Every finding on record at Mineral Point Health Services

Based on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 3 residents (R6 and R3) reviewed. R6 was taking aspirin, the facility failed to monitor for signs and symptoms of bleeding, failed to notify the physician about their change of condition, and failed to complete an assessment when R6 had a change of condition. R3, who has CHF (Congestive heart failure) was admitted with orders for daily weights and the facility did not conduct these weights to monitor her condition. The facility also did not contact the physician immediately upon a severe weight change. Evidenced by: The facility's policy titled Change in Condition of the Resident last reviewed on 9/20/22 states in part .When a resident presents with a possible change of condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: 1. Assess the resident's need for immediate care/ medical attention. Provide emergency care as needed. 2. Assess/ evaluate the resident. The assessment/ evaluation could include, but is not limited to, the following: a. Vital signs, oxygen saturation, blood glucose level.c. Swelling, edema, discoloration.e. Personality, behavioral and/or cognitive changes. f. Alteration in level of consciousness, ability to respond.h. Sensory weakness or change. I. Generalized or local weakness.o. Bleeding.q. Dyspnea or irregular breathing.3. Notify the resident's physician- Use INTERACT Change in Condition: When to report to the MD/NP/PA (Medical Doctor/ Nurse Practitioner/ Physician Assistant) as a guideline. a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: i. Acute or sudden onset, and: ii. A marked change (i.e., more severe) in relation to usual symptoms and signs, or iii. Unrelieved by measures already prescribed requires a phone call to the provider. 5. Monitor resident's condition frequently until stable or transported to a higher level of care, if needed.Documentation: Documentation needs to include, but is not limited to the following: 1. Description of change in condition noted and assessment or observation of findings. 2. Emergency care provided, if appropriate. 3. Notification of provider- include date, time, what was conveyed, any orders received (each time notified). 4. Notification of responsible party.5. Names and titles of employees involved with resident's care at that time. The facility's policy titled High Risk Medications- Anticoagulants dated 8/30/23 states in part .4. The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include but are not limited to: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool) b. Fall in hematocrit or blood pressure c. Thromboembolism (blood clot). 5. The resident's plan of care shall include interventions to minimize the risk of adverse consequences. According to a post on Harvard Health Publishing dated 10/1/21, Aspirin decreases the ability of tiny cell fragments in the blood, called platelets, from clumping together and forming clots. Preventing these clots will help you avoid a repeat heart attack. Aspirin inhibits substances that protect the stomach's delicate lining, which can provoke bleeding in the stomach and intestines. If you notice stomach upset or pain, call your doctor. Taking aspirin with food may help. Older people and others prone to bleeding may want to ask their physician about taking an over-the-counter proton-pump inhibitor such as omeprazole (Prilosec), which can help prevent aspirin-induced stomach bleeding. More serious bleeding in the gastrointestinal tract can manifest as black, tarry stools. In rare cases, you may vomit dried blood (which resembles coffee grounds) or fresh blood. These situations should be evaluated right away in an emergency room. Aspirin and bruising - Harvard Health State of Wisconsin, Chapter N6 Standards of Practice for Registered Nurses and Licensed Practical Nurses, states in part: N 6.03 Standards of practice for registered nurses. (1) General nursing procedures. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or UAPs. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis . Example 1 R6 was admitted to the facility on [DATE] with diagnoses that include heart disease, type 2 diabetes mellitus, squamous cell carcinoma of skin and neck (skin cancer), and long-term aspirin use. R6's most recent MDS (Minimum Data Set) dated 4/24/26 states that R6 has a BIMS (Brief Interview of Mental Status) of 6 out of 15, indicating that R6 is severely cognitively impaired. R6's MDS also indicates that they are dependent on staff for all their ADLs. R6's care plan dated 2/16/26 states in part .Focus: Cardiac disease r/t (related to) essential hypertension, hx of CVA (history of stroke), atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm (plaque buildup in coronary arteries causing angina, often worsened by coronary artery spasms ), thoracic aortic ectasia (mild, uniform widening of the thoracic aorta that is less than 50% greater than its normal diameter and carries a lower immediate risk than an aneurysm), long term use of aspirin, venous insufficiency.Interventions/Tasks: Administer medications as ordered. Encourage rest periods as needed. Obtain lab results as ordered and notify physician of results. Obtain vital signs as indicated; report changes to physician. Obtain weights as needed/ ordered; report significant change. Tubi Grips ON AM OFF HS (bedtime). R6's Physician orders include: Aspirin Oral Tablet Delayed Release 81 mg (milligrams) Give one tablet by mouth one time a day for prophylaxis, CVA (stroke) prevention. Start date: 2/1/23. On 5/28/26 at 8:42 AM, Surveyor interviewed LPN K (Licensed Practical Nurse). Surveyor asked LPN K what do you monitor for when a resident is receiving a blood thinner/ anticoagulant, LPN K stated bruising, bleeding, and blood in the urine. Surveyor asked LPN K if that monitoring is typically found on the MAR/TAR (Medication Administration Record/Treatment Administration Record), LPN K stated yes. Surveyor asked LPN K if R6 had that type on monitoring on their MAR/TAR prior to their hospitalization on 4/1/26, LPN K reviewed R6's MAR/TAR and reported that there wasn't any monitoring listed. It is important to note that R6's care plan and MAR/TAR (Medication Administration Record/ Treatment Administration Record) do not include directions for staff to monitor R6 for signs and symptoms of bruising and bleeding due to aspirin use. Nurses' notes state the following: On 4/1/26 at 5:14 AM: Resident requesting to get up to the bathroom but is too weak to stand in the sit to stand lift. Color is pale and voice is weak. Temp (temperature) is normal O2 sats 99% on room air. Resident has a congested cough coughing up clear phlegm. It is important to note that there is no assessment completed, no documented vital signs, and no documentation of physician notification regarding this change of condition. On 5/28/26 at 2:48 PM, Surveyor interviewed RN L (Registered Nurse). Surveyor asked RN L if they were working with R6 on 4/1/26, RN L stated yes. Surveyor asked RN L to explain R6's change of condition, RN L reported that in the morning, there were 2 CNAs (Certified Nursing Assistants) that were going to transfer them and reported that R6 was really weak, and he was coughing up phlegm, and was pale. Surveyor asked RN L if they completed and documented any type of assessment on R6, RN L stated no and that they passed it on to the next shift to monitor. Surveyor asked RN L if they notified the physician of R6's change of condition, RN L stated no and they passed it on to the day shift nurse. On 4/1/26 at 8:13 AM: Communication with physician: Resident showing shortness of breath and oxygen sats ranging in the 70's. Oxygen placed at 2L/min which improved sats to 81%. Afebrile. Respirations 32 breaths per minute. Lung sounds absent in RLL (right Lower Lobe). Skin pale and resident appears gaunt. On-call physician [MD Name] gave orders to send to ER (Emergency Room) for eval and tx (evaluation and treatment) . [Ambulance Company Name] transferred resident at 0810 (8:10 AM) to [Hospital Name]. SBAR (Situation, Background, Assessment, Recommendation) Communication Form completed by DON B (Director of Nursing) dated 4/1/26 at 7:35 AM states in part .Situation.Shortness of breath.Vital Signs: BP (Blood Pressure) 124/99 Pulse: 54 RR (Respiratory rate): 32 Temp 98.0.O2 81% .Appearance: .Resident became very weak. Skin pale. Oxygen sats out of range, oxygen applied at 2L/min (liters/minute) and improved to 81%. No respiratory distress noted but respirations 32. Right lower lobe lung sounds absent. 4/1/26 at 2:51 PM: [R6's Son's name] son called this nurse with a report. Resident is staying at [Hospital Name] for observation d/t (due to) being severely anemic. Resident has received [sic] 2 units of blood at this time and condition is improving. Abnormality noted in rectum by hospitalist. ED (Emergency Department) note dated 4/1/26 at 8:47 AM states in part Chief Complaint: Patient presents with cough, shortness of breath- Developed cough in the night, staff at facility say he has been coughing up lots of junk and his O2 (oxygen level) sats have been in the upper 70's, patient keeps saying he feels like it's his time to leave us. History of Present Illness: [R6's Name] is a [R6's age] male presenting with not feeling well. For the past 2 days he hasn't been eating, noting stomach pain, nausea. No fevers but was noted to be coughing during the night and they found low O2 sats. He is unsure if he has had blood in his stools. He currently denies pain, says he feels a little SOB ([NAME] of breath). No cough noted. He vomited what looks like blood tinged emesis on the way in. He says he has not eaten today.ED Triage Vitals: Temp 97.8, Pulse 108, Resp (Respirations) 28, BP (Blood Pressure) 77/46, O2 96% .Physical Exam: .Appearance: He is ill- appearing.Comments: Pale, thin/ cachectic.Mouth: Mucous membranes are dry. Comments: Tongue is pale. Eyes: .Comments: Conjunctival pallor (noticeable lack of pink or red coloration in the conjunctiva, the mucous membrane lining the inner surface of the eyelids) noted. Cardiovascular: Rate and Rhythm: Tachycardia (elevated heart rate) present. Rhythm irregular. Pulmonary: .Mild tachypnea (fast breathing). Abdominal: .There is abdominal tenderness. Genitourinary: Rectum: Guaiac result positive (stool positive for blood) .Skin: Coloration: Skin is pale.Neurological: .Weakness (generalized) present. ED Labs: CBC (Complete Blood Count) with Auto Differential: WBC (White Blood Cells) 19.3 (H(High)), RBC (Red Blood Cells) 2.00 (L(Low)), Hemoglobin 6.2 (LL(Lower Limit)), Hematocrit 19.7 (LL).Critical Care Documentation: The patient has a critical illness or injury that acutely impairs one or more vital organs systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. The patient's care requires complex decision making, monitoring and interventions to prevent clinical deterioration.Critical care Conditions: Shock/Hypotension: Acute anemia requiring blood transfusion.Disposition: Observation: Floor. Condition: Serious. Diagnosis: 1. Hypotension, unspecified hypotension type. 2. Acute blood loss anemia 3. Leukocytosis, unspecified type 4. Elevated troponin 5. AKI (Acute kidney injury) . Hospital Inpatient History & Physical dated 4/1/26 at 1:42 PM states in part .History of Present Illness: . Blood count revealed hemoglobin low at 6.2 with black stools which were heme (blood) positive. He also had elevated WBC and AKI.Patient has been on aspirin for many years. He is not on anything for stomach protection. He has had iron deficiency anemia in the past. In the emergency room the patient received IV (Intravenous) fluids, he was typed and crossed for 2 units (Blood transfusion) and is being admitted for ongoing care. R6 was discharged from the hospital on 4/6/26 and returned to the facility. On 5/28/26 at 9:19 AM, Surveyor interviewed DON B. Surveyor asked DON B what the expectation is for nurses when a resident has a change of condition, DON B stated that they have to start an e-interact change of condition form and notify the MD right away. Surveyor asked DON B if they would have expected the nurse caring for R6 on 4/1/26 to have completed an assessment, DON B stated yes. Surveyor asked DON B if they would expect the nurse to document their assessment and R6's vital signs, DON B stated yes. Surveyor asked DON B if they would have expected the nurse to notify the MD, DON B stated yes. Surveyor asked DON B what type of monitoring was put in place for R6's aspirin use, DON B stated that usually everyone on aspirin gets put on anticoagulant med monitoring. DON B reported they could not find any anticoagulant monitoring in R6's orders. Surveyor asked DON B if monitoring should have been implemented, DON B stated yes. Example 2 The facility's weight assessment policy states, in part: *The nursing staff will measure resident weights on admission, the next 2 days, and weekly for 3 additional weeks thereafter. *Significant weight changes: .1 month--5% change is significant; greater than 5% is severe .3 months--7.5% weight change is significant; greater than 7.5% is severe .6 months--10% weight change is significant; greater than 10% is severe. *The nursing staff will notify the individual or responsible party and physician of any individual with an unintended significant weight change. *The physician and the interdisciplinary team will identify conditions and medications that may be causing weight change. For example: .Fluid imbalance and/or edema . R3 was admitted to the facility from the hospital on 4/7/26 and has diagnoses that include hypertensive (high blood pressure) heart disease with heart failure and chronic diastolic heart failure. Upon admission, R3's weight was recorded as 142 lbs (pounds). R3's hospital discharge orders state, in part, .Notify physician if patient's weight increases or decreases by 3 lbs in one day or 3 lbs in one week. R3 experienced a change in condition on 4/9/26 and was sent back to the hospital. The facility did not have any other weights than her admission weight on 4/7/26. It should be noted that R3 was hospitalized from [DATE] through 4/28/26. There is no indication or documentation for R3's weight at the hospital. R3's next weight at the facility on 4/29/26, upon re-admission R3's weight was 121 lbs. Additional weights for R3: 5/18/26: 126 lbs 5/19/26: 153.5 lbs (this is a 27.5-pound weight gain) 5/20/26: 153 lbs 5/21/26 151.5 lbs 5/22/26: 153.5 lbs The facility initiated a change of condition on 5/21/26, which states, .change in condition were Edema (new or worsening) .Weight gain related to increased fluid and edema throughout whole body. Pitting 2-3+ edema to legs. No shortness of breath but she does report a non-productive cough. There is no evidence or documentation that R3's physician was aware of this weight change before 5/21/26. R3 did not require hospitalization. On 5/28/2026 at 9:49 AM DON B (Director of Nursing) stated to Surveyor that R3 should have been weighed daily upon admission in accordance with the original hospital discharge orders. When asked about R3's 27.5 lb weight gain in one day, DON B stated she would expect the doctor to be notified right away, not wait for 2 days.

Based on interview and record review, the facility did not ensure that a resident's medical record included documentation that indicates the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, and that the resident (or representative) either accepted, received or declined the COVID-19 vaccine for 2 of 6 residents (R10 and R7) reviewed for COVID-19 vaccinations. R10 was not vaccinated for COVID-19 and became infected with COVID-19 that resulted in a hospitalization. The facility did not have documentation stating that the vaccination was offered, declined/consented to, or that the resident and or POA (Power of Attorney) was provided education on the vaccine. R7 was not vaccinated for COVID-19. The facility did not have documentation stating that the vaccination was offered, declined/consented to, or that the resident and or POA (Power of Attorney) was provided education on the vaccine. This is evidenced by:The facility's policy titled COVID-19 Vaccination last revised on 1/16/26 states in part .14. The facility will educate and offer the COVID-19 to residents.16. A copy of the Vaccine Information Statement (VIS) will be given to all staff, residents or resident representatives prior to administration and in conjunction with education as noted above.19. Residents or resident representatives retain the right to accept, refuse or change their decision about COVID-19 immunization. If refused, the residents will adhere to the protocols set forth by specific facility policy.21. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or; c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or declination. a. Complete a risk vs benefit UDA (User-Defined Assessment) for resident declinations.The CDC's (Centers for Disease Control) article titled Symptoms of COVID-10 dated 3/10/25 states in part .Signs and Symptoms: The following list does not include all possible symptoms. Symptoms may change with new COVID-19 variants and can vary depending on vaccination status. Possible symptoms include: Fever or chills, Cough, Shortness of breath or difficulty breathing, Sore throat, Congestion or runny nose, New loss of taste or smell, Fatigue, Muscle or body aches, Headache, Nausea or vomiting, Diarrhea. When to seek emergency help: Look for emergency warning signs* for COVID 19: Trouble breathing, Persistent pain or pressure in the chest, New confusion, Inability to wake or stay awake, Depending on skin tone, lips, nail beds and skin may appear pale, gray, or blue. Symptoms of COVID-19 | COVID-19 | CDC Example 1R10 was admitted to the facility on [DATE] with diagnoses that include dementia, anxiety disorder, depression, and a wedge compression fracture of the first lumbar vertebra (occurs when the anterior (front) portion of the L1 vertebral body collapses under compressive force, creating a wedge-shaped deformity).R10's most recent MDS (Minimum Data Set) dated 4/10/26 states that R10 has a BIMS (Brief Interview of Mental Status) of 2 out of 15, indicating that R10 has severe cognitive impairment. R10 has an APOA (Activated Power of Attorney).It is important to note that the facility did not have any documentation indicating that R10 and their APOA was offered, declined, consented to, or was provided education regarding the COVID-19 vaccine.Nurses' notes state the following:On 2/24/26 at 5:45 PM: Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Fever, Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) Seems different than usual. At the time of evaluation resident/patient vital signs, weight, and blood sugar were: Blood Pressure: 115/72.Pulse: 95.RR (Respiratory Rate): 16.Temp (Temperature): 100.1.Pulse Oximetry (oxygen level) 93% .Room air.Outcomes of Physical Assessment: Mental status: altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse), Functional Status Evaluation: General weakness, Decreased mobility. Abdominal/GI status Evaluation: Decreased appetite/fluid intake.Nursing observations, evaluation, and recommendations are: skin color abnormal, lung sounds clear, drowsy but easily aroused, no difficulty swallowing, weakness and fever present. Primary Care Feedback: A.recommended labs and cont. (continue) to monitor. B. New testing orders: Blood tests, Urinalysis or culture C. New Interventions orders: Increase oral fluids.On 2/25/26 at 6:30 PM: [R10's APOA name], approached this writer and voiced concern about [R10's Name] refusing to feed herself supper, lack of appetite, generalized weakness and occasional dry cough since lunchtime. This writer went into the room and evaluated resident at 5:30 PM. Resident color pale, slight tremors to hands, drowsy but brisk appropriate response to questions. No c/o (complaints of) pain or discomfort. Elevated temp of 100.1 forehead non-contact. Lung sounds clear. Resident took PRN (as needed) APAP (acetaminophen) administered with HS (bedtime) medications at that time spouse president in room.RN (Registered Nurse) on-call updated on status change at 5:40 PM, MD (Medical Doctor) on-call [MD's Name] returned call to facility at approximately 6:10 PM; provided update and orders for labs obtained.On 2/24/26 at 8:30 PM: CNA (Certified Nursing Assistant) approached this writer at approximately 7:30 PM with update that [R10's Name] was 'gurgling upon entry of room resident was audibly gurling [sic] and immediately rolled onto her left side and HOB (Head of Bed) elevated, resident expectorated (coughed up) moderate amount of white frothy sputum. Resident O2 sats 78% on room air with a pulse of 111. Supplemental O2 (oxygen) administered. RN on call contacted at 7:40 PM and given update. RN in agreement with this writers request to sent [sic] to ER (Emergency Room) for eval and treat for tachycardia and hypoxia.It is important to note that the facility did not perform COVID-19 testing despite R10's symptoms.ED (Emergency Department) notes dated 2/24/26 state in part Chief Complaint: Breathing Problem. History of present illness: [R10's Name] .presents with hypoxia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate and bluish skin) and altered mental status. History and exam is limited due to the patient's baseline dementia.Reportedly throughout the day today she had worsening alertness and a cough. She was coughing up some frothy sputum at 1 point. Started on oxygen after sats were noted to be in the 70s.Physical Exam: ED Triage vitals (2/24/26 at 8:32 PM): Pulse 108, Resp 20, BP 122/59, Temp 99.5, SpO2 89% .Medical Decision Making, ED Course & Medical Complexity: [R10's Name] is a [R10's age] female with a history of dementia, nursing home resident who presents with worsening alertness and acute respiratory failure with a cough. She was noted to be febrile prior to arrival here but was given Tylenol. Pulse is also tachycardic. Sats in the 80s on room air. Resolved with nasal cannula. Mildly increased work of breathing but no distress. IV (Intravenous) placed and blood work sent. Given the abnormal breath sounds fever and respiratory failure with apparently a productive cough reported prior to arrival I did empirically (by means of observation or experience rather than theory or pure logic) treat for bacterial pneumonia with Septra and azithromycin (antibiotics). Also started on fluids given the tachycardia (fast heart rate).Swab returns positive for COVID. This is likely the underlying cause of the patient's symptoms. Given the acute Evoxac respiratory failure I did give her 6mg (milligrams) of IV dexamethasone (steroid).Family Medicine admission H&P (History and Physical) dated 2/25/26 states in part .In the ED, pH (a measure of a fluid's acidity or alkalinity, determined by its hydrogen ion concentration) was 7.420 demonstrating respiratory alkalosis. BMP (Basic Metabolic Panel) was non revealing, BUN (measures the amount of urea nitrogen in your blood) 22, GFR (reflects how efficiently your kidneys filter blood through tiny structures called glomeruli, which remove waste and excess fluids) 54 otherwise normal. Fourplex showed COVID infection. EKG (measures the electrical waves in your heart) showed sinus tachycardia with a rate on 109.CXR (chest x-ray) showed emphysema with left basilar opacity felt possible to represent pneumonia, atelectasis or aspiration.Physical Exam: BP (!) 182/96.Pulse (!) 124 Temp 99.4.Resp (!) 32.SpO2 92% .Respiratory: increased work of breathing with O2 in place (patient had witnessed aspiration prior to exam). Scattered rhonchi (continuous low-pitched, rattling lung sounds that often resemble snoring) and gurgling. Assessment/ Plan: .hypoxia: COVID positive. CXR on admission not impressive for aspiration, however patient had witnessed aspiration event this am after Tylenol for fever. Work of breathing increased as did O2 needs. Patient less interactive, not following commands well after event. Given witnessed aspiration will as ceftriaxone and metronidazole.continue dexamethasone 6 mg daily, continue remdesivir, respiratory therapy per protocol.FEN (Fluids, Electrolytes, Nutrition): IVFs (IV fluids): 75ml/h (milliliters/hour) Electrolytes: trend, Diet: NPO.R10 remained in the hospital until 3/2/26 and returned to the facility.On 5/27/26 at 3:03 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R10 was offered that COVID-19 vaccination, DON B stated that they believed that R10 wanted one. Surveyor asked DON B what the process is for new admissions and vaccinations, DON B stated that they review the resident's record and H&P and the ADON (Assistant Director of Nursing) is in charge of offering immunizations. Surveyor requested documentation of R10 receiving or declining the vaccination.On 5/28/26 at 9:15 AM, Surveyor interviewed DON B. Surveyor asked DON B if they were able to find documentation of R10 declination of the COVID-19 vaccine, DON B stated they were unable to find documentation. Surveyor asked DON B if there should have been signed declinations, DON B stated yes.The facility failed to offer, administer, or ensure declinations were provided to residents regarding the COVID-19 vaccine, resulting in a 6-night hospitalization for R10. Example 2R7 was admitted to the facility on [DATE] with diagnoses that include frontotemporal neurocognitive disorder, dementia with severe agitation, mood disorder, and violent behavior.R7's most recent MDS dated [DATE] states that R7 has a BIMS of 0 out of 15, indicating that R7 has severe cognitive impairment.On 3/18/26, R7 has a declination signed for the PCV20 (pneumococcal conjugate vaccine). R7 does not have a declination for the COVID-19 vaccine.On 5/27/26 at 3:03 PM, Surveyor interviewed DON B (Director of Nursing) Surveyor asked DON B what the process is for new admissions and vaccinations, DON B stated that they review the resident's record and H&P and the ADON (Assistant Director of Nursing) is in charge of offering immunizations. Surveyor asked DON B if there was any documentation indicating that R7 had received or declined the COVID-19 vaccine, DON B stated that they would have to look.Surveyor requested documentation of R7 receiving or declining the vaccination.On 5/28/26 at 9:15 AM, Surveyor interviewed DON B. Surveyor asked DON B if they were able to find documentation of R7's declination of the COVID-19 vaccine, DON B stated they were unable to find documentation. Surveyor asked DON B if there should have been signed declinations, DON B stated yes.

Based on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 12 sampled Residents (R6).R6 has facial hair that is approximately 1/4- 1/2 long and fingernails that are long with a black substance underneath them.Evidenced by:The facility's policy titled Activities of Daily Living (ADLS) last reviewed on 7/26/22 states in part .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.R6 was admitted to the facility on [DATE] with diagnoses that include heart disease, type 2 diabetes mellitus, squamous cell carcinoma of skin and neck (skin cancer), and long-term aspirin use.R6's most recent MDS (Minimum Data Set) dated 4/24/26 states that R6 has a BIMS (Brief Interview of Mental Status) of 6 out of 15, indicating that R6 is severely cognitively impaired. R6's MDS also indicates that they are dependent on staff for all ADLs.R6's care plan 2/16/26 states in part .Focus: ADL self-care deficit related to: physical limitations.Interventions/Tasks: .Check nail length and clean on bath day and as necessary. Report any changes to the nurse. Licensed nurse to trim d/t (due to) DM dx (Diabetes Mellitus diagnosis) . Bathing/Showering: Assist of 1, Prefers SHOWER Thursday Day shift. Prefers shower around 6 am if possible.Personal hygiene: Assist of 1.On 5/26/26 at 12:25 PM, Surveyor interviewed R6. Surveyor noted that R6 has facial hair that is approximately 1/4- 1/2 long and fingernails that are long (past the tip of the finger) with a black substance underneath them. Surveyor asked R6 if they prefer to have facial hair or to be clean shaven, R6 stated that they prefer to be clean shaven and that whiskers aren't for them.On 5/27/26 at 12:14 PM, Surveyor observed R6. Surveyor noted that R6 continues to be unshaven, and their fingernails remain long with a black substance underneath them.On 5/27/26 at 12:21 PM, Surveyor interviewed CNA J (Certified Nursing Assistant) . Surveyor asked CNA J if they were familiar with R6, CNA J stated yes. Surveyor asked CNA J how often residents get shaved, CNA J stated every day. Surveyor asked if residents can be shaved on any shift, CNA J stated yes. Surveyor asked CNA J if they noticed that R6 hadn't been shaved, CNA J stated yes. Surveyor asked how often nail care should be provided, CNA J stated as needed. Surveyor asked CNA J if they noticed that R6's nails are dirty, CNA J stated that they don't know how to get them cleaned and that they have asked the other shift to soak them with R6's shower.On 5/27/26 at 3:27 PM, Surveyor interviewed R6. Surveyor asked R6 if they like their fingernails shorter, R6 stated yes, and they need cleaning. Surveyor notes that R6 remains unshaven.On 5/28/26 at 8:23 AM, Surveyor observed R6. Surveyor notes that R6 remains unshaven and fingernails remain long and dirty.On 5/28/26 at 8:37 AM, Surveyor interviewed LPN K (Licensed Practical Nurse). Surveyor asked LPN K how the nurses know what residents require nail care by the nurses, LPN K stated that all diabetic residents do. Surveyor asked LPN K when nail care is provided, LPN K stated that it is provided on shower day, the CNAs clean them, and the clipping is done by the nurses. Surveyor asked how the nail care is documented, LPN K stated that it is not documented. Surveyor asked LPN K if there is documentation for the last time R6's nails have been clipped and cleaned, LPN K stated no. Surveyor and LPN K observed R6's nails together. Surveyor asked LPN K if R6's nails need to be clipped and cleaned, LPN K stated yes. Surveyor asked LPN K how often residents should be shaved, LPN K stated that if there is facial hair, they should be shaved.On 5/28/26 at 9:26 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how often they would expect residents should be shaved, DON B stated per resident preference and daily if they need it. Surveyor asked DON B if R6 refuses cares, should that be documented, DON B stated that they would look. Surveyor asked DON B how the nurses know which residents require them to perform nail care, DON B stated that it is in the care plan, and the CNAs will let the nurses know when they need taken care of. Surveyor asked DON B where nail care is documented, DON B stated that they don't think it is documented.

Based on record review and interview, the facility did not offer each resident influenza immunization, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza immunization for 1 of 5 residents (R7) reviewed for immunizations. R7 did not receive the influenza vaccine. The facility did not have documentation stating that the vaccination was offered, declined/consented to, or that the resident or their Guardian was provided education on the influenza vaccine. Evidenced by:The facility's policy titled Influenza Vaccination last reviewed on 9/5/25 states in part .2. Influenza vaccinations will be routinely offered annually when it becomes available to the facility, unless such immunization is medically contraindicated, the individual has already been immunized during the time period or refuses to receive the vaccine.9. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of the immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal. Consider use of the Risk vs. Benefit UDA (User- Directed Assessment) in the electronic medical record as means to capture the resident's choice to not receive the influenza vaccination. R7 was admitted to the facility on [DATE] with diagnoses that include frontotemporal neurocognitive disorder (progressive brain disease characterized by the degeneration of the frontal and temporal lobes), dementia with severe agitation, mood disorder, and violent behavior.R7's most recent MDS dated [DATE] states that R7 has a BIMS of 0 out of 15, indicating that R7 has severe cognitive impairment. R7 has a Guardian.On 3/18/26, R7 has a declination signed for the PCV20 (pneumococcal conjugate vaccine). R7 does not have a declination for the Influenza vaccine.On 5/27/26 at 3:03 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for new admissions and vaccinations, DON B stated that they review the resident's record and H&P (History and Physical) and the ADON (Assistant Director of Nursing) is in charge of offering immunizations. Surveyor asked DON B if there was any documentation indicating that R7 had received or declined the influenza vaccine, DON B stated that they would have to look.Surveyor requested documentation of R7 receiving or declining the vaccination.On 5/28/26 at 9:15 AM, Surveyor interviewed DON B. Surveyor asked DON B if they were able to find documentation of R7's declination of the influenza vaccine, DON B stated they were unable to find documentation. Surveyor asked DON B if there should have been signed declinations, DON B stated yes.

Based on interview and record review, the facility failed to protect a resident's (R) (R2) right to be free from sexual abuse by another resident (R1).On 3/20/26, R2 was found in bed with R1. Staff at the facility did not report this incident to management. On 4/13/26, R1 was found in R2's room and was inappropriately touching R2. On 4/18/26, R2 was found in R1's room being inappropriately touched by R1.The facility's failure to provide adequate supervision and protect R2 from sexual abuse by R1 created a reasonable likelihood for serious psychosocial harm, thus resulting in a finding of immediate jeopardy (IJ) that began on 4/13/26. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 4/28/26 at 2:50 PM. The immediacy was removed and corrected on 4/18/26. The deficient practice is being cited as past noncompliance. Evidenced by:The facility policy, Abuse, Neglect and Exploitation, dated 3/2018, with last review date of 7/15/22, states in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident. and prevent abuse. Policy Explanation and Compliance Guidelines: 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. III. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse. A. Establishing a safe environment. by establishing policies and protocols for preventing sexual abuse, such as the identify of when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded. B. Identifying, correcting and intervening in situations in which abuse. is more likely to occur. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents. IV. Identification of Abuse, Neglect and Exploitation. A. The facility will have written procedures to assist staff in identifying the different types of abuse. V. Investigation of Alleged Abuse, Neglect and Exploitation. A. An immediate investigation is warranted when allegation or suspicion of abuse. occur. VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include, but are not limited to:. C. Increased supervision of the alleged victim and residents. VII. Reporting/Response. 1. Reporting of all alleged violations to the Administrator. Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse. occurred, and what changes may be needed to prevent further occurrences; b. Defining whether care provision should be changed and/or improved to protect residents receiving services. d. Identification of staff responsible for implementation of corrective actions.f. Identification of staff responsible for monitoring the implementation of the plan.R1 was admitted to the facility on [DATE] with diagnoses that include in part: Major depressive disorder, Anxiety disorder, Alzheimer's disease, and Unspecified dementia.R1's most recent Minimum Data Set (MDS) indicates R1 has a Brief Interview for Mental Status (BIMS) score of 3 indicating R1 is severely cognitively impaired. R1 has an activated power of attorney.R1's Comprehensive Care Plan in March 2026 states in part: Focus: At times [Resident Name] exhibits socially inappropriate behaviors. Date Initiated: 1/16/26. Interventions: If [Resident Name] wants to watch TV with other residents, ensure it is in a public place where she can be monitored. Date Initiated: 3/2/26. Offer resident to hold baby doll or kitten. Offer something for resident to hold in hands to keep her pre-occupied. Date initiated: 3/7/24. Interventions: Exhibits inappropriate sexual advances. Calmly redirect and intervene when inappropriate behavior begins. Distract with alternate activities like puzzles or watercolor painting. Redirect [Resident Name] and offer newspapers/magazines/copies to organize. Date Initiated: 3/5/25. Interventions: If wandering toward resident rooms offer to close other resident's door as this makes the room less appealing for [Resident Name] to go into. Date Initiated: 3/1/24. Intervention: Provide safe and comfortable environment for [Resident Name]. Date Initiated: 3/1/24. Revision on: 10/27/25.A review of R1's Electronic Health Record (EHR) includes the following progress notes:On 5/5/25: .Increased disruptive behaviors r/t psychotropic medication changes r/t sexually inappropriate behaviors. On 9/10/25: .Changes to psychotropic medications per pharmacy recommendation r/t over-affection/sexual behaviors.R2 was admitted to the facility on [DATE] with diagnoses that include in part: Traumatic subdural hemorrhage with loss of consciousness, Adjustment disorder with depressed mood, Mild cognitive impairment, and Generalized anxiety disorder.R2's most recent MDS indicates R2 has a BIMS score of 4 indicating R2 is severely cognitively impaired. R2 has an activated power of attorney.R2's Comprehensive Care Plan in March 2026 states in part: Focus: At risk for behavior symptoms. Date Initiated: 2/26/26. Revision on: 4/21/26. Interventions: Exhibits inappropriate sexual advances. Calmly redirect [Resident Name] to a common area when inappropriate behavior begins. Distract with alternative activities such as watching TV programming. Redirect [Resident Name] and offer newspapers/magazines.1. A nursing progress note in R2's EHR written by LPN G (Licensed Practical Nurse) on 3/20/26 at 1:38 AM states the following: At 0010 (12:10 AM), room bed alarm was going off. Staff went down to this room to check on the resident and (R2) was completely in bed, covered up, lying next to (R1) resident! Staff asks [sic] the resident what are you doing in this room? He stated, she wanted me to get in bed with her. Staff redirected this resident back to his room, and as he was crawling in bed he asks the staff, can you touch my penis a little? Staff said no, and he stated, can't I have a little fun?On 4/28/26 at 11:52 AM, Surveyor interviewed LPN G about the progress note she entered regarding the incident on 3/20/26. LPN G stated at that time there were no alarms on R2's door, so when he came out of his room, they were not aware of it. LPN G stated she was doing rounds on the night shift on 3/20/26, checking to see if all the residents were in bed, when she came to R1's room and saw R2 crawling in bed with R1. LPN G stated R1 was lying on her back in the bed, and R2 was lying on his side facing R1. LPN G stated both R1 and R2 were fully clothed, and she did not witness any inappropriate touching between R1 and R2. LPN G stated she returned R2 to his room and then charted the behavior in R2's progress note. LPN G indicated she also reported what happened to the oncoming shift during shift report. Surveyor asked LPN G if finding R1 and R2 in bed together could be abuse? LPN G stated she would consider it abuse if there was touching involved, but she had come upon them in time and she did not witness any inappropriate touching between R1 and R2. Surveyor asked if R1 and R2 were consenting adults for the sexual behavior? LPN G stated with R1's dementia and R2's cognitive issues she didn't know if they would be able to give consent. LPN G indicated R1 is very friendly with everyone and R2 is a very flirty man, but that she was shocked to find them in bed together. Surveyor asked LPN G if she had reported this incident to management. LPN G stated she had not reported it to management, only the oncoming shift. Surveyor asked LPN G if she had reported this incident to R1 and R2's POAs. LPN G stated she had not.On 4/28/26 at 11:23 AM, Surveyor interviewed R2's POA H (Power of Attorney) who stated she was unaware of the incident which occurred on 3/20/26 where R2 was found with R1 in her bed.There were no changes to the care plans for either R1 or R2.2. The facility completed a self-report/investigation which states: On 4/13/26 CNA D (Certified Nursing Assistant) witnessed R1 in R2's room. CNA D reported R2 was 'slumped over with his hands on R1's wheelchair arm rests with his pants partially down'. CNA D reports he intervened, sat R2 on the bed and he (CNA D) hollered out for CNA C to come and assist. R1 was removed from the room immediately by CNA C and both CNAs reported the incident to Charge Nurse/ADON I (Assistant Director of Nursing) and DON B (Director of Nursing). NHA A (Nursing Home Administrator), doctors and families were contacted. Police department was also contacted as well as the Ombudsman.Facility interviewed residents and staff. A door alarm was placed on R2's door to alert staff if anyone is entering his room. Education was provided to all staff on not allowing R1 in R2's room and about the door alarm. Trauma Informed Care and Psychosocial assessments were completed on both R1 and R2, and a skin assessment was completed on R1 with no concerns.Facility conclusion summary states, in part: Following a thorough investigation into the incidents involving R1 and R2, the facility believes both were looking to engage with one another, however were stopped prior to anything happening. The findings indicate both may have had intent on initiating something but were separated immediately. As a result of this situation, [Facility name] placed an alarm on R2's door. Alarm box will always be monitored when he's in the building by Charge Nurse or Assigned Management. Additional interventions were placed on R1 and R2's care plans to encourage safety. This report, as well as other concerns and allegations, with be brought to QAPI monthly for review. The facility will continue to conduct routine audits. to monitor for any unwanted contact between residents.These measures will remain in place to strengthen oversight, promote resident safety. On 4/28/26 at 9:45 AM, Surveyor called and left a message for CNA D. CNA D did not return the call. On 4/28/26 at 9:47 AM, Surveyor interviewed CNA C, who stated on 4/13/26 she was passing water and clean linens to the rooms at the start of her shift, and CNA D was also passing water on the hall. CNA C stated she heard CNA D calling her to come to R2's room. CNA C stated she witnessed R1 in R2's room, fully dressed and in her wheelchair facing R2. CNA C stated she witnessed R2 sitting on the bed facing R1 with his pants all the way down and his brief halfway down. CNA C stated R1 told them to leave. CNA C stated she and CNA D took R1 out of R2's room and to the nurse's station, where they reported the incident to DON B. Following this incident, R1's care plan was updated as follows:Date Initiated: 4/13/26. Revision on: 4/21/26. Focus: Potential for elopement r/t cognitive impairment. Date Initiated: 4/13/26. Revision on: 4/21/26. Focus: At risk for unavoidable decreased social interaction and/or increased withdrawal, anger or depressive behavior.R2's care plan was updated to include the following:Alarm placed on door 4/13/26 to allow time for intervention in case of another resident entering room, including [R1 Resident Number]. Resident is to be further than arm's length from resident [R1 Resident Number] during activities and in public areas. Date Initiated: 4/16/26. Focus: Wandering/pacing r/t cognitive impairment. Date Initiated: 3/10/26. Interventions: Motion sensor to handrail outside of room pointed towards resident's doorway. Date Initiated: 4/13/26. Focus: Inappropriate undressing and verbal conversations with women (such as removing clothing) r/t cognitive impairment, hx (history of) TBI (traumatic brain injury). Date Initiated: 4/13/26. Revision on: 4/21/26. Interventions: Notify family and make arrangements to obtain adaptive clothing if needed. Date Initiated: 4/13/26. Resident [R1s Resident Number] was moved to the 200 wing on 4/18/26 to provide space and distance. Date Initiated: 4/13/26. Focus: At risk for unavoidable decreased social interaction and/or increased withdrawal, anger or depressive behavior.3. The facility completed a second self-report/investigation which states: On 4/18/26 at 7:20 AM, CNA F noticed R1's room was closed. Upon opening the door, she witnessed R2 sitting in R1's recliner with his pants down. CNA F states R1 was touching his (R2's) penis. CNA F said R1 backed away from R2 and put her hands in her lap. CNA F had R2 stand up, put his pants on and escorted him out of the room. R1 began to follow. CNA F asked R1 to go to the nurse's station, which she willingly did. CNA F ensured the safety of both residents and reported the incident to DON B, who began 1:1 (one on one) (monitoring) with R1. Police department, POAs (Powers of Attorney), and physicians were contacted. Families do not wish to press charges.On 4/28/26 at 10:33 AM, Surveyor interviewed CNA F who stated on 4/18/26, she was walking down the hall when she noticed that R1 had her door shut. CNA F stated she knocked on the door and entered the room to see R2 in R1's recliner facing R1, who was seated in her wheelchair. CNA F stated she witnessed R1 pull her hand back from R2's private area when she entered the room. CNA F stated R2's pants were on, but the zipper was down and his penis was exposed. CNA F indicated she had R1 go to the nurses' station while she helped R2 get put back together. CNA F stated she was unaware of any prior incidents of R2 being in R1's room. CNA F stated that after this incident on 4/18/26, R1 and R2 both have 1:1 staff monitoring and they are to make sure they stay separated when they are out of their rooms, and that they eat in different dining rooms. CNA F indicated there is a binder at the nurses' station where the staff write down the location of R1 and R2 each hour.On 4/28/26 at 10:00 AM, Surveyor interviewed LPN E who stated on 4/18/26 she was doing medication pass when CNA F came to her and told her that R2 had been in R1's room and when CNA F entered the room she witnessed R1 pull her hand away from R2's lap.LPN E stated that it was her understanding from CNA F that both R1 and R2 were fully clothed. LPN E stated that she made sure that R1 and R2 were separated and notified DON B. LPN E stated she had the alarm with her in the medication room, but it never alarmed while she was in the med room. LPN E stated that after separating R1 and R2, her and DON B checked that the batteries were working and tested the alarm in all parts of the building to ensure that it worked. LPN E stated she was unaware of the previous incident of R1 and R2 being found in bed together.Facility interviewed residents and staff. The door alarm for R2's door was tested and safety checks were initiated for failure to alarm due to being out of range frequency. R1 was moved down another hallway, and a door alarm was also placed on her door. Both R1 and R2 were placed on 1:1 (monitoring) when out of their rooms. Education was provided to all staff on interventions and safety plan. Trauma Informed Care, Psychosocial assessments, and skin assessments were completed on both R1 and R2 with no concerns.Facility conclusion summary states in part: Following a thorough investigation into the incident involving residents R1 and R2, the facility believes both residents continue to seek each other out. They did make contact, which the facility did attempt to prevent by having a door alarm in R2's room. Unfortunately, the nurse trying to monitor the alarm had taken it into the med room and it did not sound due to being out of frequency. The findings show that R1 and R2 were alone for about 10 minutes or less when CNA F entered the room and separated them. As a result of this situation, [Facility name] relocated R1 down another hall, placed an alarm on her door and started 1:1 (monitoring) with her when out and about. R2 has also been placed on 1:1 (monitoring) when out of his room. A past noncompliance was started to educate regarding the alarm being out of range. Alarm box will be monitored when (R2) is in the building at the Nurse's station. Additional interventions were placed on R1 and R2's care plans to encourage safety. This report, as well as other concerns and allegations, with be brought to QAPI monthly for review. The facility will continue to conduct routine audits. to monitor for any unwanted contact between residents. Staff will be trained on red flags or potential of impending sexual abuse at an all staff meeting to further prevent and protect our residents. A review of the manufacturer's recommendations for the door alarm, provided by the facility, states, in part: Important Information: Cordless and wireless systems rely on wireless technology which is subject to physical and environmental considerations. Please be aware that the transmitter will not be 100% accurate if it is out of range at any time. It is the end-user's responsibility to make sure that the product is used correctly and within range of each other. The Snart Caregiver Corporation devices are designed to be installed by the end user. As such, it is the entire responsibility of the buyer to ensure that the system is properly installed and tested. This Bed Exit Alarm Paging System alerts the caregiver wearing the pager of a resident's activities when the resident interrupts the Exit Alarm's infrared field, as long as they are within 150 feet of each other depending on the environment.On 4/28/26 at 9:24 AM, Surveyor interviewed DON B about the alarm device, who stated they were following the manufacturer's recommendations. DON B indicated they had tested the alarm at the 150 feet range but had not tested the alarm's range in all areas of the building and were unaware that it would not work in the med room.Following this incident, the facility updated R1's care plan as follows:Date Initiated: 4/21/26. [Resident Name] is currently on 1:1 supervision while out of her room due to interaction with a male resident on 4/18/26. Date Initiated: 4/18/26. [Resident Name] was moved down 200 hall to distance her from [R2s Resident Number] on 4/18/26. Date Initiated: 4/21/26. Motion sensor alarm pointed towards resident's doorway for safety. Alarm to indicate if anyone leaves or enters room. Date Initiated: 4/18/26. Offer 1:1 visit/support during periods of socially inappropriate behaviors. Date Initiated: 4/8/26. Revision on: 4/21/26. Ensure [Resident Name] is not seated near resident [R2s Resident Number] when at activities, at meals, or in common areas. [Resident Name] must be further than arm's length away from resident [R2 Resident Number] at all times. [Resident Name] is NOT allowed in resident [R2 Resident Number] room. [Resident Name] currently dines in a different dining room from [R2 Resident Number].Facility staff updated R2's care plan as follows:Date Initiated: 4/21/26. [Resident Name] often removes clothing and prefers to be naked. Offer to close door and give privacy as needed. Date Initiated: 4/18/26. Intervention: Provide [Resident Name] with a safe environment. Date Initiated: 4/18/26. Revision on: 4/20/26.A review of R1 and R2's undated Sexual Consent Assessments provided by the facility indicates questions and answers about sexual contact and having a potential sexual relationship with the other resident, however there are no questions or indication that either resident would be able to consent to sexual activity in these Sexual Consent Assessments.On 4/28/26 at 9:30 AM, Surveyor interviewed NHA A about the Sexual Consent Assessments. NHA A stated she had reached out to the Ombudsman, and this was the tool the Ombudsman sent to see if they could consent. NHA A stated she determined that R1 and R2 didn't have the ability to consent since they couldn't recall the incident. NHA A stated R1 and R2 do fluctuate in cognition but knowing them, they would not be able to consent. NHA A indicated she didn't think R1 or R2 were traumatized, as they seem mutually attracted to one another. NHA A stated POA H (Power of Attorney) was aware of this. NHA A indicated the plan going forward was to keep R1 and R2 apart with the door alarms and 1:1 monitoring by staff.On 4/28/26 at 11:43 AM, Surveyor interviewed NHA A about the incidents involving R1 and R2. NHA A stated she was unaware of the incident on 3/20/26 where R2 was found with R1 in her bed. NHA A stated it was never reported to her. Surveyor asked NHA if it was her expectation to be notified of all abuse allegations. NHA A stated she should have been notified so she could put interventions in place right away and investigate and report the incident. Surveyor asked NHA A if she would have expected the door alarms to be tested for effectiveness. NHA A stated yes, unfortunately R2's door alarm did not sound in the med room, and the door alarm should have been tested in all areas of the building.The facility's failure to provide adequate supervision and protect R2 from sexual abuse by R1 created a reasonable likelihood for serious psychosocial harm, thus leading to a finding of immediate jeopardy which began on 4/13/26. The facility removed and corrected the immediate jeopardy on 4/18/26 when it completed the following:Alarm was placed on R1 and R2's door. Alarm must stay at nurse's station and be monitored at all times by Charge Nurse or Designee.R1's room was moved to a room further down the hallway to ensure further distance between her and R2.R1 must have 1:1 Supervision at all times, unless in her room and alarmed.R2 must be supervised (within eyesight) when in main areas. Family may provide the 1:1 supervision but must report to staff when leaving the building.If at Activities, residents are not allowed to sit next to each other and must be further than arm's length away from each other.R1 and R2 are not allowed to eat in the same dining room. The facility provided training to all staff on Intervention Safety Plan, Signs of a Potential Perpetrator, facility policies NSG Accidents and Supervision, Abuse, Neglect, and Exploitation (Including Reporting Timelines), and Resident Alarms.Audits Initiated for validating Safety Plan and Alarm Function.Documentation 1:1 supervision is being documented every hour on R1 and R2.

Based on interview, record review, and policy review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for one of four residents (R3). Findings include:Review of the facility provided investigative file revealed on 08/13/25 R3 reported to the Administrator and Social Worker that Licensed Practical Nurse 1 (LPN) yelled and swore at R3. R3 was agitated and in pain when LPN1 entered the room to administer evening medications. R3 requested a pain medication and LPN1 attended to another resident's medications and when LPN 1 returned to R3's room, R3 had grown impatient and yelled at LPN1 using vulgar language. LPN1 requested R3 not to use that language and when more vulgar language was used, LPN1, who was frustrated, yelled and swore back at R3. Review of R3's admission Record, located in the EMR under the Profile tab, revealed an admission date of 08/12/24 and readmitted on [DATE] with medical diagnoses that included alcoholic cirrhosis of the liver with ascites and ankylosing spondylitis of unspecified sites in the spine. During an interview on 08/22/25 at 12:35 PM, LPN1 explained R3 was agitated and in pain on 08/13/25 when LPN1 entered the room to administer scheduled evening medications. R3 requested pain medication and LPN1 attended to another resident's medication and then returned to R3's room. R3 had grown impatient and yelled at LPN1 using vulgar language. LPN1 requested R3 not to use that language and when more vulgar language was used, LPN1, who was frustrated, yelled and swore back at R3. During an interview on 08/22/25 at 2:35PM, the Director of Nursing (DON) explained R3 had recently been increasing requests for pain medication and exhibiting the behavior of dictating what R3 wanted whenever possible. The physician was aware, a psychiatric evaluation appointment had been scheduled, and a door alarm was placed on R3's door so when R3 exits, staff were alerted for increased supervision by the staff. The DON confirmed the residents were to be protected from abuse from other residents and staff. During an interview on 08/22/25 at 2:35 PM, the Executive Director confirmed the investigations into the two incidents involving R3 were abuse. The Executive Director stated LPN1 was suspended then disciplined at the completion of the investigation. The facility continues to work with R3 and local resources to meet the needs of R3 and the facility for the safety of the residents. Review of the facility's policy titled Abuse, Neglect and Exploitation, revised 07/15/22, revealed It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.

Based on observation, interview, and record review, the facility did not assure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable in 1 of 1 medication rooms. This has the potential to affect more than a minimal number of Residents. Surveyor observed the following in the medication storage room: - 4 bottles of Enema Saline Laxative with expiration dates of 2/25. - 6 boxes of Bisacodyl Suppositories with 12 suppositories in each box with expiration dates of 1/25. - 1 Bottle of Major Cough DM Dextromethorphan Polistirex Extended-Release Oral Suspension with an expiration date of 3/25. - 2 bottles of melatonin 1 mg (milligrams) with 180 caplets in each bottle with expiration dates of 3/25. Evidenced by: The facility policy entitled, Storage of Medication, dated 1/23, states, in part: .Policy: Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . and reordered from pharmacy . if a current order exists . On 4/2/25 at 10:30 AM, Surveyor observed in the medication storage room [ROOM NUMBER] bottles of Enema Saline Laxatives, 6 boxes of Bisacodyl Suppositories, 1 Bottle of Major Cough DM Dextromethorphan Polistirex Extended-Release Oral Suspension, and the 2 bottles of melatonin. RN C (Registered Nurse) verified the 4 bottles of enemas expired on 2/25, the 6 boxes of bisacodyl suppositories expired on 1/25, the bottle of DM cough Suspension expired on 3/25, and the 2 bottles of melatonin expired on 3/25. RN C indicated the expired medications should not be in circulation. On 4/2/25 at 10:57 AM, Surveyor interviewed DON B (Director of Nursing), who entered to medication storage room with Surveyor and RN C. DON B indicated the 4 bottles of Enema Saline Laxatives, 6 boxes of Bisacodyl Suppositories, 1 Bottle of Major Cough DM Dextromethorphan Polistirex Extended-Release Oral Suspension, and the 2 bottles of melatonin were expired and should not be in circulation. DON B removed the expired medications and indicated they would be disposed.

Based on observation, interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 3 residents (R11) reviewed for enhanced barrier precautions and hand hygiene concerns during medication administration. Staff did not follow Enhanced Barrier Precautions (EBP) of wearing personal protective equipment (PPE) when providing wound care for R11. RN C (Registered Nurse) did not perform hand hygiene at the appropriate times. This is evidenced by: The facility's policy titled Enhanced Barrier Precautions, dated 8/8/24, states in part: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions .will be initiated for residents with any of the following: i. Wounds . High-contact resident care activities include: . h. Wound care: any chronic skin opening requiring a dressing. The facility's policy titled Hand Hygiene, dated 11/2/22, states in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table, states in part: Condition to use Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred): Between resident contacts; Before applying and after removing personal protective equipment (PPR), including gloves; Before preparing or handling medications; Before and after handling clean or soiled dressings; When, during resident care, moving from a contaminated body site to a clean body site. Example 1 R11 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis affecting right dominant side (paralysis and weakness). R11's physician orders include: Enhanced barrier precautions d/t (Due To) wound Cleanse left inner buttock wound with soap and water, pat dry. Skin prep peri-wound. Apply foam silicone border dressing Cleanse right buttock wound with soap and water, pat dry. Apply foam silicone border dressing Cleanse right shin wound with wound cleanser, pat dry. Topically apply leptospermum honey and cover with a gauze island w/brd (With Border) dressing On 4/1/25 at 2:45 PM, Surveyor observed an Enhanced Barrier Precaution sign on R11's door and there was a bin outside R11's door that contained personal protective equipment to wear for EBP. Surveyor observed wound care for R11 provided by DON B (Director of Nursing). DON B applied gloves and performed wound care to R11's shin and buttocks. Of note, DON B did not wear a gown during R11's wound care. On 4/1/25 at 3:19 PM, Surveyor interviewed DON B regarding EBP and PPE that should be worn during wound care. DON B indicated R11 is on EBP for his wounds. DON B indicated a gown and gloves should be worn during high contact activities with R11 including wound care. DON B indicated she should have worn a gown and did not. 41788 Example 2: On 4/2/25 at 7:47 AM, Surveyor observed RN C (Registered Nurse) during medication pass. RN C came out of a resident's room with gloves on. RN C removed the gloves and applied new gloves without performing hand hygiene. RN C pushed the medication cart from a resident's room down two hallways to the dining area with the same gloves on. RN C then went to start another resident's medication. On 4/2/25 at 8:03 AM, Surveyor interviewed RN C and asked when hand hygiene should be performed during medication pass. RN C indicated he performs hand hygiene after every other change of gloves due to it is too hard to get gloves on after hand hygiene is performed. Surveyor asked what the standard of practice for hand hygiene and glove change is. RN C indicated technically hand hygiene should be performed in between glove changes. RN C did not perform hand hygiene per standards of practice.

Based on observation, interview, and record review, the facility did not ensure each resident received the necessary care and treatment for pressure injuries (PI) to promote healing consistent with professional standards of practice (SOP) for 1 of 2 residents (R11) reviewed for pressure injuries. Staff did not perform hand hygiene and did not treat each pressure injury separately when performing wound care for R11. This is evidenced by: The facility's policy title Clean Dressing Change, dated 7/20/22, states in part: .It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Each wound will be treated individually . R11 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis affecting right dominant side (paralysis and weakness), stage 2 pressure injury to left buttock, and stage 2 pressure injury to right buttock. R11's physician orders include: Enhanced barrier precautions d/t (Due To) wound. Cleanse left inner buttock wound with soap and water, pat dry. Skin prep peri-wound. Apply foam silicone border dressing. Cleanse right buttock wound with soap and water, pat dry. Apply foam silicone border dressing Cleanse right shin wound with wound cleanser, pat dry. Topically apply leptospermum honey and cover with a gauze island w/brd (With Border) dressing. On 4/1/25 at 2:45 PM, Surveyor observed DON B (Director of Nursing) perform pressure injury wound care for R11. Surveyor observed DON B perform hand hygiene, apply gloves, apply skin prep around R11's left buttock pressure injury, then apply a dressing to the right buttock pressure injury, then apply the dressing to R11's left buttock pressure injury. Of note, DON B did not perform hand hygiene after each of the following tasks: applying skin prep around left buttock pressure injury, applying dressing to right buttock pressure injury, and applying dressing to left buttock pressure injury. DON B treated both pressure injuries at the same time and did not treat each one separately. On 4/1/25 at 3:19 PM, Surveyor interviewed DON B regarding pressure injury treatment for R11. DON B indicated wound care should be performed by treating each wound separately. DON B indicated the left buttock pressure injury and right buttock pressure injury should be treated separately because they are at different locations on the body. DON B indicated since each pressure injury is at a separate location she should treat one at a time and she did not. DON B indicated she should have completed wound care on the left buttock pressure injury and perform hand hygiene prior to moving on to the right buttock pressure injury and did not.

Based on interview and record review, the facility did not ensure residents are free of any significant medication errors for 1 of 6 reviewed for medications (R30). R30 was prescribed an antibiotic that the facility did not administer to her. Findings include R30 was admitted to the facility on [DATE] and has diagnoses that include acquired absence of left foot and infection of skin and subcutaneous tissue. R30's discharge orders, dated and printed on 2/13/25 at 12:32 PM, from the hospital state, Start taking these medications .ciprofloxacin 750 mg (milligrams), take 1 tablet every 12 hours for 19 days. (of note: this order is for twice a day) R30's MAR (Medication Administration Record) shows this medication was never given, and R30 has a skin infection. On 4/02/25 at 10:27 AM, Surveyor interviewed DON B (Director of Nursing) who stated that there was a mix-up with the paperwork that was sent over by the hospital and the ciprofloxacin was not on the orders in the paperwork the facility received. DON B stated the physician saw the resident the next day (progress note indicates this was at or around 2/14/25 at 2:17 PM) and noted that the resident did not have ciprofloxacin on her medications list. When asked if the facility has ciprofloxacin in their medication contingencies, DON B stated, yes. DON B indicated that the facility should have recognized that R30 was admitted with an infection and should have inquired if R30 was prescribed an antibiotic if it was not on the resident's orders. When asked if she thought this was a medication error, DON B indicated that she did but the facility did not document it as a medication error. R30 discharged AMA (Against Medical Advice) on 2/14/25 at approximately 4:30 PM. R30 was not given any ciprofloxacin prior to discharge but orders were sent to a local pharmacy for R30 to pick up.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 14 residents (R26) reviewed for abuse. Facility did not report an abuse allegation involving R26 within the required two hours to the state agency (SA). Evidenced by: The facility policy entitled, Abuse, Neglect, and Exploitation, dated 7/15/22, states, in part: .Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation and Compliance Guidelines: VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or . R26 was admitted to the facility on [DATE] and has diagnoses that include depression, anxiety and history of malignant neoplasm of breast (a cancer that forms in the cells of the breast). R26's Admission Minimum Data Set (MDS) Assessment, dated 1/9/25, shows R26 has a Brief Interview of Mental Status (BIMS) score of 12 indicating R26 has moderate cognitive impairment. On 4/01/23 at 9:45 AM, Surveyor interviewed R26. R26 indicated to Surveyor this morning a CNA (certified nursing assistant) had taken her to the bathroom and assisted R26 back into her recliner. R26 felt she had to go to the bathroom again and she felt she had not emptied out all the way. R26 turned her call light on. The CNA came back in and turned her call light off and told R26 to go in her diaper and the staff would clean her up later. R26 indicated she felt terrible and degraded. R26 was crying as she was telling Surveyor, I don't know if they think I can walk. R26 indicated if she could walk she would not be calling staff to help her. R26 indicated she feels she needs more help than staff give her. R26 indicated the CNA does not like her. R26 indicated she rubbed her stomach and fell back asleep and woke up about 45 minutes later and turned her call light back on. R26 indicated a different CNA answered her call light and took R26 to the bathroom. Surveyor asked R26 if she voiced her concern to anyone and R26 indicated she reported the incident to the male nurse this morning. On 4/01/25 at 1:29 PM, Surveyor interviewed RN C (Registered Nurse) and asked if R26 had brought a concern to him this morning. RN C indicated yes, R26 was tearful and stated the CNA yelled at her about needing to go to the bathroom, turned R26's call light off, and then left R26's room. R26 indicated to RN C it is not her fault that she is unable to walk. Surveyor asked RN C what he did when R26 informed him of that. RN C indicated he asked if R26 felt safe at the facility and R26 indicated yes. RN C indicated he reported the incident to NHA A (Nursing Home Administrator) around 8:30AM-8:45AM. Surveyor asked RN C if R26 reported to him a CNA told her to go in her diaper and would not take her to the bathroom. RN C indicated no. Surveyor asked if yelling at a resident and telling a resident to go in her diaper could be considered abuse. RN C indicated yes. On 4/01/25 at 1:38 PM, Surveyor interviewed NHA A and asked if RN C had reported a concern regarding R26 this morning. NHA A indicated RN C reported before 9:00AM to her that R26 had a concern with a CNA and asked if NHA A would stop in and talk with R26. NHA A indicated she went into R26's room at 9:00 AM and R26 was sleeping. NHA A indicated she went back later two times and R26 was in the bathroom both times. NHA A indicated she went back to attempt to talk with R26 at 11:00 AM and was able to speak with R26 at that time. NHA A indicated R26 informed her that two girls had taken her to the bathroom and a half hour passed after she had been in the bathroom, and R26 felt she had to use the bathroom again and turned her call light on. R26 indicated the CNA answered R26's call light and was short and abrupt with R26, and informed R26 she would be back after she helped with breakfast and was able to find someone to assist the CNA with taking R26 to the bathroom. R26 indicated the CNA turned the call light off and left. NHA A indicated she spoke with the CNA who indicated she had turned R26's call light off and told R26 she would be back with someone to assist her. NHA A indicated she spoke with the CNA about not turning residents' call lights off until the resident has been assisted. NHA A indicated she spoke with the CNA about customer service. NHA A indicated she was going to write the incident up as a grievance but has not had time to yet but feels since talking with Surveyor she needs to report it. NHA A indicated she will go and talk with R26 again. Surveyor asked NHA A to let Surveyor know what she does with the incident. NHA A's investigation/timeline on R26, dated 4/1/25, around 9:00AM, states, Around 9:00 AM RN C, while at the med cart stopped this writer and informed her to check in on room [207] as she made a comment about someone potentially yelling at her . The facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 4/1/25, at 2:09:19 PM, states, in part: . Summary of Incident: Allegation Type: Neglect: Intentionally withholding care, disregard of policy or care plan . Is Date and time when occurred known? NO Date occurred . (blank) Time occurred . (blank) Is occurred date and time estimated? (blank) Date discovered . 4/01/25 . Brief Summary of Incident: Surveyor informed this writer at around 1:45PM that resident (R26) reported to her that a cna had told her to go in her diaper (i.e. urinate/defecate in her depends) . Report Submitted Date: 4/1/25 2:09:19 PM . On 4/3/25 7:48 AM, Surveyor interviewed RN C and asked RN C to tell Surveyor again what and when he reported to NHA A regarding R26. RN C indicated it was before 9:00 AM on 4/1/25, when he reported to NHA A that R26 was crying and upset the cna had come in her room and turned her call light off. The cna told R26 she had just been to the bathroom and the cna had breakfast trays to pass. RN C indicated he reported to NHA A R26 stated the cna had yelled at her. RN C indicated he told NHA A he asked R26 if she felt safe and R26 indicated yes. On 4/3/25 at 12:09 PM, Surveyor interviewed NHA A and asked if a resident reports a CNA yelled at her, would this be considered abuse. NHA A indicated yes. Surveyor asked if an allegation of abuse should be reported within two hours and NHA A indicated it should be reported immediately when NHA A hears about it. Surveyor asked when R26 reported to RN C she was yelled at by a CNA, should this have been reported within two hours. NHA A indicated yes.

Based on observation, interview, and record review, the facility did not ensure its medication error rates are not 5% or greater. There were 2 errors in 28 opportunities which affected 2 out of 5 residents (R26 and R16) included in the medication pass task, which resulted in an error rate of 7.14%. Staff did not administer R16's nasal spray per facility policy and standards of practice. R26 did not receive ordered Senna S with her morning medications. Evidenced by: The facility policy titled Nasal Administration, dated 1/23, states in part: . Policy: To administer nasal medications in a safe, accurate, and effective manner . Procedure: . 9. Administer medication to a resident or help resident to do so if capable, using the following directions: a. Have resident keep head upright. Keep mouth closed, insert tip of pump, spray or inhaler into the nostril. Point the spray tip in the nose toward the back and outer side of the nose. Press a finger against the side of the nose to close one nostril and lean the head slightly forward so the spray will aim toward the back of the nose. Have resident sniff gently in through open nostril while pump or inhaler is quickly and firmly squeezed or activated. b. Instruct resident to hold breath for a few seconds and then breathe out through mouth . The facility policy titled Medication Administration, dated 1/23, states in part: . Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so . Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber . Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR (medication administration record) immediately following the medication being given . Example 1: R16 was admitted to the facility on [DATE] and has diagnoses that include major depressive disorder and anxiety disorder. R16's Annual Minimum Data Set (MDS) Assessment, dated 3/17/25, shows R16 has a Brief Interview for Mental Status (BIMS) score of 13 indicating R16 is cognitively intact. R16's Physician Orders as of 4/3/25, state in part: . Flonase Allergy Relief Nasal Suspension 50 MCG (micrograms)/ACT (Fluticasone Propionate .) 2 sprays in both nostrils two times a day for allergies . Order Date: 6/27/24. Start Date: 6/28/24 . On 4/02/25 at 7:35 AM, Surveyor observed RN C (Registered Nurse) administer R16's fluticasone nasal spray. RN C administered the sprays into R16's right nare without occluding the left nare, then administered the sprays into R16's left nare without occluding the right nare. RN C did not instruct R16 during the administration. On 4/2/25 at 8:03 AM, Surveyor interviewed RN C and asked what the procedure is for administration of nasal spray. RN C indicated R16 receives only one nasal spray, so I do not have to wait 5 minutes in between administration for more than one nasal spray. Surveyor asked if opposite nare should be occluded while administering spray into nares. RN C indicated he never occludes the opposite nare; RN C just does each nare without occluding opposite nare. Surveyor asked what the facility policy states, and RN C indicated he has been administering medications for a long time. Surveyor informed RN C to check the facility policy for proper procedure for administering nasal sprays. Surveyor asked RN C if he should instruct the resident during the process of administering nasal sprays. RN C indicated he has been administering medications for a long time, but yes the resident should be instructed on what to do during the administration process. Example 2: R26 was admitted to the facility on [DATE] and has diagnoses that include depression, anxiety, and history of malignant neoplasm of breast (a cancer that forms in the cells of the breast). R26's Admission MDS Assessment, dated 1/9/25, shows R26 has a BIMS score of 12 indicating R26 has moderate cognitive impairment. R26's Physicians Orders as of 4/02/25, state in part: . Senna-S Oral Tablet 8.6-50 mg (milligrams) (Sennosides-Docusate Sodium) Give 1 tablet by mouth one time a day for constipation. Order Date: 2/18/25. Start Date: 2/19/25 . On 4/02/25 at 7:47 AM, Surveyor observed RN C administer R26's morning medications. Surveyor reconciled the medications that were administered to R26 compared to R26's MAR. RN C did not include R26's ordered Senna-S in the morning medication pass. R26 did not receive her ordered Senna-S. Of note: RN C had left facility early that day due to sickness. Surveyor was unable to interview him after medications had been reconciled. R26's April Medication Administration Record (MAR) shows for 4/02/25, R26 received her AM scheduled Senna-S Oral Tablet 8.6-50 mg (Sennosides-Docusate Sodium) by being signed out; Surveyor observed this medication being omitted. On 4/02/25 at 12:20 PM, Surveyor interviewed DON B (Director of Nursing) and asked if she would expect the facility's policies and procedures to be followed regarding medication administration. DON B indicated yes. Surveyor informed DON B of observation of RN C administering R16's nasal spray. Surveyor asked if that would be considered a medication administration error and DON B indicated she would have to check with cooperate. Surveyor informed DON B of R26 not receiving her morning Senna-S. Surveyor informed DON B RN C had signed it out on the MAR but it was not included in medication pass. DON B indicated the Senna-S being omitted would be a medication error.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (R8) reviewed for accidents out of a total sample of 13 residents. The facility did not have an alarm on R27's wheelchair per the care plan. As evidenced by The facility policy, Fall Prevention and Management Guidelines, reviewed 11/8/22, states in part, as follows: .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. The plan of care will be revised as needed and should be communicated to the staff, resident, and resident's family/responsible party. Review each fall/fall investigation during the next morning meeting/clinical meeting with the interdisciplinary Team (IDT). Actions of the IDT may include: .Education of staff as to any care plan revision. R27 was admitted to the facility, on 12/22/21, with diagnoses including, but not limited to: muscle weakness, spondylosis with radiculopathy lumbar region, and major depressive disorder. R27's Quarterly Minimum Data Set (MDS), dated [DATE], indicates the following: R27's Brief Interview for Mental Status (BIMS) is 15/15, indicating she is cognitively intact. R27 requires limited assistance of 1 person to transfer, and supervision when walking in room. R27's Care Area Assessment (CAA) for falls indicates the following: Resident (R27) is at risk for falls d/t (due to) balance problems at times, general weakness, and history of falls. R27 has had several falls since last MDS assessment. Resident has been self-transferring, forgetting to call for assistance and walker. Will continue to anticipate needs. Will update MD (Medical Doctor) as needed. Physical performance limitations: Difficulty maintaining sitting balance, Impaired balance during transitions. Internal risk factors: Neuromuscular/functional, incontinence, arthritis, cognitive impairment, and depression. Care Plan Considerations: Avoid complications, maintain current level of functioning, Minimize risk On 2/1/23 R27's Post Fall Assessment indicates a New Intervention: Tab alarm. Note, on 2/11/23 this was changed to pad alarm in wheelchair and on bed. R27's care plan, dated 3/25/22, indicates: Focus: R27 is at risk for falls r/t (related to) generalized muscle weakness, history of falls, balance problems. Goal: R27 will be free of serious injury related to fall risk through the review date. (Date Initiated: 2/11/23) Interventions/Tasks: FALL RISK - pad alarm in wheelchair and on bed. On 3/9/23 at 11:16 AM, Surveyor observed R27 up in her wheelchair. Surveyor observed two alarms lying on the foot of her bed. Surveyor asked R27, do staff put an alarm on your wheelchair. Resident stated she has alarms on her bed and every place else; R27 stated staff put an alarm on her bed and recliner. R27 stated staff do not put an alarm on her wheelchair. On 3/9/23 at approximately 11:20 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, to come to R27's room. Surveyor asked DON B, should R27's alarm be on her wheelchair per the care plan. DON B stated, yes. On 3/9/23 at 1:30 PM, Surveyor spoke with CNA C (Certified Nursing Assistant). Surveyor asked CNA C, are any alarms used for R27. CNA C stated, yes, 1 in R27's recliner and 1 in bed. CNA C stated every time I've been in there today, they have been plugged in. Surveyor asked CNA C, is R27 supposed to have an alarm on her wheelchair. CNA C stated, she will need to check; however, she thinks it will benefit us, if we do get a third one for her wheelchair. Surveyor showed CNA C R27's care plan and Visual/Bedside Kardex. Surveyor asked CNA C, should R27 have an alarm on her wheelchair. CNA C stated, yes, she should. CNA C added, she was not aware of this. CNA C stated, R27 was in her wheelchair when she arrived at the facility at 5:00 AM. CNA C stated, R27 will get out of her chair on her own. Surveyor asked CNA C, what do you do if you find an alarm turned off, CNA C stated, she plugs it in. CNA C stated, R27 knows what she is doing when she stands up. Surveyor asked CNA C, should care plan interventions be followed? CNA C stated, Absolutely and if R27 has another fall her care plan should be reviewed for a better fall intervention(s). On 3/9/23 at 3:08 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, do you expect residents' fall interventions to be in place. DON B stated, I would expect that, yes. Surveyor asked DON B, how do CNAs (Certified Nursing Assistants) know how to care for a resident. DON B stated, by utilizing the care cards in the closet. DON B added, any time we change anything we leave information at the nurses' station as to what we changed and also pass it on in report. Surveyor shared observation of R27 up in her wheelchair with the alarm sitting on the foot of her bed. Surveyor asked DON B, should staff put the alarm on R27's wheelchair per her care plan. DON B stated, yes. Surveyor asked DON B, why is this important. DON B stated to prevent falls and help to ensure R27's safety. Surveyor asked DON B, should the alarm be on R27's wheelchair. DON B stated, yes, it should be.

Based on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living for 1 of 13 total sampled residents (R8) and 1 of 1 supplemental resident (R9). R8 indicates CNA D (Certified Nursing Assistant) is rough and does not communicate prior to performing assistance. Staff filed a grievance report on 2/9/23 regarding concerns of CNA D rough handling R9. A Misconduct Incident Report, or self-report, was filed with the state. This is evidenced by: Facility policy, entitled Resident Rights, dated 7/22, states: .Residents will be treated with respect and dignity and care for each resident will be given in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality . Example 1 R8 was admitted to the facility on [DATE] and has the diagnoses that include Acute and Chronic Respiratory Failure with Hypercapnia (elevated carbon dioxide levels) , Chronic Diastolic (Congestive) Heart Failure, Dependence on Supplemental Oxygen, Major Depressive Disorder, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (Damage to multiple peripheral nerves), Venous Insufficiency (insufficient blood flow), Pressure Ulcer, and Long Term and Current Use of Insulin. R8's quarterly Minimum Data Set (MDS) assessment on 1/3/23 indicates R8 had a Brief Interview for Mental Status (BIMS) score of 15 indicating R8 is cognitively intact. R8's section B shows that she understands and is understood by others. R8's Functional Assessment: extensive assistance with support of one-person physical assist with bed mobility, transfers, dressing, toilet use and personal hygiene. R8's Care Plan, dated 8/6/21, with a target date of 5/31/23, states: . pressure injury r/t (related to) Decreased mobility, diabetes and non-compliance . Interventions include Ace wrap legs bilaterally from base of toes to knees. Limit sitting to 30 minutes, offload wound using blue boot and elevate legs . Skin- Float/Elevate Heels . (Note: R8's legs are compromised with a pressure injury indicating the need for gentle staff assistance to maintain skin integrity.) Record Review of staff scheduling provided by the facility indicates CNA D was working the following shifts: - 2/21/23 from 6:00 AM- 2:00 PM. - 2/22/23 from 3:00 AM- 2:00 PM. - 2/24/23 from 6:00 AM- 2:00 PM. - 2/25/23 from 5:00 AM- 2:00 PM. - 2/26/23 from 5:00 AM- 2:00 PM. - 2/27/23 from 6:00 AM- 2:00 PM. - 2/28/23 from 6:00 AM- 2:00 PM. - 3/3/23 from 4:00 AM- 2:00 PM. - 3/6/23 from 6:00 AM- 2:00 PM. - 3/7/23 from 6:00 AM- 2:00 PM. On 3/8/23 at 11:30 AM, Surveyor interviewed R8. Surveyor asked R8 how she is treated by staff, R8 replied that CNA D is very rough and rude, she tends to be mean, she says different things that she thinks are funny but they are not. Surveyor asked R8 to provide an example, R8 stated that CNA D said to her one morning, are you getting up today, lazy bones? On 3/9/23 at 10:31 AM, Surveyor interviewed CNA I (Certified Nursing Assistant). Surveyor asked CNA I if R8 has reported to her any concerns with staff. CNA I replied to the Surveyor that R8 informed her CNA D is rough with R8 and does not explain what she is doing. On 3/9/23 at 10:39 AM, Surveyor interviewed CNA J (Certified Nursing Assistant) regarding CNA D. CNA J indicated to the Surveyor that CNA D is rough and rude with residents. On 3/9/23 at 3:40 PM, Surveyor interviewed R8 due to initial report of roughness during screening. Surveyor asked R8 to provide an example of roughness. R8 replied that CNA D Yanks my pillows out to get my legs over the side of the bed. That is when my knees hurt and the most pain is in my knees. She is not very gentle about it. Surveyor asked R8 if CNA D informs her prior to moving her. R8 replied, no. Surveyor asked R8 when was the last time this has happened. R8 replied last week. Surveyor asked R8 how she feels when this behavior occurs. R8 replied, CNA D Makes me feel that I am not doing stuff that I should be doing, or I am not doing it fast enough for her, it's like she just doesn't care. Surveyor asked R8 indicated she informed another CNA about being treated rough. On 3/9/23 at 3:17 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would expect staff to let a resident know what they are about to do before moving them, DON B replied yes. On 3/9/23 at 3:21 PM, Surveyor interviewed CNA F (Certified Nursing Assistant). Surveyor asked CNA F if she would be expected to communicate with a resident prior to doing any tasks. CNA F replied to the Surveyor, Yes, we need to tell them step by step. On 3/9/23 at 3:25 PM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E if she would communicate with a resident prior to doing any tasks. LPN E replied to Surveyor, Absolutely, if you need them to stand up, offer the bathroom, or whatever you are going to do. On 3/9/23 at 4:00 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if staff should be yanking pillows out from a resident without prior communication. NHA A replied to the Surveyor, no. Surveyor asked NHA A if she feels this behavior is disrespectful or rude, NHA A replied yes. Surveyor asked NHA A if she feels this behavior is appropriate, NHA A replied, no. Example 2 R9 was admitted to the facility on [DATE] and has diagnoses that include Fracture of Unspecified Part of Neck of Left Femur, Psychotic Disorder with Delusions, and Pressure Ulcer of the Sacral Region. R9's admission Minimum Data Set (MDS) assessment on 12/20/22 indicates R9 had a Brief Interview for Mental Status (BIMS) score of 9 indicating R9 is moderately cognitively impaired. R9's section B indicates that R9 understands and is understood by others. R9's Functional Assessment: extensive assistance with support of two plus (2+) person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. Surveyor reviewed a grievance/complaint filed by colleagues on 2/9/23 regarding CNA D. Describe the concern in detail: CNAs and housekeeping shared concerns for how CNA D has handled transfers with R9. Described as rough handling. They go on to describe this has been ongoing and reported by multiple other residents who have fear, feel dismissed, etc. A Misconduct Incident Report was filed with the state on 2/17/23 with a discovery date of 2/10/23. Facility Investigation started on 2/10/23 includes the following interviews, in part: - On 2/10/23, RN G (Registered Nurse) stated . R9 complained of being thrown around like a rag doll on Wednesday 2/8/23 at the desk with at least 3-4 staff present. After that discussion, she requested to talk to a nurse. RN G stated, R9 told her she didn't trust CNA D. RN G stated, on 2/10/23 she was informed that R9 does not want CNA D to be assisting with cares. - On 2/10/23, Medication Technician H stated . R9 came to the Med Room (Medication Room) and told RN G I'm scared of CNA D . The facility investigated this incident, sent CNA D home during the investigation for an unknown amount of time and interviewed residents and staff. The facility found no evidence of abuse or improper cares by CNA D and CNA D was able to return to work. The findings of the investigation state, in part: In our investigation we did discover that CNA D rushes or moves too sudden at times when performing cares. CNA D and staff were educated prior to their next shift of the grievance policy, abuse, neglect, and exploitation, and compliance with reporting allegations. On 2/11/23 the facility documented the following education in CNA D's personnel file. 2/11/23 Grievance Policy: Abuse, Neglect and Exploitation, compliance with reporting Allegations of Abuse/Neglect/Exploitation Policy & 3/6/23 Protecting Resident Rights in Nursing Facilities Self-Paced On 3/9/23 at 3:17 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would expect staff to let a resident know what they are about to do before moving them, DON B replied yes. On 3/9/23 at 4:00 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if she feels this behavior is disrespectful or rude, NHA A replied yes. Surveyor asked NHA A if she feels this behavior is appropriate, NHA A replied, no.

Based on observation and interview the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect 25 residents who reside in the facility. -Kitchen staff were not logging final food internal temperatures. -Kitchen staff were not logging internal dishwashing temperatures. -Surveyor observed staff cleaning food thermometer in the same sanitizing solution used to clean surfaces. Evidenced by: Facility Policy and Procedure titled, Cleaning Dishes/Dish Machine, with an effective date of May 2020, states in part: Policy .The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing .Procedure: Staff will follow these procedures for washing dishes: 1. Prior to use, verify proper temperatures/chemical titrations and machine function .Note: Thermal strips may be used as verification that the temperature is adequately [sic] The U.S. Food and Drug Administration (FDA) Food Code specifically states that .Hot Water and Chemical-Methods Sanitizing Food-Contact Surfaces .[must achieve] a utensil surface temperature of 71°C (160°F) as measured by an irreversible registering temperature indicator. From 2017 FDA Food Code 4-204.115 Warewashing Machines, Temperature Measuring Devices. The requirement for the presence of a temperature measuring device in each tank of the warewashing machine is based on the importance of temperature in the sanitization step. In hot water machines, it is critical that minimum temperatures be met at the various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the required temperature for sanitization. Facility Policy and Procedure titled, General Food Preparation and Handling, dated, April 2020, states in part: Policy Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep [sic] free of harmful organisms and substances .Procedure .3. b. All meats will be cooked or heated to a safe minimum internal temperature. A meat thermometer will be used to check internal temperatures . Facility Policy and Procedure titled, Food Temperatures, dated, April 2020, states in part: The temperatures of all food items will be taken and properly recorded prior to service of each meal. Procedure 1. All hot food items must be cooked to appropriate internal temperatures a. Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking . According to the 2017 Food and Drug Administration (FDA) Food Code, epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: * Improper holding temperatures, * Inadequate cooking, such as undercooking raw shell eggs, * Contaminated equipment, * Food from unsafe sources, and * Poor personal hygiene In addition, the 2017 FDA Food Code designates the elderly as a highly susceptible population (HSP) and as such are extremely vulnerable to foodborne illness. Example 1 On 11/9/21 at approximately 9:26 AM, Surveyor asked DM D (Dietary Manager) how food temperatures are completed. DM D indicated, final internal food temperatures are taken and if they meet minimum temperature, the food is placed into stainless steel holding containers; and put in an oven that is approximately 200F to keep warm. Surveyor asked DM D for food temperature logs. DM D provided temperature logs; however, they only included holding temperatures. Surveyor asked DM D where final internal temperatures are logged. DM D indicated, he didn't realize he needed to document final internal temperatures, only holding temperatures. The facility did not have record of final internal food temperatures to ensure that food was cooked to a safe minimum internal temperature to avoid potential food pathogens. Example 2 The facility uses a high temperature dishwasher to clean dishes. According to daily temperature logs, no internal dishwashing temperatures are documented. On 11/8/21 at approximately 9:16 AM, Surveyor observed DA C (Dietary Aide) in the dishwasher room. Surveyor asked DA C what the process is for monitoring the dishwasher temperatures. DA C stated, she monitors the external gauge and ensures wash is 150F and rinse is 180F. Surveyor asked how internal temperatures are monitored. DA C stated, she does not do internal temperatures. Surveyors asked DA C, if the dishwasher was a high temperature washer. DA C stated, yes. On 11/8/21 at approximately 9:23 AM, Surveyor interviewed DM D (Dietary Manager) and asked how internal temperatures are monitored on the dishwashing machine. DM D stated, they use internal testing strips every 2 days, he is the one that performs the test, and didn't realize he needed to document the result. DM D informed Surveyor he has been having difficulty getting strips with current supply issues. Surveyor asked if DM D has a back-up to use when he does not have internal strips. DM D stated, he did not. Surveyor asked when the last time an internal temperature had been completed. DM D stated, last Wednesday (11/3/21). DM stated, internal test strips were supposed to come with his Monday delivery and did not. On 11/10/21 at 11:46 AM Surveyors met with DM D, NHA A (Nursing Home Administrator), and SDCS E (Senior Director of Clinical Services) regarding internal dishwashing temperatures. Surveyor asked how they know if the dishes currently being used are properly sanitized given you have no way of checking internal dishwashing temperatures. They indicated they can't know for sure. The facility did not have record of internal dishwashing temperatures. Example 3 On 11/8/21 at 11:52AM, Surveyor observed DM D (Dietary Manager) temping the holding food in the steam table. In between taking temperatures DM D was observed to use sanitizer solution to cleanse the thermometer. Of note, a cloth was observed in the sanitizer bucket as well. On 11/9/21 at approximately 11:38 AM, Surveyor observed DM D taking final internal food temperatures prior to holding. Between taking temperatures DM D was observed to use sanitizer solution to cleanse the thermometer. Of note, a cloth was observed in the sanitizer bucket. Surveyor asked DM D, how often the sanitizing solution he used to clean the food thermometer is changed and how often the PPM (Parts Per Million) is checked. DM D indicated, the sanitizer is changed at breakfast, lunch and dinner and more often if needed. (Of note, the sanitizer is on an automated dispenser system) Surveyor asked DM D, what the cloth in the sanitizer is used for. DM D indicated, the cloth is used for wiping counters. Surveyor asked DM D, how often the cloth is replaced. DM D indicated the following: 1) The cloth is changed daily 2) The cloth is washed in between each meal when the sanitizer is replaced 3) The cloth is washed with detergent and thoroughly rinsed with water 4) The cloth is then rinsed using the automated sanitizer dispenser 5) The cloth is then ready to be put in with the container with the fresh sanitizer. Of note, the facility was unable to provide a policy on sanitizing food thermometers. Utilizing the same sanitizer solution for a food thermometer and a cloth used to sanitize potentially contaminated services, created a potential for cross contamination.

Based on interview and record review, the facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter for 2 of 12 sampled residents (R19 and R14) and 1 of 1 supplemental residents (R24). - R24 was not seen by a provider at least once every 30 days for the first 90 days after admission. - R14 was not seen by a provider at least once every 30 days for the first 90 days after admission. - R19 was not seen by a provider at least once every 30 days for the first 90 days after admission. This is evidenced by: The facility policy titled, Physician Visits, dated 6/17/19 describes the procedure as, The physician must: 1. Review the resident's total program of care, including medications and treatments, at each visit. 2. Write, sign and date progress notes at each visit. 3. Sign and date all orders. The policy also addresses the frequency of physician visits as, 1. The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. 2. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. Example 1 R24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse's Notes indicate R24 was seen on or around 5/6/21 by her Primary Care Physician (PCP), although neither the Surveyor nor facility were able to locate progress notes for the visit. There is no evidence of R24 being seen by a provider in June or July, therefore missing a 60 day and 90 day visit after admission. On 11/9/21, Surveyor spoke to NHA A (Nursing Home Administrator) and requested all of R24's Progress Notes for Provider visits since her admission on 4/5/21. NHA A provided the progress notes for 8/20/21, 9/17/21, and 10/7/21, but stated she was still looking to see if they had any others. On 11/10/21, at 7:15 AM, Surveyor asked NHA A if she was able to locate any additional progress notes for Provider Visits on R24. NHA A stated, No. I didn't. I checked with Director of Nursing, to see if she had any other notes, but we haven't found any yet. She is still looking. Her doctor is hard to get ahold of. I realize it probably isn't up to par. Surveyor asked NHA A if R24 had been seen by a provider anytime between 5/6/21 and 8/20/21, and NHA A stated, Not that I can tell. Example 2 R14 was admitted to facility on 4/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 had first physician office visit on 4/18/21 and then had a physician nursing home visit on 4/25/21. R14 was not seen by physician in the month of May or June. R14 was admitted to hospital on 8/25/21 and returned 8/27/21. R14 discharge summary from 8/27/21 noted R14 had physician nursing home visit on 8/27/21. Example 3 R19 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19 should have seen the physician at 30, 60 and 90 days. R19 was seen by the doctor on 6/18/21. R19 should have been seen again between day 30 and day 40. R19 was not seen until 8/2/21 45 days. R19's next should have been 30 -40 days later. However R19 was not seen until 10/8/21 approximately 67 days later.

Based on record review and interview the facility did not ensure that Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's monthly Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The facility did not have a policy regarding signed monthly orders. R24 was admitted from another skilled nursing facility on 4/5/21. On 11/9/21, at 7:20 AM, Surveyor observed medication administration on R24. Afterwards, Surveyor was unable to locate signed monthly orders for R24. Surveyor spoke with NHA A (Nursing Home Administrator) to request signed monthly orders for R24. Surveyor was later provided with a copy of faxed signed orders with a heading date of 10/14/21 at the top of the orders signed and dated on 11/9/21 by an Advanced Practice Nurse Practitioner (APNP). The fax was sent to the facility on [DATE] at 8:31 AM. NHA A and Surveyor were unable to locate R24's signed monthly orders for June 2021 or August 2021. R24's October 2021 orders were signed on 11/9/21 and not until after Surveyor requested signed orders. On 11/10/21, Surveyor asked NHA A if the facility had any other signed monthly orders for R24 besides what was scanned in the electronic charting system or what was provided on 11/9/21, and NHA A stated, No. That is all.

Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 (R1) of 3 sampled residents. R1 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The facility policy titled, Medication Orders, revised 2018, states in part . Policy: Medications are administered only upon the clear, complete, and signed order of a persona lawfully authorized to prescribe. Procedures: B. Any dose or oder that appears inappropriate considering the resident's age, condition, allergies, or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . C. The prescriber is contacted by nursing to verify or clarify an order (e.g. the directions are confusing). E. Documentation of the Medication Order. 1) Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. c. Written Transfer Orders (sent with a resident by a hospital or other health care facility) 1. Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. 4. The nurse who transcribes the orders to the [physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) The following steps are initiated to complete documentation and receive the medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Call, fax, or electronically transfer the medication orders to the provider pharmacy. According to drugs.com, when used with [MEDICATION(S)] and [MEDICATION(S)], [MEDICATION(S)] increases levels of [MEDICATION(S)] in the body. [MEDICATION(S)] is used together with [MEDICATION(S)] and [MEDICATION(S)] to treat wearing-off symptoms of [CONDITION(S)], such as stiffness, tremors, muscle spasms, and poor muscle control. [MEDICATION(S)] must be taken together with [MEDICATION(S)] and [MEDICATION(S)]. [MEDICATION(S)] used alone will not treat symptoms of [CONDITION(S)]. R1 was admitted to the facility on [DATE]. R1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's discharge summary/order indicate the following: Per Neuro: -[MEDICATION(S)]-[MEDICATION(S)] 25/100mg (milligrams) to 1.5 tablets QID (four times a day); doses separated by no more than 4 hours; she has an unusual sleep schedule at home in which was wakes up at 9am (9:00 AM (morning)) and goes to be (sic) around 8pm (8:00 PM (evening)). Recommend she doses medication at home as follows: 9am: 1.5 tabs IR 25/100mg 12pm: 1.5 tabs IR 25/100mg 3pm: 1.5 tabs IR 25/100mg 6pm: 1.5 tabs IR 25/100mg -Will also add on [MEDICATION(S)] CR (controlled release) 50/200mg 1 tab at bedtime (around 8pm) to help with morning rigidity/bradykinesia. -Continue [MEDICATION(S)] 200mg QID with each [MEDICATION(S)]-[MEDICATION(S)] dose. Discharge summary/orders, Discharge Medications and Instructions, state in part . [MEDICATION(S)]-[MEDICATION(S)] ([MEDICATION(S)]) 25-100 MG tablet. Take 1 (one) tablet by mouth as directed 9am: 1.5 tabs IR (immediate release) 25/100mg 12pm: 1.5 tabs IR 25/100mg 3pm: 1.5 tabs IR 25/100mg 6pm: 1.5 tabs IR 25/100mg [MEDICATION(S)] (Comtan) 200 MG tablet. Take 1 (one) tablet by mouth 4 times daily. Per R1's care plan, the following is documented: Initiated 6/21/21 . Focus: R1 has [CONDITION(S)]. Interventions state in part . Give medications as ordered by the physician. Monitor/document side effects and effectiveness. R1's Admission MDS (Minimum Data Set) dated 6/14/21 states in part . R1 requires extensive assistance of one for transfers, toileting, hygiene and locomotion on and off the unit. R13 requires limited assistance of one for bed mobility, extensive assistance of one staff for toileting transfers, and hygiene. BIMS (Brief Interview of Mental Status) score of 13, indicating R1 is cognitively intact. R1's eMAR (Electronic Medication Administration Record) states in part . [MEDICATION(S)]-[MEDICATION(S)] tablet 25-100 MG. Give 1 tablet by mouth one time a day related to [CONDITION(S)] at 0900 (9:00 AM). [MEDICATION(S)]-[MEDICATION(S)] tablet 25-100 MG. Give 1.5 tablet by mouth four times a day related to [CONDITION(S)] at 1200 (12:00 PM), 1500 (3:00 PM), 1800 (6:00 PM), 2100 (9:00 PM). [MEDICATION(S)] tablet 200 MG. Give 1 tablet by mouth four times a day related to [CONDITION(S)]. 0800 (8:00 AM), 1200 (12:00 PM), 1600 (4:00 PM), 2000 (8:00 PM). Note: Orders were printed from PCC and sent to the physician to sign. The physician signed the PCC orders on 6/18/21, which were incorrectly put in by the nurse. Note: [MEDICATION(S)]-[MEDICATION(S)] and [MEDICATION(S)] are not being given together. Note: Discharge medications orders do not match the eMAR orders. On 8/10/21 at 10:56 AM, Surveyor interviewed NHA A and DON B. Surveyor asked if the orders Surveyor received from the facility were the same orders used to medications into PCC (Point Click Care). DON B stated, I am unsure but would like to look. Another nurse put the orders in and I will look to see if these orders are the same as those she use to enter into PCC and get back to you. On 8/10/21 at 1:04 PM, Surveyor interviewed Pharmacist D. Surveyor asked Pharmacist D about [MEDICATION(S)]-[MEDICATION(S)] and [MEDICATION(S)] being given together. Pharmacist D states, These medications should be given simultaneously. They are usually given together from what I see. Surveyor asked Pharmacist D how the pharmacy receives medication orders from the facility. Pharmacist D stated, For this particular patient the orders were printed from PCC (point click care) and faxed to us. Personally I think this should have been clarified for one time a day dose, as if there is a one time a day dose different from other doses that is usually a ER (extended release). Surveyor asked Pharmacist D if the pharmacy every received the discharge summary and orders from the facility. Pharmacist D stated, No, only the ones from PCC. On 8/10/21 at 1:40 PM, Surveyor interviewed RN C. Surveyor asked RN C the process for getting new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They are printed after they are put in and one copy goes to the pharmacy and one copy goes to the physician to sign. Surveyor had RN C review discharge summary and orders for R1. Surveyor asked RN C if she remembered putting in the orders for R1 and sending the information to the pharmacy. RN C stated, It all looks familiar. Surveyor asked RN C if she remembers having to clarify any of R1's orders. RN C stated, I don't recall it was kind of a mess. I remember talking with DON B as the orders looked strange. Surveyor asked RN C if she knows if [MEDICATION(S)]-[MEDICATION(S)] and [MEDICATION(S)] are to be given at the same time. RN C stated, I don't know. DON B looked at the orders with me. I don't remember if we talked about clarifying the orders or not. On 8/10/21 at 1:45 PM, Surveyor interviewed DON B. Surveyor asked DON B about the facility process for putting in new admission medication orders. DON B stated, We have a checklist and two nurses are supposed to sign off that medications were put in and reviewed. The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked DON B if she reviewed R1's orders with RN C. DON B stated, I think she got the order clarified and put the orders in just PCC without writing a telephone order but I have no proof. The facility failed to ensure R1's medication was given as ordered by the Physician.

Based on observation, interview and record review, the facility did not properly store and sanitize items used to prepare and serve food in accordance with professional standards for food service safety which has the potential to affect all 26 residents residing in the facility. The following were observed during the survey: - Dishwasher temperatures were not within the required range for rinse cycle on day of observation and as recorded on previous date and time - Open food items were not properly labeled in two refrigerators and two freezers in the kitchen This is evidenced by: Facility policy, Dishwashing Procedure, last reviewed on [DATE], states, in part: . 3.4: Check temperature prior to first rack. Wash and rinse temperatures must reach required temperatures (see FS-2) prior to running any loaded racks through. Form FS-2, titled Dishmachine (sic) Temperature Log (high temp machine), notes rinse temperatures should be a minimum of 180 degrees F (Fahrenheit) and a maximum of 196 degrees F and if temperatures are out of range, the dietary manager and/or maintenance should be notified immediately. Facility policy, Sanitation and Cleaning Schedule, last reviewed on [DATE], states, in part: . the temperature log must be completed per policy and reviewed daily to ensure compliance. This policy also notes that any temperatures out of compliance must be addressed immediately. According to the (YEAR) Food and Drug Administration (FDA) Food Code, a nationally recognized professional standard of practice for food safety, when the sanitizing rinse temperature exceeds 194 degrees Fahrenheit, the water becomes volatile and begins to vaporize, reducing its ability to provide sufficient sanitization to utensil surfaces. Also, to ensure properly cleaned and sanitized equipment and utensils, dish machines must be operated properly. On [DATE] at 1:45 PM, Surveyor observed dishwashing in main kitchen. Cook F and another dietary aide did not check temperature prior to first rack. Surveyor observed temperature readings on the rinse cycle reach 195 degrees on the first cycle and 198 degrees on a subsequent cycle of dishes. Cook F recorded the first set of temperatures on the temperature log. Surveyor reviewed the temperature log, noting a rinse temperature, on [DATE], of 198 degrees F. Surveyor also observed six instances out of the 47 opportunities through lunch, of [DATE], no temperatures were recorded on the temperature log. On [DATE] at 9:26 AM, Surveyor spoke with DM G (Dietary Manager) regarding what to do when there is a problem with equipment. DM G stated it should be written on the maintenance log or put it on a maintenance slip and in his mailbox so that if it is something he can fix, he can order the part, otherwise it would be serviced out. Surveyor asked DM G what was expected if the dishwashing temperature is out of range. DM G stated, If it is too low, run it until it reaches temp. If it does not meet temperature, use the three compartment sink. Surveyor discussed observation of rinse cycle temperatures and DM G stated, Our booster is acting up. It is something with the pressure release valve. DM G indicated she intended to communicate with maintenance again. Surveyor did discuss (YEAR) Food Code rinse temperature limits. Surveyor reviewed manufacturer's instruction manual for the Hobart Dishwasher provided by DM [NAME] Operating temperatures for hot water machines note a minimum rinse temperature of 180 degrees F but do not list a maximum. It states Recommended rinse is also 180 degrees F. The facility policy, Sanitation and Cleaning Schedule, which addresses food storage, states, in part: . All refrigerated and prepared food must be covered, labeled and dated with a use-by date that is a maximum of 7 days from the date of preparation. Label must include the name of the food and the date by which it should be used. For items stored in the freezer, it states, Food must be labeled with the date placed in the freezer. On [DATE] at 9:20, during the initial tour of the kitchen, the following were observed: - Refrigerator 1 contained an open bag of lettuce with no open or use-by date - Refrigerator 2 contained a bin of pealed potatoes in water with no use-by date - Freezer 1 contained an open bag of mac and cheese wedges with no date - Freezer 3 contained an open bag of French toast sticks with no date. (Of note, a bulk bin with a small amount of oatmeal which was labeled, but expired, was observed in kitchen dry storage, but Cook F indicated that it is not used and oatmeal is made upstairs in the kitchenette out of instant oatmeal packets.) On [DATE] at 9:26 AM, Surveyor spoke with DM G regarding food storage. DM G stated that staff members are supposed to put the open date on something that has been opened. If it is a frozen item, they should put an open and frozen date on it. DM G indicated if food was found without dates and the date it was opened could not be determined, the item should be discarded. DM G indicated the expired oatmeal in the dry food storage area was being kept for the Activities Department to use for sensory activities and she planned to have it removed from the kitchen and labeled to specify it was not to be consumed.

Based on interview and record review, the facility did not ensure resident's drug regimens are free from unnecessary [MEDICAL CONDITION] drugs for 1 out of 5 residents (R13) reviewed for unnecessary medications. R13 is receiving 12.5 mg (milligram) of [MEDICATION NAME] for [MEDICAL CONDITION] with delusions due to known physiological condition. R13 has a [DIAGNOSES REDACTED]. This is evidenced by: Facility policy entitled [MEDICAL CONDITION] Drug Policy, undated, includes, in part: .Procedure . b. Antipsychotic Medication: [DIAGNOSES REDACTED]. Antipsychotic medications may be indicated if: i. Behavioral symptoms present a danger to the resident or others; ii. Expressions or indications of distress that are significant distress to the resident; iii. If not clinically contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the symptoms which present a danger or significant distress; and or iv. Gradual Dose Reduction (GDR) attempted but clinical symptoms returned. c. If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care - planned, non-pharmacological approaches, and ongoing evaluation if the effectiveness of these interventions. Upon review of R13's Level 2 PASARR (Preadmission Screening and Resident Review), the screening response is as follows: When a Preadmission Screening and Resident Review (PASARR) Level 2 screen is not needed, dated 7/13/19, includes, in part: While R13 does have a mental illness [DIAGNOSES REDACTED]. Therefore, there is no support for the [DIAGNOSES REDACTED]. The facility should consider monitoring for a period of time for symptoms/behaviors of mental illness and if no symptoms/behaviors are observed, then consider the gradual reduction. R13 was admitted to the facility, on 5/7/19, with [DIAGNOSES REDACTED]. R13's Quarterly MDS (Minimum Data Set), dated 8/14/19, with a BIMS (Brief Interview for Mental Status) score of 4 out of 15, indicates R13 has severe cognitive impairment. Section [NAME] indicates R13 wanders, has inattentive, disorganized thinking and no behavior symptoms. R13's Comprehensive Care Plan Uses Antipsychotic Medication [MEDICATION NAME] r/t (related to) anxiety, dated 7/17/19, includes, in part: Goal: R13 will be free from discomfort or adverse reactions related to antipsychotic therapy. Interventions: Administer Antipsychotic medications as ordered by physician. Monitor side effects and effectiveness Q (every) shift. Attempt the following non-pharmacological interventions: one-to-one conversations, listening to classical music, taking a walk, reading a book to / with R13. (Of note: Surveyor could not find targeted behaviors listed on this care plan.) physician's orders [REDACTED]. Hand written in next to the typed order is DX (diagnosis) [MEDICAL CONDITION]. The (MONTH) orders indicate the reason for the [MEDICATION NAME] is [MEDICAL CONDITION] with delusions due to known physiological condition. 7/9/19 -[MEDICATION NAME] consent indicates R13's [DIAGNOSES REDACTED]. (Of note: R13's Behavior Tracking Record does not indicate that delusions are to be monitored.) R13's Behavior Symptoms monitored: crying, withdraw from previously enjoyed activities, isolation, calling out, increased irritability and exit seeking. R13's Weekly Behavior Summary Report, dated 5/7/19 - 10/17/19, includes, in part: R13 had 2 episodes of threatening behavior and 16 episodes of wandering and 1 rejection of care. physician progress notes [REDACTED]. Discussed with nephew starting low dose antidepressant. physician progress notes [REDACTED]. Staff has no current behavior concerns. Nursing Progress Note, dated 7/1/19 at 2:30 PM, includes, in part: R13 had another frustrating shift. R13 continues to wander. R13 was upset with staff at breakfast when he was repeatedly asked to sit back down in w/c (wheelchair). R13 threatened to strike out at staff at least on one occasion while attempting to redirect him. Nursing Progress Note, dated 7/5/19 at 2:14 PM, includes, in part: Call placed to MD (medical doctor) office. Staff explained that R13 has been anxious and has been standing in the doorway of his room calling out. R13 stands up frequently from his w/c. R13 is easily redirected by staff with toileting and food / fluids. Nursing Progress Note, dated 7/8/19 at 2:35 PM, includes, in part: New order for [MEDICATION NAME] 12.5 mg - 1 tablet q (every) AM. Staff to update MD signs and symptoms in 3 days. Fax communication to MD, dated 7/11/19, includes, in part: Update since start of [MEDICATION NAME] 12.5 mg daily on 7/9/19. R13 has been calmer, [MEDICATION NAME] effective. Thank you! MD's response 7/9/19 - Noted, thanks! Nursing Progress Note, dated 7/15/19 at 12:17 AM, includes, in part: R13 was started on [MEDICATION NAME] 12.5 mg po (oral) daily for anxiety. This medication has been effective at reducing R13's level of anxiety. physician progress notes [REDACTED]. Since last visit, low dose Quetiapine ([MEDICATION NAME]) added Q AM. Staff has no current behavior concerns. Nursing Progress Note, dated 9/12/19 at 4:01 PM, includes, in part: R13's PCP (Primary Care Physician) called the facility and wants R13 seen by the facility psychiatrist for behaviors. Nursing Progress Note, dated 9/20/19 at 2:25 PM, includes, in part: R13 was seen by the facility psychiatrist. New order received for [MEDICATION NAME] for Dementia. Nursing Progress Note, dated 9/28/19 at 12:00 PM, includes, in part: Call placed to the on-call physician as R13 is more aggressive since starting [MEDICATION NAME]. R13 stated, You're just trying to give me meds to control me. Received order to hold [MEDICATION NAME] today and tomorrow. Nursing Progress Note, dated 10/2/19 at 2:55 PM, includes, in part: voicemail left at the psychiatrist's office regarding R13's behaviors. R13 is showing more paranoia, almost manic at times, and speaking about male genitalia. Have to keep R13 out of the dining room as it offends others. Nursing Progress Note, dated 10/6/19 at 2:12 PM, includes, in part: R13 became agitated during breakfast this morning. R13 asked the nursing assistant if she wanted eggs in her face. R13 asked another resident if he wanted a broken arm. R13 was redirected out of the dining room and given 1:1 (one-on-one) attention. R13 was given a massage and this was effective. R13 is currently seated in wheelchair and eating a snack. Nursing Progress Note, dated 10/13/19 at 9:40 PM, includes, in part: R13 walked up to the nurse's station without any pants on. History of [MEDICAL CONDITION] with delusions and dementia. Staff assisted R13 back to his room. R13 apologized for his behavior and went to bed without further incident. Nursing Progress Note, dated 10/14/19 at 12:23 AM, includes, in part: R13 is currently receiving [MEDICATION NAME] and [MEDICATION NAME]. No adverse reaction. On 10/17/19 at 1:50 PM, Surveyor interviewed DON B (Director of Nursing) regarding R13 and behaviors. DON B indicated the behavior tracking is a check box for staff to mark and they should be documenting behaviors as well. Surveyor reviewed R13's behavior tracking with DON B and asked DON B if the behaviors are persistent or harmful. DON B indicated R13's behaviors are not harmful or persistent. DON B indicates the staff need staff need more education on documenting behaviors as the staff feel these behaviors are normal for R13. There is no indication that R13 has documented behaviors since admission that would support the use of the antipsychotic [MEDICATION NAME].

Based on observation, interview and record review the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident 1). Resident 1, who is severely cognitively impaired, was known to be at risk for elopement. Staff left the key in the elevator allowing access to unalarmed exit doors where Resident 1 was able to leave the building. Five days later Resident 1 removed the Code Alert bracelet - which staff were aware she had done previously but had never addressed - and exited the front door without the alarm sounding. Both times facility staff was not aware that Resident 1 had left the building. Off-duty staff observed Resident 1 the first time and a facility resident saw and reported that Resident 1 had left the second time. The failure to ensure measures were in place to keep Resident 1 from leaving the facility unattended created a finding of immediate jeopardy. The immediate jeopardy began on 7/12/16. The Nursing Home Administrator was notified of the immediate jeopardy on 7/27/16 at 3:35 PM. The facility had removed the immediacy and corrected the deficient practice on 7/19/16, thus this is being cited as past noncompliance. This is evidenced by the following: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had worked at the facility for many years in the past. Resident 1's care plan for Elopement Risk/Wanderer was initiated on 7/6/15. Interventions include structured activities in activity room right after supper, re-direct/re-orientate as needed. Resident 1's care plan was updated on 3/22/16 to include the use of a Wanderguard (Code Alert bracelet). On 5/24/16 the facility completed a Wander Risk Assessment for Resident 1 and identified Resident 1 at risk for elopement. Resident 1's Minimum Data Set, Assessment Reference Date 7/7/16, indicates a Brief Interview for Mental Status of 7. This indicates a severe cognitive impairment. The facility has two floors. There are alarms or Code Alert sensors at the exits on the first floor. The elevator does not have a Code Alert sensor; however, to operate the elevator on the inside you need to insert and turn a key that is kept hanging on the handrail of the elevator. The basement is not a resident area and the exit doors do not have any type of alarm. Resident 1's department notes include: -6/20/16 Resident 1 has a Wanderguard/Code Alert on her ankle to alert staff of possible elopement from facility. Check for functioning every shift. Resident 1 continues to exit seek but is easily redirected by staff. -7/12/16 Incident details: Director of Nursing (DON) B was leaving at the end of her shift and noticed an elderly person propelling in a wheelchair up the street behind the building. DON B drove her car to see who the person was noted it was Resident 1. Resident 1 was returned to the facility and assessed for injuries, none noted. Physician and family notified. The facility completed a self-report to the state and an investigation into the incident. The incident occurred at about 7:32 PM. Resident 1 was approximately 350 feet from the building. Resident 1 was dressed in pants and mid-length sleeved shirt. It was 77 degrees outside at the time of the incident. On 7/27/16 Surveyor observed the area Resident 1 likely traveled. The road is not in good repair, cracks and broken black top, and there is no sidewalk. Resident 1 was located at the bottom of a steep hill away from the facility. The facility investigation concluded that staff had left the elevator key in the key hole. Resident 1 turned the key, activated the elevator, pushed the button to go downstairs and exited the building. The facility immediately began educating all staff on the need to remove the key from the key hole. The facility posted signs in the elevator to remind staff and added a coded key box to store the key for the elevator in to ensure residents cannot access the key. On 7/13/16 the facility updated Resident 1's care plan to include: Monitor-safety check every 1 hour from 6 AM to 5 PM, every 30 minutes from 5 PM to 9 PM and every 3 hours from 9 PM to 6 AM. Offer assistance when awake. Resident 1's department notes include: -7/17/16 Incident details, another resident told Certified Nursing Assistant (CNA) that a resident had gone outside. CNAs went out front door and across parking lot when they saw Resident 1 in wheelchair in the street. The wheelchair was stuck in a gravel area where pavement was missing. Resident 1 did not want to return inside but agreed when staff said they could talk about it inside. CNA remained with Resident 1 until she decided to get ready for bed. Another Code Alert bracelet was put on her ankle and wheelchair. -7/19/16 Physician updated on 2 recent elopements from facility. Laboratory tests ordered to rule out underlying cause for elopement. The facility completed a self-report to the state and an investigation into the incident. The incident occurred at 6:45 PM. The temperature at the time was 80 degrees and Resident 1 was wearing dark colored slacks, tennis shoes, undershirt and short sleeved blouse. No alarms sounded at the time and Resident 1 was located approximately 20 feet off property onto an infrequently traveled road. It was noted when Resident 1 returned to the facility the Code Alert was not in place however there was an indentation in Resident 1's leg where it had been. Resident 1 was assessed with [REDACTED]. Code Alert replaced to Resident 1's ankle and one placed under her wheelchair out of reach. Code Alert last seen on Resident 1 at 4:00 PM by CNA. Between 4:00 PM and 6:30 PM Resident 1 was observed either in her room or in the dining room. Resident 1 last observed at 6:30 PM by CNA H in dining room engaged in an activity. CNA H's statement indicates she checked Resident 1's Code Alert bracelet placement at 4:30 PM. She was doing cares for residents and last saw Resident 1 in the dining room just after 6:30 PM. CNA H was assisting another resident into bed and was told Resident 1 had left the building and was brought back in. New Code Alert bands were ordered on [DATE] and placed on Resident 1 on 7/19/16. These bands cannot be easily removed and must be cut to remove. On 7/17/16 Resident 1's care plan was updated to include a Code Alert on wheelchair in addition to ankle. The facility is in a residential area on side streets that has steep hills going away from the facility. The paths Resident 1 took from the facility do not have sidewalks on the facility side of the street. There are no crosswalks to cross the street to get to the sidewalks. The roads are not in good repair and have pot holes and broken pavement/gravel areas. On 7/27/16 Surveyor observed the area where Resident 1 was found with Director of Operations (DOC) C. The blacktop was broken up in areas and there were gravel spots in the road. The road was a downward slope but was not steep. Resident 1 had not made it to the sidewalk on the other side of the street. On 7/19/16 Resident 1's laboratory tests came back including a urinalysis that indicated a urinary tract infection and Resident 1 began treatment. On 7/27/16, at 10:19 AM, Surveyor interviewed Nursing Home Administrator (NHA) A, DOC C and Maintenance I. Maintenance I stated on 7/18/16 a new type of Code Alert bracelet was ordered and received on 7/19/16. Surveyor noted the new bracelet is a more firm plastic that cannot be stretched or torn. The previous bracelets were more like paper and were easy to rip/pull apart. On 7/27/16, at 10:41 AM, Surveyor interviewed Registered Nurse (RN) F. RN F confirmed she was working on 7/17/16 when Resident 1 eloped. RN F stated she was not at the facility when Resident 1's Code Alert bracelet was found but was told it was in Resident 1's drawer. RN F stated she was aware prior to 7/17/16 that Resident 1 had removed her Code Alert bracelet a couple of times previously. RN F stated she thought Resident 1 even cut it off once that is why she is not allowed to have scissors in her room. RN F stated they do check placement and function of the Code Alert bracelet every shift. On 7/27/16, at 11:04 AM, Surveyor interviewed CNA G. CNA G stated on 7/17/16 he was just starting his shift at 6:30 PM and had helped a resident when another resident reported a woman was going down the street. CNA G stated Resident 1 was located in the gravel area in line with the back of the facility. Resident 1 was concerned she was in trouble and she was brought back to the building. CNA G stated a co-worker found the Code Alert bracelet in Resident 1's drawer and stated she has removed it before. On 7/27/16, at 11:14 AM, Surveyor interviewed CNA E. CNA E stated Resident 1 does not tend to exit seek much on first shift, occurs more on second shift. Resident 1 will ask if the Code Alert bracelet is needed and she has attempted to remove it. CNA E stated if she takes it off she usually will put it in her dresser. CNA E stated the new bands now have to be cut where the old ones could just be peeled apart. On 7/27/16, at 2:20 PM, Surveyor interviewed CNA D. CNA D stated she was working both days Resident 1 eloped from the facility. CNA D stated on 7/12/16 Resident 1 was on hourly checks at the time. Someone left the key in the elevator and Resident 1 went down the elevator and outside where she was noted by DON B. They educated staff about not leaving the key in the elevator and said to have Resident 1 fold items in the activity room after supper. Then on 7/17/16 CNA D said about 5:30 PM, Resident 1 was in the dining room eating and CNA D left to assist another resident. The other CNA left during that time too to answer a call light. When CNA D returned to the dining room another resident said a lady went out the door and down the street. CNA D got CNA G and went outside to look. CNA D and G found Resident 1 down the street. CNA D described the area as across the street where the road is broken up and there is a patch of gravel. CNA D stated Resident 1 was stuck in the gravel area. Upon return to the facility CNA G looked for Resident 1's Code Alert and noted Resident 1 had taken it off. It was later found in her dresser drawer. CNA D stated the Code Alert band looked like it had been stretched out as it was still intact. CNA D stated they applied a new Code Alert to her ankle and one to her wheelchair. CNA D stated following the incident staff were re-educated about safety checks and told how to change the time the checks were done if documenting it later. CNA D stated Resident 1 has not made any attempts to remove the Code Alert that she is aware of since then. On 7/27/16, Surveyor reviewed the safety check documentation for Resident 1 on 7/17/16. The facility uses a computer system to document safety checks. The record indicates Resident 1 was located at 1:08 PM. The next entry is at 6:34 PM; there are 9 checks documented at this time. The next entry is at 8:00 PM. The documentation does not indicate the time the checks were actually completed, just the time it was documented. On 7/27/16, at 11:21 AM, Surveyor interviewed DOC C who stated the facility prefers CNAs to document at the time of the event but that is not always possible. DOC C stated it was identified last week when Resident 1 eloped that staff were not documenting when the safety checks were being completed. DOC C stated education was completed on how to chart the actual time the checks were completed even if documented later. The facility was aware Resident 1 was able to and had removed her Code Alert bracelet prior to 7/17/16 and interventions were not implemented to ensure Resident 1 did not elope from the facility. The failure to ensure processes were in place to prevent Resident 1 from elopement created a finding of immediate jeopardy. The facility removed the immediacy and corrected the deficient practice on 7/19/16 when they added a coded lock box for the elevator key and educated staff about removing the key from the key hole and locking it in the box, more frequent checks were initiated for Resident 1 during waking hours, a new/more durable Code Alert bracelet was ordered and applied to Resident 1 and staff were educated regarding documenting the actual times the safety checks were completed.

Based on observation, interview and record review the facility did not ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident 3). Resident 3 was identified as at risk for elopement. Resident 3 exited the building and was across the street and on the top of a steep hill before being found by staff. Because of the steepness of the hill, it is unlikely Resident 3 would have been able to control her wheelchair had she started down the hill. Upon return to the facility staff did not assess Resident 3 or investigate why resident 3 was able to get so far from the faciltiy before staff was able to get to there. The facility did not identify that door alarms could not be heard when staff was in a resident's room or in certain areas of the facility and did not put measures into place to prevent this from occurring in the future. The failure to ensure the alarm system to alert staff of possible elopement was functioning and loud enough to be heard created a finding of immediate jeopardy. The immediate jeopardy began on 5/14/16. The Nursing Home Administrator was notified of the immediate jeopardy on 5/24/16 at 3:35 PM. The facility removed the immediacy on 5/24/16, however the deficient practice continues at a severity/scope of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. This is evidenced by the following: Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's Power of Attorney for Health Care (APOA-HC) is activated. Resident 3's care plan for the concern of Elopement risk/wanderer was initiated on 8/16/15. Interventions include: Provide structured activities, redirect/reorient as needed. Ask if she needs to use the bathroom when seeking doors and Wanderguard in place. Resident 3's care plan indicates Resident 3 walks with assist of 1 and a front wheeled walker within the facility and a wheelchair for independent mobility. Resident 3's care plan identifies the risk of falls related to poor safety awareness and attempts to self-transfer, revised on 7/1/15. Interventions included: anti-roll back brakes on wheelchair, remind her to use walker, and pressure sensor alarm in wheelchair or stationary chair. On 12/14/15 the facility completed a Wander Risk Review. The assessment indicates the following for Resident 3: -Is cognitively impaired with poor decision-making skills. -Has hearing, vision or communication problems. -Has verbally expressed the desire to go home, packaged belongings to go home, or stayed near exit door. -Facility or responsible party has voiced concerns that would indicate the resident may have wandering tendencies or try to leave. -Summary: Resident 3 is at risk for elopement or wandering. Resident 3's most recent Minimum Data Set assessment was completed on 4/19/16. Resident 3 was assessed as the following: -Short term memory problem -Long term memory problem -Cognitive skills for daily decision making--3 (severely impaired) -Locomotion on unit--3, 2 (Extensive staff assistance of one person) -Locomotion off unit--3, 2 The facility schedule indicates on 5/14/16 day shift there was 1 Registered Nurse (RN), 1 Licensed Practical Nurse (LPN) until 1:00 PM, and 2 Certified Nursing Assistants (CNA) working the day shift. Resident 3's nursing notes, dated 5/14/16, written by RN C indicate: Door alarm in chapel was sounding when RN came out of another resident's room. No sign of a resident outside chapel door or parking lot. Resident was located on the sidewalk a block away from facility in wheelchair. RN caught up to resident who did not want to return to building. RN suggested to call and see if someone would be available to take her out for a while. She then was agreeable to return to facility. She decided to lie down in bed when we returned. There are no other notes for Resident 3 on 5/14/16 related to her elopement. The next entry in Resident 3's nursing notes is 5/17/16, by RN C. This note indicated that the physician had been updated on symptoms last few days of dizziness and emesis on 5/14, generally not herself. On the facility's Daily Communication Tool, dated 5/16, it states Resident 3 got outside Saturday . This is written by Director of Nursing (DON) B. On 5/24/16, at 12:40 PM, Surveyor interviewed RN C. RN C stated she was in another resident's room giving medications. When she came out of the room she heard the alarm sounding. RN C went to the nursing station to see where the alarm was and noted it to be the chapel door. RN C then went to the chapel and looked out the door and did not see anyone. RN C went around the building and saw Resident 3 down the sidewalk. RN C stated it was sunny outside and Resident 3 did not want to come back inside but stated maybe they could find someone to take her out so Resident 3 returned to the building with RN C. Upon return to the building other staff was at the front doors and said they were looking for Resident 3. Resident 3 decided to lay down once back in the building. RN C stated Resident 3 slept for a while and she already had a bed alarm so staff would be alerted if she tried to get out of bed. RN C confirmed she did not complete an assessment on Resident 3 upon return. RN C stated she documented the incident in the nursing notes and passed it on in report to the next nurse. Surveyor asked if she reported the incident to DON B or NHA A. RN C stated no but they were aware because it was in the Daily Communication Tool book. Surveyor then walked with RN C to see where Resident 3 was found. RN C and Surveyor exited the chapel door Resident 3 had exited. The alarm sounded, but it was not very loud. After exiting you have to take approximately a 45 degree turn onto the sidewalk. Resident 3 went to the end of the block, crossed the street to the sidewalk on the other side. Resident 3 was found approximately 109 steps from the door. The sidewalk was uneven and there is a large dip from the sidewalk to street and back up on the other sidewalk. Resident 3 was at the top of a very steep downgrade when RN C caught up to her. Resident 3 would not have been able to control her wheelchair down the hill. RN C stated Resident 3 told her she was headed to town but did not say why. On 5/24/16, at 1:30 PM, Surveyor interviewed CNA E. CNA E stated on 5/14/16 she and the other CNA were transferring another resident with the lift. CNA E stated she thought she heard the alarm but could not leave the resident to go check. When they were done with the transfer CNA E exited the room and heard the alarm. Licensed Practical Nursing (LPN) F stated she could not find Resident 3. CNA E and LPN F went to the front doors and RN C was bringing Resident 3 back in the building. On 5/24/16, at 1:32 PM, Surveyor interviewed LPN F. LPN F stated on 5/14/16 she was clocking out around 1:00 PM. She was on the elevator and when she got off she heard the alarm sounding. LPN F went to the chapel doors, looked around and did not see anyone. LPN F then went back in and found CNA E to see if she had seen Resident 3. CNA E had not seen her and they went to the front door and saw RN C walking in with Resident 3. LPN F then left for the day. On 5/24/16, at 12:00 PM, Surveyor interviewed DON B. DON B stated she was not aware that Resident 3 had eloped from the building and thus there was not an incident report or any follow up. On 5/24/16, at 1:50 PM, Surveyor again interviewed DON B who stated she did not know about Resident 3's elopement on 5/14/16 until today. Surveyor asked about the note in the communication book. DON B stated when she was told she thought Resident 3 had just gone outside and did not understand that it was an elopement. DON B stated she would also have expected the family and physician along with herself and NHA A to have been notified on 5/14/16. DON B confirmed there was no investigation or changes made prior to 5/24/16 to determine how Resident 3 got out the doors and across the street or to prevent it from occurring again. On 5/24/16, at 12:37 PM, Surveyor interviewed NHA A who stated she was unaware Resident 3 had eloped from the building on 5/14/16. On 5/24/16, at 1:43 PM, Surveyor interviewed Resident 3's POA-HC, Family Member D. Family Member D stated he did not recall being contacted about Resident 3 exiting the building on 5/14/16. Family Member D checked his call logs and stated there was not a call from the facility on 5/14/16 from the facility. On 5/24/16, at 3:35 PM, Surveyor and DON B checked the facility exit doors. There are 5 exit doors all with some type of alarm which were all functioning. When DON B opened the chapel door the alarm sounded. As Surveyor walked down the hall toward the nursing station approximately a quarter of the way down the hall you could not hear the alarm and then when Surveyor was closer to the nursing station it was audible from the panel. Surveyor noted the resident room RN C stated she was in was in the area where the alarm could not be heard. The facility did not investigate the incident thus did not know there were areas the exit alarm could not be heard. The facility's failure to follow up and investigate how Resident 3 was able to exit the building and cross the street before staff were aware created a finding of immediate jeopardy. The facility removed the immediacy on 5/24/16 when they placed a mat with a louder alarm in front of exit doors and placed a call to maintenance for a permanent fix, audited all residents at risk for elopement and their Wanderguard bracelets, educated current staff and on-coming staff on the exit seeking policy and how to respond to an emergency situation and notification of management. The facility also implemented audits to ensure alarms are audible throughout the facility and to ensure DON B is aware of all incidents involving resident safety. Resident 3's physician and Family Member D were updated and Resident 3's care plan was updated.

Based on record review and interview the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, and advanced directives for 1 of 10 residents (Resident 10). Resident 10's Advance Directives indicate Resident 10 wished to be a full code/receive CPR (Cardiopulmonary Resuscitation). Resident 10's plan of care indicated that he was to be a full code. When Resident 10 was found not breathing on [DATE], the Licensed Practical Nurse (LPN) did not provide CPR to Resident 10. The facility failed to provide Resident 10 with CPR. This created a situation of immediate jeopardy beginning on [DATE]. The Nursing Home Administrator was informed of the immediate jeopardy situation at 1:45 PM on [DATE]. The facility removed the jeopardy the same day ([DATE]). The deficient practice continues at a scope/severity level E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan for the 8 residents who are full-code. This is evidenced by the following: Centers for Medicare and Medicaid Services S&C memo ,[DATE]-NH, revised [DATE] indicates: Initiation of CPR-Prior to the arrival of emergency medical services, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advanced directives or in the absence of advanced directives or a Do Not Resuscitate order. CPR-certified staff must be available at all times. If a resident experiences [MEDICAL CONDITION] facility staff must provide basic life support, including CPR prior to the arrival of emergency medical services, and in accordance with the resident's advanced directives, or in the absence of advance directives or a Do Not Resuscitate order, and if the resident does not show obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection or decomposition). At the time of the survey the facility census was 27 residents. Of those 27 residents 8 requested to receive CPR. The facility's Resuscitate (Full Code) form, signed by Resident 10's Activated Healthcare Power of Attorney on [DATE], includes the following: It is my understanding that the term Resuscitate (Full Code) means that staff members will provide CPR for any resident who becomes pulseless and nonbreathing unless: 1. the resident has a do not resuscitate (DNR) order. 2. the resident has obvious sign of clinical death (e.g., rigor mortis, dependent lividity (pooling of the blood that occurs after death and may look blue, purple, or black and is similar to bruising), decapitation, transection, or decomposition or 3. the initiation of CPR could cause injury or peril to the rescuer. Local emergency personnel will be contacted for continued resuscitation and transportation to the area hospital. Resident 10's most current physician's orders [REDACTED]. Resident 10's Care Plan, The resident has advanced directive/wishes in place, date initiated [DATE], Intervention: Code Status: CPR, date initiated [DATE]. Resident 10's Medication Administration Record, [REDACTED]. The facility's Full Code, [DATE] informational paper, posted in the room adjacent to the nurses station and above the time clock includes the names of 9 residents who are full code including Resident 10. Resident 10's Progress Notes include the following entries: [DATE], 23:20 (11:20 PM), Nursing Note: When CNA (Certified Nursing Assistant) went into room to check on resident at 2320 (11:20 PM) and found resident with no respirations. When I checked him there was no apical pulse and skin was already mottling and still warm. Son (Resident 10's 1st son's name) was called but did not answer so left a message at 2323 (11:23 PM). Called (Resident 10's 2nd son's name) at 2324 (11:24 PM) and updated him on resident's death. Stated he would try to get (Resident 10's 1st son's name). (Resident 10's on-call physician's name) paged at 2330 (11:30 PM) as on call for (Resident 10's physician's name) and called back at 2335 (11:35 PM). Updated on death and family being notified and gave permission to release the body to the funeral home. Message for (Nursing Home Administrator (NHA) A) of death of resident at 2345 (11:45 PM) and she returned the call at 2350 (11:50 PM). Called (Director of Nursing (DON) B) at 2345 (11:45 PM) and notified her of resident's death also. Notified the county coroner (coroner's name) of death also because of the stent placement at 2358 (11:58 PM) but he did not need to come. (Resident's 2nd son's name) called back at 0010 (12:10 AM) and stated he had not been able to reach (Resident's 1st son's name) and that he had called the funeral home as we did not have the name on file. (Funeral home) here and at 0030 (12:30 AM) remove the boy and also took his glasses. Signed by: Licensed Practical Nurse (LPN) K. [DATE], 19:17 (7:17 PM), Discharge Summary: Was admitted to the (Facility) after having a RT (right) [MEDICAL CONDITION](stroke). On [DATE] was up in w/c (wheelchair) as usual and went to bed before 1830 (6:30 PM) which was his normal routine. Was bed checked 2200 (10:00 PM) and was ok. When night CNA went into his room at 2320 (11:20 PM) found him with no resp (respirations) also mottled all over and skin was still warm. Signed by: Licensed Practical Nurse (LPN) K. On [DATE] at 1:10 PM Surveyor interviewed Licensed Practical Nurse (LPN) K regarding the circumstances surrounding Resident 10's death. LPN K stated the night aide had found Resident 10 gone during her routine rounds. LPN K stated she went into the room and found Resident 10 with no respirations, no apical pulse and no oxygen saturation level, he was mottled on his arms and chest and (LPN K) knew there was no need to resuscitate him at that time. LPN K stated that Resident 10 was warm and had not been gone too terribly long. LPN K stated Resident 10 was covered by a lot of blankets and that was probably why he was warm. LPN K stated she was unaware of Resident 10's code status. LPN K stated she did not look at Resident 10's code status to see if he was a full code or not. LPN K stated she just called his family to let them know of Resident 10's death. LPN K stated there is a list of residents in the facility who are full code above the time clock and indicated on the nurses' sheets used for shift to shift report. LPN K stated she had been recently CPR certified at the facility on [DATE]. LPN K stated she was not educated on when to start CPR and when not to start CPR on a resident who wishes to be a full code. On [DATE] at 2:50 PM Surveyor interviewed Certified Nursing Assistant (CNA) I. CNA I stated she was completing her walk through at the beginning of the night shift. When she got to Resident 10 she turned on the light in the room, as she did every night she works. Resident 10 did not answer and she noticed he was staring at the ceiling. CNA I stated she hollered down the hall for Licensed Practical Nurse (LPN) K, and asked LPN K to bring a stethoscope and blood pressure cuff. CNA I stated LPN K checked Resident 10 and said he was gone. CNA I stated she questioned LPN K if he was a full code. CNA I stated LPN K stated she would have to observe him take his last breath, then CPR would be initiated and 911 called. CNA I stated she was CPR certified at the facility on [DATE]. CNA I stated that if a resident is a full code CPR should always be initiated. CNA I stated CPR should have initiated on Resident 10. CNA I stated she did not feel she could start CPR on her own after LPN K stated not to as LPN K was a nurse and she was directed to always follow the direction of the nurse. On [DATE] at 1:45 PM Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated she would have expected staff to perform CPR on all residents who are a full code. NHA A stated Resident 10 should have had CPR performed on him and 911 called and transported to the hospital. On [DATE] at 5:00 PM Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated she instructed the staff during the CPR recertification classes. NHA A stated she did not educate the staff on when to start CPR and when not to start CPR on a resident who wishes to be a full code. NHA A stated this should be reviewed annually. Surveyor requested the education documentation for LPN K and CNA I. This education documentation was not received. Resident 10's Advance Directives indicates Resident 10 wished to be a full code/receive CPR (Cardiopulmonary Resuscitation). Resident 10's plan of care indicated that he was to be a full code. When Resident 10 was found not breathing on [DATE], Licensed Practical Nurse K (LPN) did not provide CPR to Resident 10. The facility denied Resident 10 the only chance he had for living. Regardless of the small chance for a positive outcome, there was virtually no chance for a positive outcome from failing to attempt CPR. The failure to provide CPR to Resident 10 as he had requested denied Resident 10 the only chance he had for living. This created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when: *Medical Director was updated on occurrence [DATE]. *All residents who expired on (or) since [DATE] at the Center reviewed for code status on [DATE]. *NHA and DON will conduct a medical record review of each resident that expires in the Center by the next business day to ensure policy and procedure for Full Code adhered to and if any opportunities for improvement are identified. *Verified full code list as correct and posted per Center's policy. *Licensed Professional staff and applicable Direct Care and Department staff had their CPR certification verified as current. *All Licensed, Direct Care Staff and any Department staff member certified with CPR immediately re-educated on CPR policy and procedure. Staff mot currently on duty will be re-educated prior to next tour of duty. *Crash cart check and supplies verified. *Nursing staff identified who did not initiate CPR will be interviewed to determine process improvement. *Code Blue drills will be conducted for each shift. *5 staff will be interviewed each week on variable shifts regarding CPR policy and procedure. *Current CPR policy will be revised to include the stipulations for when CPR should or should not be initiated, as stated on Full Code form. *All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and determine if further action is necessary.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer for 3 of 10 residents (Resident 5, 1 and 4). In addition, the facility failed to identify pressure ulcers (PU) that developed in the facility and failed to implement interventions to prevent further pressure ulcers from developing. Resident 5 was readmitted to the facility without a pressure ulcer (PU) and was identified to be at risk for PU development. Interventions were not put into place to prevent Resident 5 from developing a PU. Resident 5 developed an avoidable, unstageable PU to the left heel, an avoidable Stage 3 PU to the left ischial tuberosity and an avoidable Stage 2 to the scrotum while in the facility. Resident 1 was identified to be at risk for PU development and had a history of [REDACTED]. Resident 1's shoes were not assessed and were ill fitting. Resident 1 developed an avoidable, unstageable PU to the left heel and an avoidable deep tissue injury to the right heel. Resident 4's pressure ulcer treatment was not performed according to the Physician Orders. This is evidence by This is evidenced by the following: According to the www.NPUAP.com <http://www.NPUAP.com> the National Pressure Ulcer Advisory Panel (NPUAP) defines PU's in the following catergories: Category/Stage I: Non-blanchable [DIAGNOSES REDACTED]Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The Quick Reference Guide entitled Pressure Ulcer Prevention published by the National Pressure Ulcer Advisory Panel (NPUAP) in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves so the heels are elevated (i.e., floating) will accomplish reduction of pressure on heels. The facility's policy entitled Braden Scale states in part: Purpose: 2.1 To assist in identifying the associated risk factors for pressure ulcer (PU) development so that appropriate preventative interventions may be implemented. 3.1 C. Scores of 9 or below indicate very high risk. Scores of 10-12 indicate high risk. Scores of 13-14 indicate moderate risk. Scores of 15-18 indicate at risk. Scores of 19-23 indicate no risk. D. Update resident care plan and Certified Nursing Assistant (CNA) kardex based on any identified risk factors using specific interventions. The facility uses a Joerns mattress as their standard mattress. The mattress is rated for PU's up to Stage 2. On 11/11/15, at 4:15 PM Surveyor interviewed Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and Registered Nurse Consultant (RNC) D regarding the facility's PU's and PU procedures. NHA A stated RN G is the facility's wound care certified nurse. DON B stated that upon admission or re-admission the facility completes a skin assessment within 2 hours then every 8 hours for 72 hours and weekly thereafter. RN D stated a Braden is completed on admission then weekly times 4 weeks. NHA A stated that when the facility identifies a resident to be at risk for skin impairment the facility puts something in place on the care plan to prevent the skin impairment. Example 1 Resident 5 was re-admitted to the facility on [DATE] after a fall in the facility with a resulting [MEDICAL CONDITION] hip. Additional [DIAGNOSES REDACTED]. Resident 5's Braden assessment, (potential for skin impairment tool) dated 9/30/15 indicated Resident 5 scored a 23 indicating Resident 5 was not at risk. Resident 5 was readmitted to the facility following a left [MEDICAL CONDITION] on 10/14/15, Resident 5's Braden assessment on 10/14/15 indicates Resident 5 scored an 11 indicating Resident 5 was at high risk for PU development. On 10/14/15 Resident 5's Braden score changed from a 23 not at risk to an 11 indicating high risk. The facility failed to implement an intervention at this time to prevent potential skin integrity impairment. Resident 5 developed a suspected deep tissue injury (SDTI) to the left heel on 10/30/15. Resident 5's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/26/15, indicates A Brief Interview for Mental Status (BIMS) was completed with Resident 5 scoring a 15 indicating Resident 5 is cognitively intact. Section M0150 of the MDS indicates Resident 5 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 5 requires 2 staff and extensive assistance for bed mobility and 2 staff and total assistance for transfers. A Care Area Assessment (CAA) worksheet dated 10/27/15 states in part; triggering conditions: extensive assistance with bed mobility, frequently incontinent of urine, and frequently incontinent of bowel and at risk for PU development. Extrinsic risk factors: Requires regular schedule of turning, needs special mattress or seat cushion to relieve or reduce pressure. [MEDICATION NAME] risk factors: immobility, incontinence. Treatments and other factors that cause complications: newly admitted or readmitted . Resident 5's comprehensive care plan Potential for impaired skin integrity dated 11/28/14 states in part: 11/5/15 - low air flow alternating air pressure mattress on bed; pressure redistribution cushion on wheel chair. Get resident up for meals only; after eating return to bed to reposition off buttock. Resident 5's comprehensive care plan Resident has left heel deep tissue injury dated 10/30/15 states in part: - 10/30/15 - [MEDICATION NAME] daily at noon, blue heel lift boots at all times remove for AM/HS cares and put back on when cares complete. Nursing notes dated 10/15/15 at 12:21 PM state in part; fall on 10/12 resulted in fine fracture. Family and resident choose not to do a surgical intervention. Full body lift, non-weight bearing left; complains of pain, grimaces and guards leg. Nursing notes dated 10/18/15 at 12:40 AM state in part; resident had the following mobility changes due to fracture of left acetabulum on 10/12/15 resident is now a full body lift; transfers with no weight bearing on left side. Nursing notes dated 10/28/15 at 8:20 PM state in part; assisted with bed mobility and transfers are with a full body lift. Has no skin problems except for old bruises and abrasions related to his recent fall. Nursing notes dated 10/30/15 at 6:46 AM state in part; resident found to have large whitish blister to left heal with open center and blackish skin underneath. Nursing notes dated 10/30/15 at 7:07 AM state in part; has a PU - acquired in-house incident on 10/30 /15 at 6:46 AM. Deep tissue injury of left {sic} with open dry blister noted. Range of motion: no change stiffness of left leg related to fractured acetabulum. Immediate care plan intervention: start heel boots, air mattress, slider sheet, reposition every 2 hours and [MEDICATION NAME] supplement. The facility PU scale for Healing (PUSH) tool dated 10/30/15 states in part; suspected deep tissue injury (SDTI) left heel measure 4.0 centimeter (cm) x 6.0 cm dark purple colored area in center of wound bed depth unknown at this time. No drainage, no signs or symptoms of infection. Nursing notes date 11/1/15 at 12:25 PM state in part; visit by wound care Registered Nurse (RN) and treatment of [REDACTED]. Every 2 hour turning from side to side. Nursing notes dated 11/5/15 at 5:36 AM state in part; open area to left buttock with large area of redness/firmness around it. Also found open area to left posterior scrotum 2.5 cm x 1cm width. Abrasion to left mid buttock with redness/firmness around the area and abrasion to posterior mid scrotal area. Resident turned on right side with wedge behind back to keep resident off area. Immediate care plan intervention: Repositioning resident from side to side and keeping off of back continue with air mattress. Nursing notes dated 11/5/15 at 6:30 AM state in part; area to left buttock 5.5 cm wide x 5.0 cm length. Reported to DON B and NHA A. Nursing notes dated 11/6/15 state in part; new area to left buttock was seen by wound nurse today during rounds. Reports area appears to be a sebaceous cyst. Open area to left buttock 2.0 cm x1.5 cm x unknown depth has moderate amount of yellow drainage there is a firm 4 cm diameter around this area that is warm. On 11/10/15 at 1:23 PM Surveyor observed care being provided for Resident 5. Certified Nursing Assistant (CNA) F and CNA R assisted Resident 5 to bed once in bed CNA F removed Resident 5's bilateral blue heel lift boots and assisted Resident 5 onto the bedpan. Surveyor noted a foam dressing on the left ischial tuberosity and a Stage 2 PU on the scrotum. Surveyor asked CNA F about the area on the ishium and the scrotum and CNA F stated the areas on the ischium and the scrotum have been there just a few days. CNA F positioned Resident 5 on the bed pan covered Resident 5 for privacy and stated to Surveyor that Resident 5 needs privacy on the bedpan and will ring his call light when he is finished using the bedpan. On 11/10/15 at 2:55 PM Surveyor noted CNA Q stated Resident 5 was ready to get off the bed pan. Of note Resident 5 had been on the bedpan from 1:23 PM until 2:55 PM. On 11/10/15 at 2:55 PM Surveyor observed CNA J and CNA Q assist Resident 5 off the bed pan. CNA Q rolled Resident 5 onto his side and Surveyor noted Resident 5 had a large deep, ruddy, red bedpan indention around his sacrum, buttocks and thighs were the bedpan was sitting. CNA Q placed barrier cream on Resident 5's buttocks and over the bedpan indention and Stage 2 area on the scrotum. Surveyor questioned CNA Q about Resident 5 being on the bedpan for such a long period of time. CNA Q stated that Resident 5 takes a long time on the bedpan but he also forgets that he is on the pan and sometimes forgets to call for assistance to get off the bedpan. CNA Q stated I did check on him a couple of times and he was not ready to get off the bedpan. Of note, Resident 5 also had his blue heel lift boots off while in bed from 1:23 PM until approximately 3:00 PM. CNA Q placed the blue heel lift boots back on Resident 5 at approximately 3:00 PM. Surveyor asked CNA Q why the blue boots are removed and CNA Q stated that Resident 5's care plan states to remove during care. On 11/11/15, at 4:15 PM Surveyor interviewed Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and Registered Nurse Consultant (RNC) D regarding the facility's PU's. Surveyor asked DON B regarding the facility's policy regarding the use of bed pans and length of time a resident should be left on a bedpan. DON B stated that she would not expect a resident to be left on a bedpan any longer than possible. Surveyor discussed the observation of Resident 5 being on the bedpan from 1:23 PM until 2:55 PM DON B stated that is way too long to be left on a bedpan. On 11/11/ 15 at 8:45 AM Surveyor observed the wound care treatment for [REDACTED]. RN C removed the old dressing and Surveyor noted yellow/tan dressing on the old dressing. The wound on the left ischial tuberosity appeared to be the size of quarter the wound bed had 3 circular islands of slough with 50 % of the wound bed covered with slough and 50 % of the wound bed with pink granulation tissue. Surveyor asked RN G about the wound RN G stated she thought the area was a Stage 2 PU but with the slough present she will be changing the PU to a Stage 3. RN G completed the wound treatment per physician order. Surveyor noted an area to the scrotum and questioned RN G regarding the area. The area was a small crater shaped like a raindrop with a pink wound bed which appeared as a Stage 2. Surveyor asked RN G about the scrotal area. RN G stated the facility was calling the area friction from incontinent moisture and that there was no treatment to the area except for barrier cream. RN G then proceeded to complete the dressing change for the left heel. RN G removed the old dressing and Surveyor noted quarter sized elongated unstageable PU to the left heel. The wound bed of the left heel was 100 % covered in grayish slough. Surveyor asked RN G if the PU to the left heel had worsened RN G stated the area was a SDTI and that it had worsened RN G agreed the area had 100% slough and was unstageable. Surveyor asked RN G regarding Resident 5's PU's. RN G stated the PU's developed in house after Resident 5 fell and fractured. RN G stated the facility implemented the blue heel lift boots, air mattress and turning program after Resident 5 developed the left heel ulcer. Nursing notes dated 11/11/15 at 6:10 PM state in part; Resident has worsening PU's present. Resident had a SDTI to left heel which is now 95% covered in slough and is unstageable. Abrasion to scrotum has developed into a Stage 2 PU and left buttock sebaceous cyst has developed into an unstagable PU. Changed left heel treatment to [MEDICATION NAME] covered with AMD foam dressing changed Twice daily and as needed, changed left buttock treatment to [MEDICATION NAME] covered with AMD foam dressing changed twice daily and as needed ; added treatment for [REDACTED]. On 11/11/15, at 4:15 PM Surveyor interviewed Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and Registered Nurse Consultant (RNC) D regarding the facility's PU's. NHA A stated that she recognized there was a problem with PU's when Resident 5 developed a PU on his left heel. NHA A stated the facility implemented a new air mattress, [MEDICATION NAME] (protein supplementation) and heel lift boots once the PU was discovered. Surveyor asked NHA A if Resident 5 was at risk for PU development upon re- admission. NHA A stated that Resident 5 was at risk as evidenced by the significant change in the Braden score. Surveyor asked NHA A if the facility implemented an intervention to prevent the development of a PU when Resident 5's returned from the hospital and was noted to be at an increased risk for PU development. NHA A stated the facility did not implement a new intervention and that she had provided education to the staff on 11/11/15 regarding the need to implement interventions when a resident becomes at risk. Surveyor asked NHA A what the facility had in place to prevent Resident 5 from developing a PU upon return from the hospital. NHA A stated Resident 5 was to be repositioned every 2 hours and heels should be floated for all residents. Surveyor asked NHA A if the facility follows a standard of practice for wound care. RNC D stated the facility follows the NPUAP as the facility standard of practice. NHA A stated the facility completed a skin sweep of all in house residents on 11/6/15 and no other concerns were identified. Surveyor asked NHA A regarding the development of the Stage 2 PU on the Scrotum and the Stage 3 on Resident 5's left buttock which developed on 11/5/15. NHA A stated the facility did not identify these areas PU's. Of note, despite the facility skin sweep the facility failed to identify 2 additional PU's for Resident 5. On 11/11/15 Surveyor interviewed Certified Nursing Assistant (CNA) F regarding Resident 5's PU and facility PU education. CNA F stated that Resident 5 acquired the PU's after he fractured his hip. CNA F stated that Resident 5 was pretty independent and now requires total assistance. CNA F stated that the facility implemented the heel lift boots and mattress after Resident 5 received the heel ulcer. Surveyor asked CNA F if she received education regarding PU's. CNA F stated that the facility discussed PU's with the staff today 11/11/15. Resident 5 developed an avoidable, unstageable PU to the left heel, a Stage 2 to the scrotum and a Stage 3 to the left ischial tuberosity. Resident 5 was identified as at risk for PU development upon re-admit, however the facility failed to implement interventions to prevent PU development and failed to identify additional facility acquired PU's. Example 2 Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] following a hospitalization . Resident 1's [DIAGNOSES REDACTED]. Resident 1 was admitted on [DATE] with a pressure ulcer to his left heel due to the cast for his ankle fracture. Resident 1 also acquired a pressure ulcer on his coccyx due to friction and shearing on 8/6/15. Both of these pressure ulcers healed. Resident 1's Braden assessment, (potential for skin impairment tool) dated 8/25/15 indicated Resident 1 scored a 17 indicating Resident 1 was at risk for pressure ulcer development. Resident 1's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/15, indicates A Brief Interview for Mental Status (BIMS) was completed with Resident 1 scoring a 15 indicating Resident 1 is cognitively intact. Section M0150 of the MDS indicates Resident 1 is at risk for developing a PU and has no unhealed pressure ulcers. Section G0110, Activities of Daily Living (ADL's) indicates Resident 1 requires 2 staff and extensive assistance for bed mobility and 2 staff and total assistance for transfers. Resident 1's comprehensive care plan, impairment to skin integrity r/t (related to) [MEDICAL CONDITION], dated 1/11/15 and revised 11/10/15, includes the following interventions: Administer meds/vitamins as ordered, date initiated 1/11/15. Encourage good nutrition and hydration in order to promote healthier skin, date initiated 1/11/15. Monitor incision for evidence of infection, redness, odor, drainage, warmth and [MEDICAL CONDITION], date initiated 10/28/15. No shoes until areas above heels resolve; just socks, date initiated 10/8/15. Shift weight in wheelchair at least every 2 hours when up. Assist to reposition at least every 2 hours when in bed, date initiated 4/28/15, revision 8/21/15. Skin - Float /elevate heels skin prep PMs and NOCs, date initiated 2/16/15, revised 4/16/15. Skin - Pressure reduction chair, date initiated 1/11/15. Skin - Specialty mattress, date initiated 10/19/15. To wear tubi grip BLE (bilateral lower extremities) from toes to knees for [MEDICAL CONDITION] control, is to lie supine with BLE elevated for 30 minutes before lunch, date initiated 11/6/15. Use a draw sheet or lifting device to move resident, date initiated 8/6/15. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, date initiated 10/19/15. Resident 1's progress note, dated 10/8/15, 1630 (4:30 PM) includes, in part, the following: Type of incident: injury of known cause (skin tear, bruise, abrasion, etc). Date and Time of incident: 10/8/15, 06:45 (AM). Location: above right and left heel. Describe incident in detail: small opening area above left heel and intact blister above right heel. Describe any injuries and first aid provided: left foot area cleaned and covered w/ (with) gauze; right foot area skin prepped. Immediate care plan intervention to prevent further incidents: keep shoes off until areas healed. Resident 1'a Non-Pressure Skin Condition form, dated 10/8/15, includes, in part, the following: Site and description of skin problems, include measurements, length, width and depth if applicable: Left heel, open area 0.2 x 1.5 w/ bruising beneath area 1.0 x 2.0. Right heel, intact blister 0.8 x 1.0. Additional wound characteristics (drainage, odor, appearance). Identify site and explain: scant yellowish drainage from open area above left heel. Resident 1'a Non-Pressure Skin Condition form, dated 10/14/15, includes, in part, the following: Site and description of skin problems, include measurements, length, width and depth if applicable: Right heel, blister r/t (related to) increased [MEDICAL CONDITION] and ill-fitting shoes. Size 2.0 x 2.7 x 0.0, area dry and flat to the surface of skin, skin prep applied and will leave open to air. Left heel, blister r/t to increased [MEDICAL CONDITION] and ill-fitting shoes. Blister has burst and has some scant drainage, will start ultra thin duoderm to provide extra protection to area. Additional wound characteristics (drainage, odor, appearance). Identify site and explain: no s/s (signs/symptoms) of infection and does not c/o (complain of) pain due to [DIAGNOSES REDACTED]. Signed by Registered Nurse (RN) E on 10/15/15. RN E is the facility's wound care certified nurse. Resident 1's Head to Toe form, dated 10/26/15, includes, in part, the following: 8. Feet: a. warm, b. wounds. 8a. Describe: left heel. Resident 1's Non-Pressure Skin Condition form, dated 10/30/15, includes, in part, the following: Site and description of skin problems, include measurements, length, width and depth if applicable: Right heel, blister r/t ill-fitting shoes and increased [MEDICAL CONDITION] blister intact and fluid reabsorbed and is dry and surface even with surrounding skin. Size: 0.7 x 1.5 x 0.0 cm (centimeters). Left heel, blister r/t ill-fitting shoes and increased [MEDICAL CONDITION]. Size: 1.0 x 1.4 x 0.1 cm. Blister burst and has dark area in the center of wound bed, no s/s of infection, no drainage, duoderm applied and heel lift boot on. Additional wound characteristics (drainage, odor, appearance). Identify site and explain: there is no documentation. Signed by Registered Nurse (RN) E on 11/8/15. RN E is the facility's wound care certified nurse. Resident 1'a Non-Pressure Skin Condition form, dated 11/6/15, includes, in part, the following: Site and description of skin problems, include measurements, length, width and depth if applicable: Right heel, blister from increased [MEDICAL CONDITION] and ill-fitting shoes, Size 0.7 x 1.0x 1.0 cm, moist with scant amount of serous drainage, area improving, continue with duoderm. Left heel, blister from ill-fitting shoes r/t increased [MEDICAL CONDITION]. Size 0.5 x 0.5 x 0.0 cm, area dry with no drainage, no s/s of infection, continue with skin prep. Additional wound characteristics (drainage, odor, appearance). Identify site and explain: both areas improving, no s/s of infection to either area. Signed by Registered Nurse (RN) E on 11/8/15. RN E is the facility's wound care certified nurse. Resident 1's Progress Notes include the following entries: 10/7/15, 15:23 (3:23 PM), Dietary Care Conference Note: Note text: . King is intact however this resident has a history of pressure ulcers so he receives a gelatein protein supplement BID (twice a day) with lunch and supper and takes a MVI (multivitamin) with minerals to help maintain good skin integrity. 10/8/15, 16:30 (4:30 PM), Incident Note: Note Text: (Resident 1) had a injury of known cause (skin tear, bruise, abrasion, etc.), incident on 10/8/15, 6:45 AM. Incident details: small open area above left heel & intact blister above right heel. The following injuries or first aide noted: left foot area cleansed & covered w/ gauze, right foot area skin prepped. Pain: none. Range of motion: n/a (non-applicable). Resident taken to hospital: no. Immediate care plan intervention: keep shoes off until areas healed. 10/13/15, 04:31 (AM), Nursing Note: Narrative: Dressing to L (left) outer heel removed due to saturation of serosanguinous/foul smelling drainage. Grey colored/moist 4 cm x 2 cm area with tiny opening in center with drainage. Area cleanse with saline, dried well and dressing applied overall. 10/15/15, 12:40 (PM), Focus Note: Reason for Review: Infection, skin. Diagnoses: [REDACTED]. Skin and wounds heels, right has a dry area measuring 2 x 2.7. Left heel is moist measuring 2.2 x 3.5. Wound care nurse recommends not adding moisture to area, covering with duoderm and alternating air mattress. Infections: UTI (urinary tract infection) being treated. Care plan interventions: continue to follow with plan of care. On 11/11/15 at 8:15 AM Surveyor observed wound care treatment for [REDACTED]. It was noted there was a thin duoderm on the left heel. Director of Nursing (DON) B removed the duoderm. The wound bed was noted to be covered with 90% white slough with pink wound edges. RN E measured the wound. The wound measurements were 0.8 cm x 1.2 cm x 0.2 cm. Surveyor asked RN E if the wound was caused by pressure and at what stage he thought it was. RN E stated he was told it was a blister, so not pressure; therefore he did not stage the wound. Surveyor asked RN E what a blister was considered if not pressure. RN E stated it was probably due to pressure from Resident 1's shoes. RN E stated another nurse had done the initial assessment and he went with what that assessment documented. On 11/11/15 at 8:25 AM Surveyor observed wound care treatment for [REDACTED]. It was noted the wound was not open, dry and with a dark/purple colored dime sized area in the middle. Surveyor asked RN E is he thought the wound was pressure. RN E stated yes, it was caused by the ill-fitting shoes. On 11/11/15 at 4:50 PM Surveyor interviewed DON B. DON B stated she believed Resident 1's left and right heel wounds were caused by pressure from his ill-fitting shoes. DON B stated they should be documented as pressure. On 11/11/15 at 12:15 PM Surveyor interviewed Certified Nursing Assistant (CNA) H. Surveyor asked CNA H when she was educated about pressure ulcers and what was said during the education. CNA H stated the facility had a pressure ulcer education this morning (11/11/15). CNA H stated the education included the need to float heels and how to float heels, how to report any skin changes, try to position residents on their sides, and try to keep residents off their back. Surveyor asked CNA H if she floated Resident 1's heels. CNA H stated sometimes he would choose not to float his heels and that Resident 1 had heel boots when he was first admitted due to having a heel wound on admission. CNA H stated once the wound healed he no longer wore the boots and they were no longer in his room. CNA H stated once it was explained to Resident 1 why he should have his heels floated he cooperated and allowed the staff to float his heels. On 11/11/15 at 4:30 PM Surveyor interviewed Certified Nursing Assistant (CNA) I. Surveyor asked CNA I when she was educated about pressure ulcers and what was said during the education. CNA I stated the facility had a pressure ulcer education today (11/11/15). CNA I stated the education included making sure heels are floated and keep residents turned on their sides. Surveyor asked CNA I if she floated Resident 1's heels. CNA I stated he usually floats his heels when he is in bed. CNA I stated Resident 1 always cooperates with having his heels floated. On 11/11/15 at 5:30 PM Surveyor interviewed Certified Nursing Assistant (CNA) J. CNA J stated she works for an agency and has worked at the facility for about 2 weeks. CNA J stated she has not had any education regarding pressure ulcers at the facility and her agency did not provide any either. CNA J stated she knows that every resident should have their heels floated when they are in bed. CNA J stated she always floats Resident 1's heels and encourages him to lie on his side when he is in bed. CNA J stated she would follow the care plan that is in the resident closet for each resident. Example 3 Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4 developed an unavoidable, Stage II pressure ulcer on her coccyx on 10/30/15. Resident 4's Physician order [REDACTED]. Every 72 hours for open area on coccyx. On 11/11/15 at 2:45 PM, Surveyor observed Resident 4's treatment to her pressure ulcer. Registered Nurse (RN) C performed the dressing change. RN C applied an Alginate [MEDICATION NAME] dressing. RN C did not apply a Duoderm as ordered by the Physician. On 11/12/15 at 4:30 PM, Surveyor spoke with Director of Nursing (DON) B. Surveyor asked DON B if she expects staff to follow Physician Orders. DON B stated, Yes. Surveyor spoke with DON B regarding RN C using an Alginate [MEDICATION NAME] dressing instead of the Duoderm ordered by the Physician. Surveyor asked DON B if RN C should have applied the Duoderm as ordered. DON B stated, Yes.

Based on record review and interview in 1 of 10 sampled residents (Resident 1) the facility did not ensure that each resident was free of any significant medication errors. Resident 1 was identified as being allergic to Sulfa medications. Resident 1 received a Sulfa medication and experienced an allergic reaction requiring medications. This is evidenced by the following: Resident 1's [DIAGNOSES REDACTED]. Resident 1 was reviewed as a closed record. Resident 1's comprehensive physician orders [REDACTED]. Resident 1's Nurses Notes show the following documentation: 1/27/11 3:41 am - "Physician notified: (Physician's name) notified of Urine Dip. Physician response: TMP Sulfa DS (Double Strength) 1 po (orally) BID (twice a day) x 10 days." 1/27/11 6:01 pm - "Resident examined. See new orders. New order [MEDICATION NAME]([MEDICATION NAME]), d/c (discontinue) bactrim (TMP Sulfa DS). UA for C & S (urinalysis for culture and sensitivity). Significant other notified...." 1/29/11 1:38 pm - "Additional information for 1/28/11. Physician notified: (Physician's name) notified that resident was itching and rashy from allergic reaction to bacrtim. Physician response: 1) [MEDICATION NAME] 10 mg (milligrams) po tid (three times a day) x 5 days for allergic reaction 2) [MEDICATION NAME] 50 mg prn (as needed) every 4 hours for itching. Significant other notified..." Resident 1's MAR (Medication Administration Record) for 1/2011 shows that Resident 1 received 1 dose of "Bactrim DS (TMP Sulfa DS) on 1/26/11 at 5:00 pm. In addition, this MAR indicated [REDACTED]. On 2/17/11 Surveyor asked NHA (Nursing Home Administrator) A for the investigation into this medication error. NHA A stated that all the information would be in the electronic record and part of the facility's QA (Quality Assurance) notes. Please note QA minutes are not reviewed by the state survey team. Surveyor was unable to find any investigation into this medication error in Resident 1's electronic record. On 2/17/11 at 5:20 pm Surveyor spoke with DON B regarding several topics including the medication error involving Resident 1 on 1/26/11 . DON B stated she was unable to find any information into the investigation of this medication error.

Based on record review and interview, in 3 of 10 sampled residents and 1 of 11 supplemental residents (Residents 1, 2, 5 and 21) the facility did not immediately consult a physician, and / or inform the residents legal representative and / or family member when there was a significant change in the residents physical, mental or psychosocial status and a need to alter treatment significantly. Resident 1 had a chest x - ray completed on 12/1/10. The findings of this chest x -ray were abnormal. Although this information was "faxed" to the physician on Friday 12/3/11 (no time noted), there is no evidence the physician responded to this fax, and no evidence that any physician was consulted in a timely manner regarding this chest x - ray. Resident 1 developed a fever on 12/11/11 and was subsequently started on [MEDICATION NAME], an antibiotic often used for treatment of [REDACTED]. Resident 21 had a chest x - ray on 1/17/11 which was 'possibly" abnormal. The facility was made aware of this late on 1/17/11. There is no evidence the facility immediately contacted a physician. The facility received orders for treatment (antibiotic) on 1/18/11; however these orders were not noted and initiated until 1/19/11. Resident 5 had a significant 9 % weight loss in a two month period and a severe 17% weight loss over a three month period. The Resident's guardian and physician were not notified at the time of the weight loss. Resident 2 had 4 instances where he had signs/symptoms of a urinary tract infection where antibiotics were ordered. Resident 2's family was not notifed in a timely manner in 2 of these instances, and in 2 instances the family was not notified at all. This is evidenced by the following: Example 1 Resident 1's [DIAGNOSES REDACTED]. Resident 1's Physician's Progress note dated 12/1/10 states: "S (Subjective). . . She is an [AGE] year old white female with a longstanding history of asthma, [MEDICAL CONDITION] and chronic anxiety and depression. . . Her body habitus looks poor. She is normally obsessive about her appearance. She appears to be ill - kept. She does not have her usual new hair - do although this is hair day for her. She is unable to recognize me and appears to be generally confused. She has had a general decline over a period of the last 2 - 3 months. . . P (Plan): Obtain portable chest x - ray. . . and will follow up as a nursing home inpatient." Resident 1's radiology report from 12/1/10 states: "Mild [MEDICAL CONDITION] vascular congestion noted in lower lung fields with early infiltrate in the right lung base. Clinical correlation is requested. The remainder of the lung fields are essentially clear." Although this report notes it was faxed to Resident 1's physician on Friday 12/3/10, there is no evidence that there was a consultation with Resident 1 physician regarding this report, and no evidence a physician had indeed received / reviewed the fax and report on 12/3/10. Resident 1's Nurses Notes document the following entry 10 days after the chest x - ray was taken. 12/11/10 - 10:40 am - "@ (at) 00:30 (12:30 am) Physician notified: (physician name) notified that resident had an elevated temperature of 102.6. She (Resident 1) did not display any symptoms of acute illness except for the fever. Physician response: Straight cath (catheterize) for UA (urinalysis). Get C & S (Culture and Sensitivity) of urine. After UA is done [MEDICATION NAME]([MEDICATION NAME]) 500 mg (milligrams) and then continue [MEDICATION NAME] mg BID (twice a day) x 7 days. Tylenol 650 mg po (orally) or Tylenol 650 mg supp (suppository) q (every) 4 hours PRN (as needed) for elevated temperature. Significant other notified... " 12/11/10 - "@ 05:00 (5:00 am) Physician notified: (Physician name) notified that UA was negative, Physician response; Start [MEDICATION NAME] 500 mg 1 po daily times 1 week. Disregard order [MEDICATION NAME] C & S of urine...." 12/11/10 - "@ 11:15 (am) Physician notified. (Physician's name) notified that [MEDICATION NAME] was not covered under the resident's pharmacy plan. The pharmacist recommended [MEDICATION NAME] 600 mg as a substitute. Physician response: Change [MEDICATION NAME] to [MEDICATION NAME] 600 (sic) mg 1 daily PO for 7 days..." Resident 1's radiology report for the chest x - ray of 12/1/10 shows this report was "refaxed" to Resident 1's physician on 12/13/11 with a notation stating; "FYI (for your information) Spiked fever over weekend. On [MEDICATION NAME] 400 mg daily 7 days. Please note - any new changes?" The response is noted as "No" (change) and has Resident 1's physician name stamped. This is noted by nursing staff on 12/14/10. On 2/17/11 at 5:20 pm Surveyor spoke with DON (Director of Nursing) B regarding Resident 1 and the treatment on 12/11/10. Surveyor asked DON B why Resident 1's treatment had been changed [MEDICATION NAME]. DON B stated that it was thought that Resident 1's infection may be respiratory in nature, not urinary. Surveyor asked DON B where in Resident 1's note does it state that. DON B was unable to find documentation of this however referenced the chest x - ray from 12/1/10. Surveyor asked DON B why there was such a delay in response and treatment to the chest x - ray report from 12/1/10 which identified an "early infiltrate in the right lung base?" DON B stated "I caught that to when I looked (at the report.)" DON B was unable to give an explanation for the delay in treatment. Surveyor asked DON B for any evidence that a physician was consulted (communication back and forth between the facility and the physician) regarding Resident 1's chest x - ray of 12/1/10 on 12/3/10 when a fax was originally sent to Resident 1's physician. No additional information was provided to Surveyor . Example 2 Resident 21's [DIAGNOSES REDACTED]. [MEDICAL CONDITION], and DM (Diabetes Mellitus). Resident 21's record shows that on 1/17/11 Resident 21 had a chest x - ray done. The result of this x- ray was faxed to the facility on [DATE] at "23:36" (11:36 pm). The findings are note as ". . . Mild [MEDICAL CONDITION] vascular congestion is noted in both lower lung fields with possible infiltrate in the right lung base. Clinical correlation is requested...." There is no evidence the facility consulted a physician regarding this abnormal chest x-ray at this time. Resident 21's record shows Nurse Practitioner orders dated 1/18/11 which state "1) Z pack ([MEDICATION NAME] - antiinfective) - infiltrate." This order is not "noted" until 1/19/11 as evidenced by the LPN's (Licensed Practical Nurse's) initials and the word "noted" dated 1/19/11 on the orders. Resident 21's MAR (Medication Administration Record) for 1/2011 shows an entry for "Z - pack - [MEDICATION NAME] 250 mg (milligrams) (give 2 tablets po (orally) on day 1, then 250 mg po once a day days 2 - 5. Dx (diagnoses): Infiltrate." This order is dated 1/19/11. Documentation shows that this antibiotic was started on 1/19/11 during the "am" hours. On 3/2/11 at 3:40 pm Surveyor spoke with RN (Registered Nurse) H regarding Resident 21 and the chest X - ray of 1/17/11. (Director of Nursing B was unavailable at this time. NHA A designated RN H to answer Surveyor 's questions). Surveyor asked RN H, in her professional opinion, if an abnormal chest x - ray came into the facility late (11:36 pm), what would she do? RN H stated she would contact the physician on call. Surveyor asked RN H, as a professional working at this facility, if she could help Surveyor understand the delay in Resident 21 receiving an antibiotic for this abnormal chest x - ray? RN H stated she was unable to explain the delay. Please know RN H is the RN working at the facility on this day, but was not present at the time of the occurrence in question. Example 3 Resident 5's Minimum Data Set (MDS) assessment, dated 11/3/10, shows her Brief Interview for Mental Status (BIMS) score to be 3 which indicates severe impairment of cognitive status. A guardian was appointed by the court on 11/4/10 due to several concern areas related to Resident 5's decision-making. Resident 5's monthly weights as recorded in the medical record are: 8/10/10 - 140 pounds; 9/1/10 - 147 pounds; 9/28/10 - 157 pounds; 10/8/10 - refused; 11/2/10 - 143 pounds; 12/2/10 - refused; 1/5/11 - 130 pounds; and 2/9/11 - 132.5 pounds. The weight loss from 9/28/10 to 1/5/11 is 17% and the weight loss from 11/2/10 to 1/5/11 is 9%. There is no indication in the medical record that the physician or guardian was notified when the weight loss was discovered on 1/5/11. Resident 5's Care Plan for Nutrition dated 2/17/10 notes that one Sign/Symptom of Problem is "Weight Loss 5% per month" and an Approach dated 11/25/09 states "Registered Dietician (R.D.) consult as needed." When the weight loss was discovered on 1/5/11, there is no mention of a dietary consult. There are no further dietary assessment notes until 1/24/11 when a Quarterly Review was completed. The review notes resident weight of 130 pounds and states it is below the Goal Weight Range (GWR) of 150-160 pounds. Dietary notes dated 1/26/11 state that Dietary Manager (DM) M spoke with Resident 5 about her weight loss and Resident 5 stated she was fine with her weight and that her usual weight is 140 pounds. Note: Resident 5 has a guardian for decision-making. The Care Plan printed on 2/17/11states a Goal Weight Range (GWR) of 130-140 pounds but this entry is undated and is different from the GWR noted on 1/24/11 of 150-160 pounds. The GWR was updated to reflect a lower goal without consultation of the guardian or physician and without information in the record about planned weight loss. On 2/16/11 at 3:00 PM, Surveyor interviewed Registered Dietician (RD) L. RD L states that a significant weight loss is 5% in 30 days and 10% over 180 days. RD L states that, when there is a significant weight loss, the Physician and the family should be notified. She states that it is a nursing responsibility to notify the family and physician. RD L does not make that type of notification. She states that when there is a significant weight loss, a Resident should have a Nutrition Risk check list assessment and be scheduled for daily or weekly weights. RD L agrees that Resident 5 has had a significant weight loss and states Resident 5 is now on weekly weights. Weekly weights were added to Resident 5's Care plan on 1/24/11. Her first weekly weight was recorded on 2/9/11 which is more than one month after the weight loss was discovered on 1/5/11. RD L notes that Resident 5 has a history of refusing to be weighed and refusing many treatments and interventions. On 2/16/11 at 3:30 PM, Surveyor interviewed DON B about the weight loss. DON B states that Resident 5's guardian visited around Christmas time and she knows they spoke about many issues including Resident 5's diet but she could not find any documentation of it. No contact was made with the guardian in January about weight loss or about new dietary interventions. DON B states that the Physician is aware of Resident 5's weight in general but that there was no specific contact made with him about the 13 pound weight loss in January. Example 4 Resident 2 arrived to the facility on [DATE] with an indwelling catheter. On 2/5/10 Resident 2 had signs/symptoms of a UTI and facility staff notified Resident 2's physician but did not show evidence of notifying Resident 2s family until 2/9/10 at 4:45 PM. On 10/15/10 Resident 2 had signs/symptoms of a UTI and facility staff notified Resident 2's physician but did not show evidence of notifying Resident 2's family until 10/15/10 at 4:58 PM. On 11/30/10 Resident 2's physician prescribed an antibiotic to treat a UTI but the facility could provide evidence that the Resident's family was notified. On 12/3/10 Resident 2's physician stopped the antibiotic Resident 2 was on and started him on a different antibiotic. The facility could not provide evidence that the family was notified. On 1/14/11 Resident 2's physician prescribed an antibiotic to treat a UTI but the facility could provide evidence that the Resident's family was notified. At 5:51 PM on 2/17/11, Surveyor interviewed Registered Nurse (RN) I who stated that it is the facilities policy if a resident has signs and symptoms of an urinary tract infection [MEDICAL CONDITION] to do a urine dip in the facility. RN I stated that if that urine dip is positive it is facility policy to notify the resident's physician and family. At 5:53 PM on 2/17/11, Surveyor interviewed Nursing Home Administrator (NHA) A who stated she expects that if staff do a urine dip in the facility and it is positive, she expects the resident's family to be notified the same day unless it is late evening or early morning then she would expect staff to notify family during the next business hours.