's shower transfer or transfer to bed on 5/16/24. When asked if CNA-P ever saw R1 transferred with a sit-to-stand lift, CNA-P stated, I have never transferred (R1) in a sit-to-stand. I just started working PMs recently. Mostly work night shift and we never get (R1) out of bed at night. On 5/22/24, Surveyor reviewed hospital documentation for R1 which indicated the following: ~ A note by a hospital Registered Nurse (RN) on 5/18/24 at 9:08 AM indicated: R1 came via EMS with complaints of left hip pain that started on Wednesday (5/15/24). R1 stated R1 was dropped from the Hoyer lift onto the ground on (5/15/24) by CNA-C. R1 stated R1's left leg hurt on palpation. R1 has left-sided deficits from a stroke in 2024. R1 is alert and oriented to person, place, time, and situation. ~ A note by an ER physician on 5/18/24 at 9:16 AM indicated: R1 stated approximately two days ago, R1 was dropped out of a Hoyer lift, fell approximately two feet, and landed on R1's bottom. R1 complained of left hip pain. ~ A note by a hospital admission Nurse Practitioner (NP) on 5/18/24 at 12:22 PM indicated: R1 stated the reason R1 came to the ER was for persistent left hip pain. R1 stated on Wednesday (5/15/24), R1 was being transferred via Hoyer lift and slipped out of the lift onto R1's left side. R1 stated neither R1 or the CNA reported the fall at the time and R1 did not want the CNA to get in trouble. By Thursday (5/16/24) morning, R1 had increased pain and was only given ice and Tylenol. Today the pain increased to the point that R1 could not tolerate it and R1 came to the ER for evaluation.

Based on observation, staff interviews, and record review, the facility did not implement an infection control policy to effectively prevent and/or contain the spread of COVID-19 infection. The practices had the potential to affect all 35 residents. The facility did not exclude seven (7) staff (Therapy Staff (TS)-F, Registered Nurse (RN)-G, TS-H, RN-I, Certified Nursing Assistant (CNA)-J, CNA-K, and CNA-L) from work while they were experiencing COVID-19 symptoms; staff attributed symptoms to other causes and not all COVID-19 symptoms per current Centers for Disease Control and Prevention (CDC) guidance were included on the facility screening tool. The facility did not test five (5) COVID-19 symptomatic residents (Resident (R)7, R8, R10, R14, and R15) on the same day symptoms began although rapid point of care/[MEDICATION NAME] tests (test results available in 15 minutes) were available at the facility. The facility resident symptom assessment did not include all COVID-19 symptoms per current CDC guidance and the facility failed to recognize a change in fatigue level for R14 and a change in nasal congestion for R15 as COVID-19 symptoms until after COVID-19 positive results were obtained. The facility failed to initiate isolation precautions when R13 was symptomatic and the Polymerase Chain Reaction (PCR) test (test results typically available in 24 to 72 hours for this type) results were pending. The facility failed to include documentation of R16's COVID-19 symptoms and positive COVID-19 test on the surveillance log. The facility failed to isolate positive residents by leaving room doors open for COVID-19 positive residents (R6, R7, R8, R9, R10, and R11). The facility failed to ensure staff completed proper hand hygiene and failed to ensure the proper wearing and changing of Personal Protective Equipment (PPE) by staff when moving between rooms. The facility failed to follow CDC guidance related to aerosol-generating procedures by allowing R1 to self-administer a nebulizer treatment with R1's room door open. Facility failure to screen for all COVID-19 symptoms and exclude symptomatic staff from work and its failure to quickly identify ill residents and to quarantine them created a finding of Immediate Jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy on [DATE] at 2:00 PM. The Immediate Jeopardy was removed on [DATE]. However the deficient practice continues at a severity/scope of F as the facility continues to implement its action plan. Findings include: On [DATE] and [DATE], Surveyor reviewed the facility respiratory symptom surveillance log titled Outbreak Line List. Outbreak Line List identified the first case of the current outbreak began with symptoms [DATE] and 37 residents (updated to 38; one additional resident (R16) was identified as positive but not on line list) and 27 staff tested COVID-19 positive (65 people total) from outbreak start to time of investigation beginning [DATE]. Four COVID-19 positive residents and one COVID-19 positive staff person died during the outbreak which was ongoing at the time of investigation. Symptomatic Staff Worked/Screening Tool Not Comprehensive The Centers for Disease Control and Prevention (CDC) documents the following regarding symptoms: People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear ,[DATE] days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea CDC documents isolation is required to prevent the spread of COVID-19. Duration of isolation and precautions. For most persons with COVID-19 illness, isolation and precautions can generally be discontinued 10 days after symptom onset and resolution of fever for at least 24 hours, without the use of fever-reducing medications, and with improvement of other symptoms. A limited number of persons with severe illness may produce replication-[MEDICAL CONDITION] beyond 10 days that may warrant extending duration of isolation and precautions for up to 20 days after symptom onset; consider consultation with infection control experts. For persons who never develop symptoms, isolation and other precautions can be discontinued 10 days after the date of their first positive RT-PCR test for [DIAGNOSES REDACTED]-CoV-2 RNA. The CDC also notes: As part of routine practice, ask HCP (Health Care Personnel) (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19. Remind HCP to stay home when they are ill. Surveyor noted the Outbreak Line List documented the following staff had COVID-19 symptoms but continued to work: TS-F had symptoms [DATE] and continued to work through [DATE]. RN-G had symptoms [DATE] and continued to work through [DATE]. TS-H had symptoms [DATE] and continued to work through [DATE]. RN-I had symptoms [DATE] and continued to work through [DATE]. CNA-J had symptoms [DATE] and continued to work through [DATE]. CNA-K had symptoms [DATE] and continued to work though [DATE]. CNA-L had symptoms [DATE] and continued to work through [DATE]. On [DATE] at 3:32 PM, Surveyor interviewed Director of Nursing (DON)-B via telephone regarding Outbreak Line List. DON-B explained the practice of DON-B is to interview each staff member following a positive test in part to assist the Local Health Department (LHD) with contact tracing efforts. DON-B indicated that during these interviews, DON-B noticed staff were often attributing COVID-19 symptoms to alternate causes. For TS-F, an elevated temperature (which was still under 100 degrees Fahrenheit) was attributed to dressing too warm. RN-G indicated to DON-B that fatigue was experienced but RN-G attributed it to working extra shifts. RN-I had a cough but indicated to DON-B that it was mild. (Surveyor reviewed staff screening tool on [DATE] and noted RN-I did not document a cough on the screening tool.) CNA-K had muscle aches documented as chest tightness on the Outbreak Line List but indicated to DON-B the symptom was ignored because CNA-K attributed it to a [DIAGNOSES REDACTED]. On [DATE], Surveyor reviewed Facility COVID-19 Screening Tool and noted the only COVID-19 symptoms specified on the screening tool were fever, cough, and shortness of breath. On [DATE] at 8:41 AM, Surveyor interviewed DON-B via telephone regarding the Facility COVID-19 Screening Tool. DON-B confirmed the only COVID-19 symptoms specified on the Screening Tool were fever, cough, and shortness of breath. DON-B indicated there was a posting of additional symptoms in the screening area which directed staff to notify DON-B if symptoms were experienced. DON-B expressed an expectation that staff write any symptoms not listed on the Screening Tool into the comment area of the Screening Tool. DON-B indicated the staff completed a read-and-sign education regarding symptoms. Surveyor reviewed education provided, which documented Be alert for symptoms. Watch for fever, cough, shortness of breath, or other symptoms of COVID-19. Surveyor noted other symptoms were not disclosed or outlined in the training document. Symptomatic Resident Testing Delayed CDC documents screening and testing are required: At least daily, take the temperature of all residents and ask them if they have any COVID-19 symptoms. Perform [MEDICAL CONDITION] testing of any resident who has signs or symptoms of COVID-19. CDC documents [MEDICAL CONDITION] testing helps prevent detect cases quickly and prevents transmission: [MEDICAL CONDITION] testing of residents in nursing homes, with authorized nucleic acid amplification tests or [MEDICATION NAME] detection assays, is an important addition to other infection prevention and control (IPC) recommendations aimed at preventing [DIAGNOSES REDACTED]-CoV-2 from entering nursing homes, detecting cases quickly, and stopping transmission. On [DATE] and [DATE], Surveyor reviewed the facility respiratory symptom surveillance log titled Outbreak Line List and noted the following residents had COVID-19 symptoms but testing was not completed on the day of symptom onset when rapid point of care [MEDICATION NAME] testing was available at the facility: R7 had symptoms beginning on [DATE] but no documented [MEDICATION NAME] test until [DATE]. R8 had symptoms beginning on [DATE] but no documented [MEDICATION NAME] test until [DATE]. R10 had symptoms beginning on [DATE] but no documented [MEDICATION NAME] test until [DATE]. R14 had symptoms beginning [DATE] but no documented [MEDICATION NAME] test. A PCR test was obtained [DATE]. R15 had symptoms beginning [DATE] but no documented [MEDICATION NAME] test until [DATE]. On [DATE] at 3:32 PM, Surveyor interviewed DON-B via telephone regarding Outbreak Line List. DON-B verified R8 and R10 did not have rapid [MEDICATION NAME] tests the same day as symptom onset and verified the expectation is residents should be offered an [MEDICATION NAME] test the same day as symptom onset. On [DATE] at 8:41 AM, Surveyor interviewed DON-B via telephone regarding Outbreak Line List. DON-B verified R7, R14, and R15 were not offered rapid [MEDICATION NAME] tests the same day as symptom onset and verified [MEDICATION NAME] tests should have been offered the same day as symptom onset. Resident Deviation From Norm; Symptoms Not Identified On [DATE] during interview with DON-B via telephone that began at 8:41 AM, DON-B verified R14 and R15 were not offered [MEDICATION NAME] tests the day of symptom onset. DON-B explained R14 relied on staff to recognize needs. R14 had an overall decline which included fatigue. Staff did not identify R14's increased fatigue on [DATE] as a possible COVID-19 symptom until a post positive test interview when R14's routine testing PCR test result came back positive. DON-B explained R15 had a [DIAGNOSES REDACTED]. When R15 had a change in nasal congestion, staff administered [MEDICATION NAME] but did not identify R15's change as a possible COVID-19 symptom so no [MEDICATION NAME] test was offered. DON-B indicated R15 did not take [MEDICATION NAME] since order date until the symptom on [DATE]. DON-B verified this was a change for R15 and R15 should have been offered an [MEDICATION NAME] test on [DATE]. Symptomatic Resident Not Isolated Timely On [DATE], Surveyor reviewed the closed medical record of R13 which documented R13 experienced COVID-19 symptoms on [DATE] and was offered a rapid [MEDICATION NAME] test. [MEDICATION NAME] test results were negative. R13's PCR test obtained on [DATE] as part of routine testing was returned on [DATE] as positive. R13's record documented isolation precautions were put in place on [DATE] when the PCR test results were returned. On [DATE] at 3:32 PM, Surveyor interviewed DON-B via telephone regarding R13. DON-B verified R13 experienced increased fatigue and indicated fatigue wasn't uncommon for R13 because of [MEDICAL TREATMENT] treatments. DON-B verified there was a change in fatigue that prompted the [MEDICATION NAME] test on [DATE]. DON-B was not able to explain why R13, who was symptomatic, was not isolated while PCR test results were pending and verified symptomatic residents should be isolated. Incomplete Surveillance Log On [DATE] at 8:41 AM, Surveyor reviewed facility Outbreak Line List and resident room list together with DON-B via telephone in an attempt to confirm which residents in the building were COVID-19 negative or COVID-19 positive recovered with initial [DIAGNOSES REDACTED]. While reviewing the documents, DON-B indicated R16 tested positive for COVID-19 on [DATE]. DON-B verified R16 was missing from the Outbreak Line List. Improper Isolation of Infectious Residents The facility's policy, titled Suspected or Confirmed COVID-19 Management Policy, revised [DATE], states: The center will isolate infected residents: place in private room with private bathroom and door to room to remain closed . On [DATE] at 9:33 AM, 10:20 AM, and 12:40 PM, the Surveyor observed the doors of R6, R7, R8, R9, R10, and R11 to be open with no masks on the residents. On [DATE] at 12:10 PM, the Surveyor interviewed DON-B, who verified that R6, R7, R8, R9, R10, and R11 were COVID-19 positive and still in their infectious period. Proper PPE/Hand Hygiene On [DATE] at 11:40 AM, the Surveyor observed CNA-M passed lunch trays to the 300 wing, which was a mixed wing of isolation and non-isolation rooms. CNA-M donned a plastic gown, reusable goggles, and a surgical mask, which was below CNA-M's nose. CNA-M left the tray cart in the hallway while passing trays to individual rooms. CNA-M went into room [ROOM NUMBER] (isolation) and set up the lunch tray, touched the coffee pot on the cart, went to room [ROOM NUMBER] (isolation), set up tray, to room [ROOM NUMBER] (non-isolation) and touched the call light and items on tray, back to room [ROOM NUMBER] (isolation), to room [ROOM NUMBER] (non-isolation), touching resident wheelchair, to room [ROOM NUMBER] (isolation), touching tray table and items on tray, touched the coffee pot on the cart, to room [ROOM NUMBER] (isolation), to room [ROOM NUMBER] (non-isolation), then to room [ROOM NUMBER] (non-isolation), touching items on tray. This was all completed without any hand hygiene or PPE change between rooms. CNA-M then assisted the resident in room [ROOM NUMBER] with eating without changing PPE, with the surgical mask still below CNA-M's nose. On [DATE] at 12:10 PM, the Surveyor interviewed DON-B, who verified that CNA-M should have worn mask properly, completed hand hygiene between rooms and changed PPE before going from isolation to non-isolation rooms. Nebulizer treatment for [REDACTED].>A publication titled, Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review, dated [DATE], states: Procedures that are believed to generate aerosols and droplets as a source of respiratory pathogens include . nebulizer treatment and those procedures are known to stimulate coughing and to promote the generation of aerosols. On [DATE] at 9:33 AM, the Surveyor observed LPN-C setting up a nebulizer treatment for [REDACTED]. R1 self-administered the nebulizer treatment with R1's door open. On [DATE] at 10:45 AM, the Surveyor interviewed DON-B, who stated that the expectation is that R1's door would be closed during the nebulizer treatment for [REDACTED]. Facility failure to screen for all COVID-19 symptoms and exclude symptomatic staff from work and its failure to quickly identify ill residents and to quarantine them created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it completed the following: Facility updated COVID-19 staff screening tool to include all COVID-19 symptoms and re-educated all staff on the proper use of the tool and COVID-19 symptoms. All staff in the facility were re-screened with the updated COVID-19 screening tool. DON or designee will review signed screening tool at the beginning of each shift to ensure compliance. Any staff noted to have symptoms will have a rapid test performed and be sent home immediately pending results. Medical Director consulted and updated regarding the use of new COVID-19 screening procedures. DON or designee to report findings at monthly Quality Assurance meeting related to monitoring of screening tool process. The deficient practice continues at a severity/scope of F as the facility continues to implement its action plan.

Based on staff interviews and record review, the facility did not ensure each resident was provided sufficient fluid intake to maintain proper hydration and health for 1 (R (Resident) 1) of 6 sampled residents reviewed for hydration status. R1's medical record included documentation that the resident had documented findings of poor oral intake of fluid. The facility did not assess R1's fluid intake and output to determine if interventions were needed to prevent dehydration. R1 was admitted to the hospital on [DATE] for dehydration. Findings include: The facility policy entitled Hydration Risk Evaluation and Assessment Hydration Screener with a revised date of 3/24/15 indicated the purpose is to identify residents at risk for dehydration, screen and comprehensively assess residents for signs and symptoms of dehydration. Per procedure, nursing is to complete a Hydration Risk Evaluation and Assessment on admission, re-admission, quarterly, annually, and on change of condition. If the assessment identifies signs and symptoms of dehydration are present, the resident is placed on Dehydration Symptom pursuit and daily Hydration Screener. The Hydration Screener should also be scheduled more frequently if there is suspicion of increased output or decreased intake. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. R1's admission MDS (Minimum Data Set) assessment dated [DATE], documented R1's cognition was severely impaired, R1 required extensive assistance from staff for eating/drinking, was dehydrated, and was administered a diuretic (water pill) daily. R1's current plan of care, with an initiated date of 4/3/18, indicated R1 had potential fluid deficit related to diuretic use, poor intake and a [DIAGNOSES REDACTED]. The goal was to keep R1 free of symptoms of dehydration, maintain moist mucous membranes and good skin turgor. The Nutritional Assessment/Screening was completed by CD (Corporate Dietician)-P with a date of 4/3/18 documented the following regarding R1: ~ did not have fluid restrictions ~ calculated estimated fluid needs as 1470 ml (milliliter) per day ~ average fluid intake was less than 1200 ml ~ usual appetite/food intake was 0 to 25 percent ~ received nutritional supplements with meals R1's documented daily fluid ml intake was as follows: ~ 3/30/18 - 945 ml ~ 3/31/18 - 1340 ml ~ 4/01/18 - 1300 ml ~ 4/02/18 - 420 ml ~ 4/03/18 - 960 ml ~ 4/04/18 - No documentation ~ 4/05/18 - 985 ml ~ 4/06/18 - 1090 ml ~ 4/07/18 - 140 ml ~ 4/08/18 - 360 ml ~ 4/09/18 - 920 ml ~ 4/10/18 - 720 ml ~ 4/11/18 - 600 ml prior to transfer to hospital emergency department R1's documented fluid intake of 9180 ml from 3/30 to 4/10/18 was 52% of her estimated fluid need of 17,640 ml. From 4/07 to 4/10/18, her fluid intake was 36% of her estimated fluid need. R1's daily hydration screener from date initiated documented the following: ~ 4/03/18 thru 4/06/18 - not completed as ordered ~ 4/07/18 - mucous membranes box was checked moist, concentrated urine box was checked no, rapid pulse box was checked not applicable, rapid weight loss past 7 days box was checked no, and orthostatic systolic drop of greater than 20 mm Hg (millimeters of mercury) box was checked not applicable ~ 4/08/18 - mucous membranes box was checked moist, concentrated urine box was checked no, rapid pulse box was checked not applicable, rapid weight loss past 7 days box was checked no, and orthostatic systolic drop of greater than 20 mm Hg box was checked not applicable ~ 4/09/18 - mucous membranes box was checked moist, concentrated urine box was checked no, rapid pulse box was checked no, rapid weight loss past 7 days box was checked no, and orthostatic systolic drop of greater than 20 mm Hg box was checked no. ~ 4/10/18 - mucous membranes box was checked moist, concentrated urine box was checked no, rapid pulse box was checked no, rapid weight loss past 7 days box was checked no, and orthostatic systolic drop of greater than 20 mm Hg box was checked no ~ 4/11/18 - not completed prior to transfer to hospital emergency department Per the progress note dated 4/6/18 at 11:21 a.m., R1 was transferred with a Hoyer lift and the transfer was assessed by a nurse. Per the PT (physical therapy) daily treatment note written by PTA (Physical Therapy Assistant)-I and dated 4/8/18 at 12:29 p.m., R1 had poor motor planning with inability to initiate and complete motion without tactile cueing. As treatment continued, R1 was more alert with improved response and actively completed trunk flexion. Per the progress note dated 4/8/18 at 3:56 p.m., R1 did require the use of the Hoyer lift and two staff members for transfers. R1 had complaints of pain in the lower portion of back. Tylenol was administered and was effective for relieving pain. R1 was anxious/agitated at times during the shift. R1's fluid intake was documented as 840 ml and output was documented as R1 was incontinent of a moderate amount of urine twice during the day shift. Per the progress note dated 4/9/18 at 2:54 a.m., R1 was groaning in room. When asked if having pain, R1 stated yes. Tylenol was administered and was effective. Per the PT daily treatment note written by PTA-I and dated 4/9/18 at 1:14 p.m., R1 had increased rambling, eyes were closed and had decreased motor planning with cueing. Nursing was advised of rambling, closing of eyes and decreased motor planning. Per the progress note dated 4/10/18 at 3:48 p.m., the physician was updated on R1's increase in anxiety/aggression with activities of daily living, complaints of pain in lower back, and increase in amount of assistance required for activity. The physician ordered a urinalysis, CBC, (complete blood count) and a CMP (comprehensive metabolic panel). The CMP provides the physician with information regarding the body's fluid balance as well as levels of electrolytes like sodium and potassium. Per the progress note dated 4/11/18 at 3:31 p.m., a call was received from the lab indicating R1 had critical labs. Sodium was 162 with a reference range of 135 - 145, chloride was 131 with a reference range of 100 - 109, BUN (blood urea nitrogen) was 31 with a reference range of 7 - 22, and creatinine was 2.2 with a reference range of 0.50 to 1.50. An order was obtained from the physician to send R1 via ambulance to the emergency room to evaluate and treat. After R1 was evaluated at the emergency room , R1 was admitted to the hospital due to high sodium and altered mental status. The emergency room evaluation dated 4/11/18 at 8:28 p.m., indicated R1's dry mucous membranes are oropharynx, R1 had significant [MEDICAL CONDITION] with appearance of acute kidney injury. Suspect dehydration. The final [DIAGNOSES REDACTED]. The hospital history and physical dated 4/11/18 at 10:15 p.m., indicated R1 had dry mucous membranes, appeared clinically dry currently and likely had not taken in free water for some time. IV (intravenous) hydration started and staff to hold the [MEDICATION NAME] (diuretic) 10 mg (milligram) daily dose. The hospital discharge summary dated 4/20/18 at 12:57 p.m., indicated R1's [MEDICAL CONDITION] was due to R1's decreased oral intake and dehydration. R1 was administered IV fluids for rehydration and acute kidney injury. On 4/24/18 at 11:47 a.m., the Surveyor interviewed DON (Director of Nursing)-H regarding R1. DON-H confirmed R1 had not been eating or drinking a lot, was confused. DON-H indicated R1 came with a poor appetite and was not drinking and R1 became more resistant to drinking, eating and ambulating, gradual decline. On 4/25/18 at 11:31 a.m., the Surveyor interviewed RN (Registered Nurse)-L by telephone regarding R1. RN-L indicated PTA-I had asked her to look at R1 after therapy on 4/9/18. RN-L indicated when entering R1's room, R1 seemed alert and talkative, so she did not complete an assessment on R1 after PTA-I requested that a nurse to look at R1. RN-L indicated R1 did not have changes from a nursing point of view, Looked at (R1), did not see changes. RN-L indicated without changes, an assessment was not required as R1 was eating and drinking. RN-L verified when talking to R1 or assisting with feeding, she would look in R1's mouth, and the resident's mouth was supple/good and she did not see dryness or cracking and was nothing to set a spark to investigate further. RN-L confirmed orthostatic blood pressures were not completed on R1 on 4/9/18 and 4/10/18, even though documented as completed with no drop on the hydration assessments. RN-L stated if the orthostatic blood pressures had been completed, they would not be accurate because R1 would be combative many times when lifting with the Hoyer the Blood pressure will shoot up. When asked if the blood pressure could be done prior to transfers, RN-L stated no. RN-L was not aware there was a not applicable box to check if needed. RN-L indicated did not report orthostatic blood pressures were not being completed and verified not completing an assessment to include vitals. RN-L verified did not review R1's intake and output records and did not review R1's medical record after PTA-I requested that a nurse look at R1 because PTA-I was concerned. On 4/25/18 at 12:03 p.m., the Surveyor interviewed DON-H regarding R1. DON-H confirmed R1's intake and output was not being monitored. DON-H then stated maybe could have found sooner if assessment had been completed and physician notified of PTA observations. On 4/25/18 at 12:25 p.m., the Surveyor interviewed CNA (Certified Nursing Assistant)-J regarding R1. CNA-J indicated R1 would not take any fluids on 4/9/18 at lunch and she advised the nurse R1 would not take any fluids from her (CNA-J). On 4/25/18 at 12:31 p.m., the Surveyor interviewed CNA-K regarding R1. CNA-K indicated R1 was assisted by CNA-K numerous times and R1 wouldn't hardly take any fluid, R1 would clamp mouth shut and would not take more food or fluids. CNA-K stated would document intake and make nurses aware of R1's decreased fluid intake. On 4/25/18 at 12:48 p.m., the Surveyor interviewed CNA-M regarding R1. When assisting R1 with meals or when observing R1 being assisted by other staff, CNA-M indicated R1 did not eat or drink well, R1 would close mouth. CNA-M stated would document fluid intake and let the nurse know R1 didn't take in much fluid or food. On 4/25/18 at 1:22 p.m., the Surveyor interviewed DON-H regarding hydration screeners for R1. DON-H verified the hydration screeners were not completed as ordered for R1 on 4/3/18, 4/4/18, 4/5/18, and 4/6/18. DON-H verified there was not any other charting on orthostatic blood pressures for R1, as the facility charts by exception and the box should not be checked no if orthostatic blood pressures were not taken. On 4/25/18 at 3:12 p.m., the Surveyor interviewed PTA-I regarding R1's therapy note dated 4/9/18. PTA-I indicated nothing was changing for R1. Felt the facility needed to do something. Not making gains, not getting anywhere. Need to get more testing, run labs. Felt something wasn't right. Even though PTA-I did not feel the changes on 4/9/18 were acute, PTA-I did feel the nurse should see R1. On 4/26/18 at 2:03 p.m., the Surveyor interviewed CD-P per telephone regarding R1. CD-P verified R1 would need approximately 1470 ml of fluid daily and when she reviewed R1's food and fluid intake, she reviewed documentation to include intake and output as well as the hydration screeners to determine which direction to go. If CD-P had been notified of the intakes recorded on 4/7/18 of 140 and 4/8/18 of 360, CD-P she would have reviewed the hydration screeners. CD-P indicated the hydration screeners should have been completed more often. Regarding the intakes recorded on 4/9/18 and 4/10/18 of 920 ml and 720 ml, CD-P indicated if the resident's intake was less than 1000 ml daily, CD-P would worry about it and monitor intake and output closer. CD-P stated would want to be notified of intakes below 1000 ml daily, and was not notified by the facility. Per the MAR (medication administration record) for (MONTH) (YEAR), R1 received 10 mg of [MEDICATION NAME] daily from 4/1/18 through 4/11/18. On 4/27/18 at 12:27 p.m., the Surveyor interviewed R1's PCP (primary care physician) CN (Clinic Nurse)-Q. CN-Q had talked to R1's PCP regarding R1. The PCP indicated facility staff had not contacted the PCP for any pain concerns and agitation/aggression prior to 4/10/18 when the fax came to the clinic indicating R1 was having lower back pain, an increase in agitation/aggression and pulling at the crotch of pants. The PCP order a urinalysis, CBC and CMP. The facility did not make the PCP aware of decreased intake of fluids. Decreasing or discontinuing R1's [MEDICATION NAME] would have been dependent on the results of the lab work ordered. Facility staff were aware R1 had a change of condition and was not drinking as much fluids. Poor fluid intakes were documented from 4/7/18 to 4/10/18 as well as other days. After nursing was made aware of change of condition on 4/9/18, a nursing assessment to include vitals, review of intake and output, and review of medical record, was not completed to evaluate the need for interventions to attempt to prevent R1 from becoming dehydrated.