Every finding on record at Oak Park Place of Nakoma

Based on observation, interview, and record review, the facility did not ensure garbage and refuse was disposed of properly. This has the ability to affect all 23 residents who reside at the facility.During the initial walk through of the kitchen Surveyor observed dumpster lids open, bag of garbage outside of dumpsters, food wrappers, gloves, and cardboard on the ground near the dumpsters. Evidenced by:The facility policy, Food-Related Garbage and Refuse Disposal, dated, 2017, states, in part;.Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.On 1/20/26 at 9:30 AM, during the initial walk through of the kitchen, Surveyor observed the facility dumpsters. The dumpster lids were open, a bag of garbage outside of dumpsters, food wrappers, gloves, and cardboard were on the ground near the dumpsters. Dietary Manager C (DM) indicated the lids should be down and there should not be garbage on the outside of the dumpsters.On 1/22/26 at 2:00 PM, Nursing Home Administrator A (NHA) indicated the dumpster lids should be down, and garbage should not be left on the ground.The facility did not ensure garbage and refuse was disposed of properly.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 23 residents who reside in the facility.Certified Nursing Assistant entered kitchenette 3 times without wearing a hair restraint during mealtime. Evidenced by:The facility policy, Hair Restraints, dated 7/13/25, states, in part;.Hair must be pulled back and properly restrained when working with exposed food, clean equipment, utensils, linens, and unwrapped single service and single use articles.On 1/20/26 at 12:15 PM, Certified Nursing Assistant D (CNA) entered kitchenette three times to get resident drinks. Surveyor observed hairnets to be available for all staff outside the kitchenette. CNA D indicated she knows she needs to wear a hairnet when going in the kitchen and kitchenette. CNA D indicated she remembers when she is going in the big kitchen, but she doesn't always remember when she goes into the kitchenette to wear a hairnet.On 1/22/26 at 1:08 PM, Dietary Manager C (DM) indicated all staff should wear a hair restraint any time entering the kitchen and the kitchenettes.On 1/22/26 at 2:00 PM, Nursing Home Administrator A (NHA) indicated all staff should wear a hair restraint any time entering the kitchen and the kitchenettes.The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

Based on interview and record review, the facility did not ensure the required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly. This practice had the potential to affect the census of 23 residents residing in the facility.The facility did not ensure the required members of the QAPI committee met at least quarterly in 2025.This is evidenced by:The facility's policy Quality Assurance and Performance Improvement (QAPI) Program, dated 2020, includes: This facility shall develop, implement, and maintain an ongoing, facility-wide, data-drive QAPI program that is focused on indicators fo the outcomes of care and quality of life for our residents. Authority 3. The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements. Implementation 3. The committee meets monthly.On 1/20/26 at 9:00 AM, Surveyor asked NHA A (Nursing Home Administrator) for the facility's QAPI plan and committee information.The facility's document QA Team Members, include Administrator, Director of Nursing, Dietary Manager, Therapy Director, Maintenance Director, Regional Nurse (Infection Preventionist), and Medical Director.Surveyor reviewed the facility's QAPI binder for 2025. QAPI sign in sheet dated 7/9/25 had the following team members Dietary Manager, Social Services/Activities, Regional Nurse (Infection Preventionist), Minimum Data Set Coordinator, Director of Nursing, Therapy Director, and Administrator.On 1/22/26 at 2:00 PM, Surveyor interviewed NHA A regarding QAPI team members. NHA A indicated the medical director was not included in the QAPI meeting.QAPI sign in sheet dated 9/18/25 had the following team members Administrator, Director of Nursing, Minimum Data Set Coordinator, Dietary/Environmental Services Director, Maintenance Director, and Director of Rehabilitation.On 1/22/26 at 2:00 PM, Surveyor interviewed NHA A regarding QAPI team members. NHA A indicated the medical director and infection preventionist was not included in the QAPI meeting.On 1/22/26 at 2:00 PM, Surveyor interviewed NHA A regarding the facility's QAPI program. NHA A indicated the facility failed to meet quarterly in 2025. NHA A indicated during the meetings not all the required members were present. NHA A indicated the facility held one quarterly QAPI meeting that met the requirements during 2025.

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 3 of 12 sampled Residents (R2, R19 & R34) and 1 of 1 supplemental residents (R23). R2 was observed with long facial hair.R19 was observed with long facial hair.R23 reported that they were not receiving their showers and had long facial hair.R34 reported that they were not receiving their showers and had long facial hair. Evidenced by:The facility's policy titled Activities of Daily Living (ADL), Supporting dated 3/2018 states in part Policy statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .Example 1R2 was admitted to the facility on [DATE] with diagnoses that include hip fracture, weakness, major depressive disorder, and dementia. R2's most recent MDS (Minimum Data Set) dated 1/2/26 states that R2 has a BIMS (Brief Interview of Mental Status) of 13 out of 15, indicating that R2 is cognitively intact. R2's MDS also states that they are dependent on staff for toileting, require substantial/ maximal assistance for bathing, and required supervision/ touching assistance for personal hygiene.R2's care plan dated 12/15/25 states in part: Focus: [R2] has demonstrated a decreased ability to perform ADLs (activities of daily living) related to impaired mobility and declining cognitive function secondary to dementia.Interventions/ Tasks: .Personal Hygiene: [R2] requires set- up assist by 1 staff with personal hygiene and oral care.R2's CNA (Certified Nursing Assistant) Kardex states in part .Personal Hygiene/ Oral Care: [R2] requires set- up assist by 1 staff with personal hygiene and oral care.It is important to note that R2's care plan and CNA Kardex do not address shaving, and there is no documentation in R2's EHR (Electronic Health Record) that shaving was completed.On 1/20/26 at 10:05 AM, Surveyor observed R2 lying in bed sleeping. Surveyor noted that R2's whiskers were approximately 1/2 (half inch) long.On 1/21/26 at 9:22 AM, Surveyor observed R2 in bed and he remained unshaven. Surveyor asked R2 if they liked the whiskers on their face, R2 stated no. Surveyor asked R2 if they preferred to be clean shaven, R2 stated yes.On 1/22/25 at 9:04 AM, Surveyor observed R2 in their room. R2 remained unshaven.Example 2R19 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (stroke), muscle weakness, dementia, and anxiety disorder.R19's most recent MDS (minimum data set) dated 1/7/26 states that R19 has a BIMS (brief interview of mental status) of 3 out of 15, indicating that R19 has severe cognitive impairment. R19's MDS also states that R19 requires substantial/ maximal assistance from staff for bathing and personal hygiene.R19's care plan dated 3/21/25 states in part: Focus: [R19] has an ADL (activities of daily living) self- care performance deficit r/t (related to) deconditioning.Interventions/ Tasks: .Personal Hygiene: The resident requires assist of 1 staff with personal hygiene and oral care.R19's CNA Kardex states: .Personal Hygiene: The resident requires assist of 1 staff with personal hygiene and oral care.It is important to note that R19's care plan and CNA Kardex do not address shaving and there is no documentation in R19's EHR (electronic health record) that shaving was completed.On 1/20/26 at 9:42 AM, Surveyor observed R19 sitting in their Broda chair. R19 was noted to have whiskers that were approximately 1/4- 1/2 (quarter inch to half inch) long. Surveyor asked R19 if they liked having facial hair, or if they preferred to be clean shaven, R19 stated their preference was to be clean shaven.On 1/21/26 at 9:44 AM, Surveyor observed R19 in their room; R19 remains unshaven.On 1/22/26 at 9:00 AM, Surveyor observed R19 in the dining room; R19 remains unshaven.Example 3R23 was admitted to the facility on [DATE] with diagnoses that include bimalleolar fracture of right lower leg (a severe, unstable ankle injury involving breaks in both the lateral (fibula) and medial (tibia) malleoli, often causing the ankle joint to shift), muscle weakness, and hypertension (high blood pressure).R23's most recent MDS (Minimum data set) dated 12/22/25 does not have a BIMS (brief interview of mental status) score evaluated. R23 was able to answer Surveyor's questions appropriately. R23's MDS states that they are dependent of staff for bathing and require supervision/ touching assistance for personal hygiene.R23's care plan dated 12/10/25 states in part .Focus: Decreased ability to perform ADLs (activities of daily living) related to NWB (Non-Weight Bearing) to RLE (Right Lower Extremity) .Bathing/ Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Bathing: chair swap at toilet grab bar into rolling shower chair, cover fiberglass cast.Personal Hygiene: 1 staff assist.R23's CNA Kardex states: .Personal Hygiene: 1 staff assist.Bathing: ADL- Bathing schedule (prefers shower) Showers on Tuesday and Friday dayshift. Bathing/ Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Bathing: chair swap at toilet grab bar into rolling shower chair, cover fiberglass cast.R23's task documentation states that R23's showers are to occur on Tuesdays and Fridays. Per facility documentation, R23 has received a shower on 12/23/25 and 1/6/26, missing showers on 12/12/25, 12/16/25, 12/19/25, 12/26/25, 12/29/25, 1/2/26, 1/9/26, 1/13/26, 1/16/26, and 1/20/26.It is important to note that R23's care plan and CNA Kardex do not address shaving and there is no documentation in R23's EHR (electronic health record) that shaving was completed. On 1/21/26 at 10:50 AM, Surveyor interviewed R23 as part of the group interview. Surveyor noted that R23 had facial whiskers approximately 1/2 (half inch) long. Surveyor asked R23 if staff offers to assist with shaving, R23 stated that no one has asked, and they prefer to be clean shaven. Surveyor asked R23 if they were getting their showers when they were supposed to, R23 reported that they believe that they have only had one shower since being at the facility.On 1/22/26 at 8:56 AM, Surveyor observed R23 in their room. R23 remains unshaven.Example 4R34 was admitted to the facility on [DATE] with diagnoses that include stroke, history of a liver transplant, hypertension (high blood pressure), and type 2 diabetes mellitus.R34's care plan dated 1/15/26 states in part .Focus: Decreased ability to perform ADLs (activities of daily living) related to recent functional decline d/t (due to) advanced age and multiple system involvement.Interventions/ Tasks: .Showering: [R34] is required to use extensive physical assist by 1 staff with showering twice weekly.Personal Hygiene: [R34] requires set- up assist by 1 staff with personal hygiene and oral care.R34's CNA Kardex states .Bathing: ADL- bathing schedule (Prefers Showers). Showering: [R34] is required to use extensive physical assist by 1 staff with showering twice weekly.R34's task documentation does not indicate R34's shower frequency or schedule. R34 has one documented shower that occurred on 1/16/26.It is important to note that R34's care plan and CNA Kardex do not address shaving and there is no documentation in R34's EHR that shaving was completed.On 1/21/26 at 10:50 AM, Surveyor interviewed R34 as part of the group interview. Surveyor noted that R34 had facial whiskers approximately 1/2 (half inch) long. Surveyor asked R34 if staff offers to assist with shaving, R34 stated that no one has asked, and they prefer to be clean shaven. R34 reported that they typically shave every 2-3 days at home. Surveyor asked R34 if they were getting their showers when they were supposed to, R34 reported that they believe that they have only had one shower since being at the facility.On 1/22/26 at 9:21 AM, Surveyor interviewed CNA F (Certified Nursing Assistant). Surveyor asked CNA F how they know when a resident is scheduled for a shower, CNA F stated that they would find the schedule on the shower sheet. Surveyor asked CNA F how often men get shaved, CNA F stated residents are shaved when they ask, or on their shower days. CNA F stated that they will look around the resident's room to see if they have shaving supplies and that they do not believe the facility has shavers or shaving cream.On 1/22/26 at 10:35 AM, Surveyor requested a tour of the supply room from CNA F. CNA F reported that there are two supply closets- one in the spa room and one in the storage room. Surveyor and CNA F toured the supply closet in the spa and noted there were disposable shavers and shaving cream in a bin on the shelf. CNA F reported to Surveyor that this was the first time they had ever seen shavers and shaving cream on the shelf. Surveyor and CNA F toured the storage room and found shavers and shaving cream in a bin on the shelf.On 1/22/26 at 10:39 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how the CNAs know which residents are on the schedule for a shower, DON B stated that it would be on their POCs (Point of Care) and they are on the shower schedule. Surveyor asked DON B if they would expect staff to document showers, DON B stated yes. Surveyor asked DON B if residents should be offered/ received showers on their scheduled days, DON B stated yes. Surveyor asked DON B what their expectation is for shaving facial hair, DON B stated that shaving should be offered on shower days and as needed.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 1 resident (R3) reviewed for transmission-based precautions.On 1/20/26 Surveyor observed staff entering and exiting R3's bedroom without wearing any PPE and sanitizing hands. R3 has a Contact Precautions sign hanging up outside of R3's bedroom. Evidenced by:CDC's (Centers for Disease Control and Prevention) most recent recommendations state;. Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.R3's current order states; Please implement contact precautions for shingles to right buttocks and right lower back/flank every shift.start date 1/2/26.The Contact Precautions sign outside of R3's bedroom states;.EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person.On 1/20/26 at 2:46 PM, Licensed Practical Nurse E (LPN) was observed entering R3's bedroom without any PPE (Personal Protective Equipment) and sanitizing hands before entering and exiting. Surveyor observed R3 to have a contact precautions sign outside bedroom and PPE. LPN E indicated R3 has shingles and staff only need to wear PPE when providing direct cares. LPN E indicated she was not providing direct cares. LPN E indicated the shingles has been going on since last week, so it might be scabbed over now too. LPN E indicated she would wear a gown, gloves, and mask if she was providing direct care. LPN E indicated she would also sanitize her hands if she was providing direct care. LPN E indicated she did go into R3's bedroom.It is important to note CDC's most recent recommendations state, Contact Precautions, use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning (putting on) PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.On 1/22/26 at 2:00 PM, Nursing Home Administrator A (NHA) indicated staff should follow contact precautions signs and recommendations. NHA A indicated understanding of the above concern.

Based on record review and interview the facility did not provide the accurate Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) thus did not provide the accurate potential financial liability to residents whose Medicare coverage was ending for 3 of 3 residents reviewed (R21, R38, and R39).R21, R38 and R39 were not provided SNFABN letters regarding financial liability. Evidenced by:Example 1:R21 was receiving Medicare A benefits. R21's Medicare coverage ended on 1/13/26. R21 was not provided the SNFABN form thus not provided with the accurate financial liability. Example 2:R38 was receiving Medicare A benefits. R38's Medicare coverage ended on 1/8/26. R38 was not provided the SNFABN form thus not provided with the accurate financial liability. Example 3:R39 was receiving Medicare A benefits. R39's Medicare coverage ended on 12/16/25. R39 was not provided the SNFABN form thus not provided with the accurate financial liability. On 1/21/26 at 11:45 AM, Licensed Practical Nurse G (LPN/Regional MDS Nurse Coordinator) stated the facility has no SNFABN for R21, R38, and R39. LPN G stated, the facility has not been completing any SNFABN's. Surveyor asked LPN G when this was noted. LPN G stated, on 1/20/26 after the entrance conference with Surveyors. LPN G stated the facility is educating the staff member that is responsible and is working to fix the issue.

Based on interview and record review, the facility did not follow their Discharge Planning Process for 3 of 3 residents (R1, R2, R3) reviewed for discharge planning. R1, R2, and R3 did not have a recapitulation of their stay after discharge. R3 did not have a discharge goal in his care plan. Evidenced by: The facility policy entitled Discharge Summary and Plan, dated 10/2022, states, in part: . Policy Statement: When a resident's discharge is anticipated, a discharge summary and post- discharge plan is developed to assist the resident with discharge. Policy Interpretation and Implementation: The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 3. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside; b. arrangements that have been made for follow-up care and services; c. a description of the resident's discharge goals; d. the degree of caregiver/support person availability, capacity and capability to perform required care; . 12. A copy of the following is provided to the resident and .a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. Example 1: R1 was admitted to the facility for a respite stay on 11/21/25 and discharged [DATE]. R1 has diagnoses that include progressive supranuclear palsy (a rare progressive brain disorder causing gradual deterioration of the nerve cells, affecting movement, speech, swallowing, and cognition) and encounter for palliative care (a specialized medical care focused on relieving symptoms, pain, and stress from serious illness). R1's care plan, dated 10/2/25, states, in part: . Focus: Preparing for discharge and requires coordination of care, education and resources to ensure safe and effective transition to the next care setting. Date initiated:11/24/25. R1's progress note dated 12/19/25 at 12:00 PM, states Ascorbic Acid Oral Tablet 500 mg (milligrams). Give 0.5 tablet by mouth three times a day for supplementation. (250mg) Take with food. discharged . Of note: this is the only entry put in on R1's discharge date . There is no discharge summary. In R1's medical record in Point Click Care under Assessments, it shows Discharge Summary and Recap of Stay. Due 12/29/25. Overdue by 28 days. This entry is highlighted in red. On 1/8/26 at 11:35 AM, Surveyor interviewed DON B (Director of Nursing) and asked DON B to explain the entry: Discharge Summary and Recap of Stay. Due 12/29/25. Overdue by 28 days. under assessments in Point Click Care highlighted in red. DON B indicated it was not completed. DON B indicated he would expect it to be completed on R1's discharge date , 12/19/25. Example 2: R3 was admitted to the facility on [DATE] and has diagnoses that include fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, and weakness. R3 discharged from facility on 12/29/25. R3's discharge instructions, dated [DATE] by R3, states, in part: . Date of discharge: [DATE]. Discharge to: home. Recommended Services: Home Health Agency Interim 1/12/2026, Physical Therapy Home Health, and Occupational Therapy Home Health. R3's progress notes for day of discharge, 12/29/25, includes: 12/29/25 12:56 AM, Note Text: Pain monitoring every shift using 1-10 narrative or FACE scale. Resident Pain Goal is:4 every shift. Generalized pain. 12/29/25 1:56 AM. Note Text: oxycodone hci (hydrochloride) oral tablet 5 mg. Give 1 tablet by mouth every 4 hours as needed for acute pain. Take 0.5-1 tablet every 4 hours as needed. 12/29/25 11:31 AM. Note Text: Acetaminophen Oral Tablet 325 mg. Give 2 tablets by mouth three times a day for pain management. Of note: there is no entry of a discharge summary or mention of discharge. R3's Care Plan dated 12/10/25 does not include a discharge goal. In R3's medical record in Point Click Care under Assessments, it shows Discharge Summary and Recap of Stay. Due 12/19/25. This entry is highlighted in red. On 1/8/26 at 11:35 AM, Surveyor interviewed DON B (Director of Nursing) and asked DON B to explain the entry: Discharge Summary and Recap of Stay, under assessments in Point Click Care highlighted in red. DON B indicated it was not completed. DON B indicated he would expect it to be completed on the day of discharge. Surveyor asked if he would expect residents' care plans to include a discharge goal. DON B indicated yes. Surveyor handed DON B R3's care plan and asked if R3 had a discharge goal in his care plan. DON B indicated no. Example 3 R2 was admitted to the facility on [DATE] with diagnosis that include urinary tract infection, muscle weakness, cognitive communications deficit, and vascular dementia. R2 was discharged from the facility on 12/22/25 to a private residence. R2's electronic medical record, under Assessments, it shows Discharge Summary and Recap of Stay. Due 12/19/25. This entry is highlighted in red and is unable to be opened. On 1/8/26 at 11:35 AM, Surveyor interviewed DON (Director of Nursing) B and asked DON B to explain the entry: Discharge Summary and Recap of Stay highlighted in red. DON B indicated this means it was not completed. DON B indicated he would expect it to be completed upon discharge. Facility did not complete the required discharge documentation for R1, R2, and R3.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were assessed for self-administration of medications for one of four residents (Resident (R) 6) reviewed for self-administration of medications out of 12 sample residents. Findings include:Review of the facility's policy titled, Administering Medications, last revised April 2019, revealed the policy statement, Medications are administered in a safe and timely manner, and as prescribed and Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.Review of R6's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia, anxiety disorder, chronic kidney disease stage 3A, and hypertension.Review of R6's care plan, dated 12/16/25 and located under the Care Plan tab of the EMR, revealed .has demonstrated a decreased ability to perform activities of daily living (ADLs) related to impaired mobility. Interventions in place, dated 12/16/25, included .currently requires set-up assist by one staff with eating.wears glasses, and wears hearing aids. Review of R6's assessments located under the Assessments tab of the EMR, revealed that R6 was not assessed for self-administration of medications.Review of all progress notes under the Progress Notes tab in the EMR, revealed that R6 was not assessed for self-administration of medications.Review of the orders located under the orders tab of the EMR revealed no orders related to self-administration of medication. Review of the Medication Administration Record (MAR) located under the orders tab of the EMR, revealed R6 had a physician's order for Ipratropium Bromide Nasal Solution 0.06 % (Ipratropium Bromide (Nasal)) two spray in both nostrils three times a day for seasonal allergic rhinitis, start date 12/16/25.During an observation for medication administration for R6 and interview on 12/23/25 at 7:46 AM, while Registered Nurse (RN) 1 was pulling the morning medications to administer to R6, RN1 stated, I don't have the nasal spray in the cart because usually the other nurses leave the nasal spray in the resident's room because she can do it by herself. During this observation, R6 picked up the nasal spray from a white box located on top of her bedside table and administered the nasal spray in front of RN1.During an observation and interview on 12/23/25 at 8:02 AM, when asked what the white bottle was on her bedside table, R6 stated, that's my nasal spray. They leave it there because I have been using nasal spray for a long time and I can do it on my own. R6 proceeded to demonstrate how she had to hold the right nostril closed as she sprayed in the left nostril and then she demonstrated how to spray in the right nostril.During an interview on 12/23/25 at 3:50 PM, the Director of Nursing (DON) stated that when a resident was able to administer their own medications, this would be documented in the assessments tab of the EMR, it will also be care planned, and they had an Interdisciplinary Team (IDT) meeting progress note stating that the resident was able to self-administer their own medications.

Based on interview, record review, and policy review, the facility failed to ensure professional standards were in place for ensuring medication administered was not borrowed from another resident for one of six residents (Resident (R) 9) reviewed for professional standards and medication administration of 12 sample residents. This failure had the potential to affect the potential for negative outcome for 26 residents currently residing in the skilled nursing floor of the facility.Findings include:Based on review of a facility reported incident submitted to the State Agency (SA) on 08/12/25 and provided by the facility, revealed that narcotic pain medication ordered for one resident was administered to another resident. The facility's investigation revealed that R9 was administered physician-ordered narcotic pain medication for R8.Evidenced by:Review of the facility's policy titled, Medication Administration, last revised on 04/19, revealed that the facility's policy statement was Medications are administered in a safe and timely manner, and as prescribed. The policy further revealed, Policy Interpretation and Implementation item number eight stated, if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Item number nine stated, The individual administering medication verifies the resident's identity before giving the resident His/her medications. Methods of identifying the resident include: a. checking the identification band; b. checking photograph attached to medical record; and if necessary, verifying resident identification with other facility personnel. Item number ten stated, The individual administering the medication checks the label THREE (3) ties to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. And item number 26 stated, Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services. Example 1Review of R8's admission Record located under the Profile tab of the electronic medical record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses that included pain left knee, pain in left hip, type two diabetes, solitary pulmonary nodule, panic disorder, difficulty walking, and cognitive communication deficit.Review of R8's Order Summary Report under the Orders tab of the EMR, revealed that R8 had a physician's order on 07/16/25, for oxycodone HCl [hydrochloric acid] Oral Tablet 5 MG [milligram] (Oxycodone HCl) Give 0.5 tablet by mouth every six hours as needed for pain (2.5MG).Review of R8's Medication Administration Record (MAR) located under the Orders tab of the EMR, dated 08/08/25, revealed R8 was not administered the narcotic pain medication, oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 0.5 tablet by mouth every six hours as needed for pain.Review of R8's Controlled Drug Use Record for the narcotic pain medication, Oxycodone 5 milligram tablet Instant release (I.R.), revealed that two tablets were withdrawn from R8's medication card on 08/08/25 at 7:00 PM by Registered Nurse (RN) 2 with a note under the signature that revealed, it's given to R9 (Administrator knows this borrowing the medication for the resident).Example 2Review of R9's admission Record located under the Profile tab of the EMR revealed R9 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, cognitive communication deficit, muscle weakness, chronic embolism and thrombosis of unspecified deep veins of left lower extremity, primary insomnia, non-rheumatic aortic (valve) stenosis, lumbago with sciatica on the left side, and sciatica on left side. Review of R9's Order Summary Report located under the Orders tab of the EMR, revealed R9 had a physician's order on 08/08/25, for oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) (a narcotic pain medication). Give one tablet by mouth every four hours as needed, for pain.Review of R9's MAR located under the Orders tab of the EMR, revealed that R9 was administered the narcotic pain medication, oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give one tablet by mouth every four hours as needed for pain, on 08/08/25 at 6:52 PM. This record also revealed that R9 had a pain level of 9/10, indicating that R9 was experiencing strong/severe pain at that time.Review of the five-day investigation report that was signed on 08/19/25 by the Regional Registered Nurse (RRN) and provided by the facility, revealed that on 08/11/25, during a routine audit, it was discovered that two 5MG Oxycodone tablets were withdrawn from R8's medication card and these two tablets were administered to R9. This investigation further revealed that the two Oxycodone physician orders for the two residents were not the same. R8 had an order for five milligram Oxycodone tablets and R9 had an order for ten milligram Oxycodone tablets. This investigation further revealed that Administrator (ADM) 2 gave instructions to RN2 to remove two Oxycodone tablets from R8's supply and administer these two Oxycodone tablets to R9. During an interview on 12/22/25 at 4:34 PM, RN2 stated, I did give medication from another patient to give to R9. I do remember that the patient I borrowed from, they don't use their pain medication on a daily basis. I had this other patient that was in big pain, and the family was not happy. When asked if she checked if the dosage of the two orders were the same, RN2 stated, Yes, I did check definitely. Oxycodone 5 milligram tablets I pulled but I really cannot remember now what exactly the dosage was. When asked if she knew the effects of narcotic pain medication, she stated, drowsiness, respiratory distress, mood changes, and nausea. RN2 further stated, I have never done this before with other residents. When asked what prompted her to do what she did, she stated, when I spoke with [ADM2], she was trying to solve a crisis over the phone. I asked if it was going to be a problem and [ADM2] said that it would be okay. (RN2 pulled out her personal telephone and showed a picture of a section of R8's 'Controlled Drug Use Record') while she stated, I pulled the medication oxycodone at 1900 on 08/08/25. When asked if she would consider this action a medication error, she stated, Well, in my honest opinion, I thought I was trying to solve a crisis, the patient just came from the hospital and the family was upset, at the time I didn't think that it was a medication error, because I was trying to solve a problem because the patient was in big pain. I realized that it was a medication error, but my Administrator [ADM2] said it was going to be okay, so I trusted her. I don't mean to blame her [ADM2], but she told me it was going to be okay, otherwise, I wouldn't have given the medication to [R9].During an interview on 12/23/25 at 3:49 PM, the Director of Nursing (DON) stated, there was a new admit and I was not in the building at the time it happened. [ADM2] called me and I told her there was not much I could do from where I was at. I was out of town. [RN2] was the only nurse in the building because the census was enough for one nurse. Education was provided to [RN2] to prevent this from happening again and the Controlled Drug Use Record pages are now spiral bound and no longer kept in a binder.

Based on interviews, record review, and review of professional standards of practice, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 1 of 5 sampled residents (R1). R1 has diagnoses of CHF (congestive heart failure) and had orders for daily weight for monitoring of CHF. The facility did not monitor daily weights. Evidenced by:The facility policy entitled Weight Assessment and Intervention, dated 3/22, states, in part: . Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain. Policy Interpretation and Implementation: Weight Assessment. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record.3. any weight change of 5% or more since last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietician in writing.5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months- 10% weight loss is significant; greater than 10% is severe. The facility policy entitled Change in a Resident's Condition or Status, dated 2/21, states, in part: . Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation:1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition; e. needs to alter the resident's medical treatment significantly, f. refusal of treatment or medications two (2) or more consecutive times.2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff. c. requires interdisciplinary review and/or revision to the care plan. R1 admitted to the facility on [DATE] and has diagnoses that include fracture of first lumbar vertebra, CHF (a condition where the heart muscle is weakened and cannot pump blood effectively), cognitive communication deficit, and type 2 diabetes mellitus (Chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels). R1's NP (nurse practitioner) Nursing Facility Acute Visit, dated 8/13/25, states, in part: . Assessment and Plan: . No weights documented since 7/20/25. Obtain updated weight tomorrow morning and daily thereafter for CHF (Congestive Heart Failure) . R1's Telephone order dated 8/13/25, states: Please obtain updated weight tomorrow morning on 8/13/25 and daily thereafter for CHF. R1's Physician Orders, dated 10/08/25, states, in part: . Daily Weight one time a day for monitoring due to CHF. Call NP if weight gain/loss 3 lbs. in a day OR 5lbs. in a week. Start Date: 7/11/25. R1's MAR (Medication Administration Record) for July, August, September, and October of 2025 shows:-Daily weight one time a day for monitoring due to CHF. Call NP if weight gain/loss 3 lbs. (pounds) in a day OR 5 lbs. in a week. Start Date: 7/11/25. D/C (discontinue) Date: 10/15/25.Note: MARS are showing R1's weight was completed on some days, refused on some days, held on some days, and marked as other/see progress notes on some days. R1's weight record in medical record shows the following weights recorded as:-7/16/25 281.4 lbs.-7/20/25 280.0 lbs.-8/20/25 280.0 lbs.-9/14/25 265.0 lbs.-9/23/25 238.0 lbs.Of note: Weights are not being obtained daily as physician ordered. R1 had a weight loss of 43.4 lbs. in three months. R1's Progress Note dated 8/17/25 at 4:11 PM states: Daily Weight one time a day for monitoring due to CHF Call NP if weight gain/loss 3 lbs. in a day OR 5 lbs. in a week.Physical Therapist told aides that he must have a back brace on and to not attempt to get him up for his weight; they will do it. On 10/23/25, at 11:20 AM, Surveyor spoke with PTD C (Physical Therapy Director) who indicated therapy does not weigh the residents. Surveyor read the progress note to PTD C regarding PT telling aides to not attempt to get R1 up to weigh that PT will do it. PTD C indicated he does not know where that note came from and assured Surveyor therapy does not weigh residents regularly. On 10/23/15, at 2:16 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if he was aware R1 had an order for a daily weight for monitoring of CHF, and DON B indicated yes. Surveyor asked DON B if he would expect physician's orders to be followed and DON B indicated yes. Surveyor reviewed R1's weights that were documented with DON B and asked if there were weights documented somewhere else. DON B indicated no. DON B indicated R1 refuses weights and has issues with orthostatic blood pressures. DON B indicated whenever staff wants to get R1 up R1 gets nauseated and refuses. Surveyor asked DON B if R1's physician was updated on refusals. DON B indicated R1's physician had been working on getting orthostatic blood pressures under control at some point. Surveyor asked DON B if he would expect documentation of refusals in R1's medical record for refusal of weights, and DON B indicated yes. DON B indicated he had a conversation with R1's NP but he does not think it was documented. DON B indicated he would look for documentation to support the physician was aware of refusals. Surveyor asked if DON B would expect physician notification of daily ordered weights for a resident with CHF not being done and the reason. DON B indicated yes.

Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 3 residents (R1) reviewed for nutrition. R1 had a severe weight loss of 15.3% in 2 months. The facility did not complete daily weights as ordered or notify physician. Evidenced by:The facility policy entitled Weight Assessment and Intervention, dated 3/22, states, in part: . Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain. Policy Interpretation and Implementation: Weight Assessment. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record.3. any weight change of 5% or more since last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietician in writing.5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months- 10% weight loss is significant; greater than 10% is severe. R1 admitted to the facility on [DATE] and has diagnoses that include fracture of first lumbar vertebra, CHF (a condition where the heart muscle is weakened and cannot pump blood effectively), cognitive communication deficit, and type 2 diabetes mellitus (Chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels). R1's Physician Orders, dated 10/08/25, states, in part: . Daily Weight one time a day for monitoring due to CHF. Call NP if weight gain/loss 3 lbs. in a day OR 5lbs. in a week. Start Date: 7/11/25. R1's MAR (Medication Administration Record) for July, August, September, and October of 2025 shows:-Daily weight one time a day for monitoring due to CHF. Call NP if weight gain/loss 3 lbs. (pounds) in a day OR 5 lbs. in a week. Start Date: 7/11/25. D/C (discontinue) Date: 10/15/25.Note: MARS are showing R1's weight was obtained on some days, refused on some days, held on some days, and lists other/see progress notes on some days. R1's weight record in medical record shows the following weights recorded as:-7/16/25 281.4 lbs.-7/20/25 280.0 lbs.-8/20/25 280.0 lbs.-9/14/25 265.0 lbs.-9/23/25 238.0 lbs.Of note: Weights are not being obtained daily as physician ordered. R1 had a weight loss of 43.4 lbs. in three months. This is a severe weight loss. On 10/23/15, at 2:16 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if he was aware R1 had an order for a daily weight for monitoring of CHF, and DON B indicated yes. Surveyor asked DON B if he would expect physician's orders to be followed and DON B indicated yes. Surveyor reviewed R1's weights that were documented for R1 with DON B and asked if there were weights documented somewhere else. DON B indicated no. DON B indicated R1 refuses weights and has issues with orthostatic blood pressures. DON B indicated whenever staff wants to get R1 up R1 gets nauseated and refuses. Surveyor asked DON B looking at R1's weight on 9/14/25 being 265.0 lbs. from 280.0 lbs. on 8/20/25, that is a weight loss of 15 lbs. in one month. Is that a severe weight loss and DON B indicated yes. Surveyor asked DON B if he would expect physician to be notified of severe weight loss and DON B indicated yes. Surveyor asked DON B if R1's physician was updated on weight loss and refusals. DON B indicated the physician should have been updated. R1's physician had been working on getting orthostatic blood pressures under control at some point. DON B indicated he had a conversation with R1's NP but he does not think it was documented. Surveyor asked DON B if he would expect documentation of refusals in R1's medical record for refusal of weights, and DON B indicated yes. DON B indicated he would look for documentation to support the physician was aware of refusals and weight loss. Surveyor asked DON B if risks and benefits had been explained to R1 regarding refusal of weights and DON B indicated no. On 10/23/25, at 3:30 PM, DON B indicated to Surveyor the facility does not have any notification that NP or physician was updated on weight loss.

Based on interviews and record review, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 5 of 6 residents (R5, R8, R9, R10 and R1). R5, R9, R10 and R1's vital signs were not completed as ordered. R8, was admitted to the facility with orders for daily vital signs. The facility did not complete these physician's orders as ordered and assess the Residents' vital signs daily. This is evidenced by: The facility policy entitled, Resident Examination and Assessment, dated 02/2014, states, in part: Purpose: The purpose of this procedure is to examine and assess the resident for any abnormalities in heath status, which provides a basis for the care plan . Physical Exam: 1. Vital Signs: a. blood pressure (standing and sitting); b. pulse (carotid); c. respirations; and d. temperature . Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 3. All assessment date obtained during the procedure . 5. If the resident refused the procedure, the reason(s) why the intervention taken .Reporting: . 2. Notify the physician of any abnormalities such as, but not limited to: a. abnormal vital signs . The facility policy entitled, Blood Pressure, Measuring, dated 09/2010, states, in part: . Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the blood pressure was measured . 3. The blood pressure reading. 4. If the resident refused the treatment, the reason(s) why and the intervention taken . The facilities Policy and Procedure entitled Charting and Documentation dated July 2017 documents, in part: .2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives . Example 1 R5 was admitted to the facility on [DATE], and has diagnoses that include: periprosthetic fracture around internal prosthetic left hip joint (fracture around a prosthetic hip), muscle weakness, type 2 diabetes, salmonella sepsis, hypertension (high blood pressure), atrial flutter (irregular heart rhythm). R5's Admission Minimum Data Set (MDS) Assessment, with Assessment Reference Date (ARD) of 11/28/24, shows R5 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating R5 is cognitively intact. R5's physician orders state, in part: Medicare charting and Daily vital signs in the morning. Order Status: Active. Start date: 11/30/24. R5's Vital Sign records from November 2024 through January 2025 state, in part: Blood Pressure, Pulse, Respiratory Rate, and Temperature were not recorded on: 12/3/24, 12/7/24, 12/14/24, 12/18/24, 12/19/24, 12/20/24 12/23/24, 12/24/24, 12/25/24,12/31/24, 1/2/25, Example 2 R8 was admitted to the facility on [DATE], and has diagnoses that include, in part: osteomyelitis of vertebra-sacral and sacrococcygeal region (infection of the bones of the spine in the lower back), hypertension (high blood pressure). R8's Admission Minimum Data Set (MDS) Assessment, with Assessment Reference Date (ARD) of 11/14/24, indicates a Brief Interview of Mental Status (BIMS) should be conducted, however the assessment has not been completed and no score was provided. R8's physician orders state, in part: Medicare charting and Daily vital signs in the morning. Order Status: Active. Start date: 11/30/24. R8's Vital Sign records from November 2024 through January 2025 state, in part: Blood Pressure, Pulse, Respiratory Rate, and Temperature were not recorded on: 12/4/24, 12/7/24 12/19/24, 12/20/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/30/24 Example 3 R9 was admitted to the facility on [DATE], and has diagnoses that include, in part: dysarthria following cerebral infarction (difficulty forming words due to a stroke), hypertension (high blood pressure), and pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit. R9's Admission Minimum Data Set (MDS) Assessment, with Assessment Reference Date (ARD) of 11/19/24, indicates a Brief Interview of Mental Status (BIMS) shows R9 has a Brief Interview of Mental Status (BIMS) score of 7 out of 15 indicating severe cognitive impairment. R9's physician orders state, in part: Medicare charting and Daily vital signs in the morning. Order Status: Active. Start date: 11/30/24. R9's Vital Sign records from November 2024 through January 2025 state, in part: Blood Pressure, Pulse, Respiratory Rate, and Temperature were not recorded on: 12/3/24, 12/7/24, 12/14/24, 12/19/24, 12/20/24, 12/21/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/31/24, 1/2/25, 1/4/25, 1/6/25, 1/8/25, 1/9/25, 1/10/25,1/12/25. Example 4 R10 was admitted to the facility on [DATE], with diagnoses that include, in part: metabolic encephalopathy (brain dysfunction caused by an underlying condition), decreased white blood cell count (white blood cells fight infections), and atrial fibrillation (irregular heart rhythm). R10's Admission Minimum Data Set (MDS) Assessment, with Assessment Reference Date (ARD) of 11/17/24, indicates a Brief Interview of Mental Status (BIMS) shows R9 has a Brief Interview of Mental Status (BIMS) score of 7 out of 15 indicating severe cognitive impairment. R10's physician orders state, in part: Medicare charting and Daily vital signs in the morning. Order Status: Active. Start date: 11/30/24. R10's Vital Sign records from November 2024 through January 2025 state, in part: Blood Pressure, Pulse, Respiratory Rate, and Temperature were not recorded on: 12/1/24, 12/2/24, 12/3/24, 12/14/24, 12/16/24, 12/18/24, 12/19/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/31/24, 1/1/25, 1/2/25, 1/3/25, 1/4/25, 1/5/25, 1/8/25, 1/9/25, 1/10/25,1/12/25. On 1/15/25 at 11:01 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if physician orders should be followed. DON B states, yes. Surveyor asked DON B if someone has an order for daily vitals, should their vitals be taken daily. DON B states, yes. Surveyor asked DON B what the expectation is for when a resident refuses vitals. DON B indicates, a progress note or some sort of documentation should be completed that the resident refused and a physician would need to be notified on a case-by-case basis. Surveyor asked DON B if R5, R8, R9, and R10, all who have orders for daily vitals, should have their vital signs documented daily. DON B states, yes. The facility failed to complete physician orders as ordered and complete daily vital signs for R5, R8, R9, R10. 38725 Example 5 R1 admitted to the facility 12/20/24. R1 has the following diagnoses: cellulitis of left lower limb (soft tissue infection), paroxysmal atrial fibrillation (irregular heartbeat), and essential (primary) hypertension (high blood pressure). R1's Physician Orders document: 12/20/24 Check blood glucose four times daily and as needed. Notify physician if blood glucose <60 or >350. before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED (E11.40) 12/22/24 Check blood glucose four times daily and as needed. Notify physician if blood glucose <60 or >350. before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED (E11.40) AND as needed for diabetes check prn if symptomatic of hypo or hyperglycemia. 12/27/2024 Daily Vital Signs and Medicare charting AM every day shift. It is important to note that R1 admitted to this facility on a skilled care stay, this requires documentation daily surrounding R1's skilled care needs. R1's Vital Sign (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation) Record log documents vital signs every day except 12/22/24. R1's Assessments contain a template for Medicare Follow up and Clinical Follow up: Clinical Follow Up- 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24. Medicare templates- 12/26/24, 12/30/24, 12/31/24, 1/2/25, 1/3/25, 1/7/25, 1/8/25. It is important to note that there is no Medicare documentation on 12/20/24, 12/21/24, 12/27/24, 12/28/24, 12/29/24, 1/1/25, 1/4/25, 1/5/25, and 1/6/25. R1's MAR (Medication Administration Record) documents the following: Blank boxes- 12/20/24 at 1200 (12 PM), 1700 (5 PM), and 2100 (9 PM). Of note there is a documented blood sugar on 12/20/24 in R1's Vital Sign Record at 2335 (11:35 PM). Check marks (indicating task completed)- 12/21/24 for 0700 (7 AM), 1200, 1700 and 2100. It is important to note that the only recorded result for R1's blood sugar on 12/21/24 is at 2258 (10:58 PM), there is no blood sugar result recorded in R1's medical record on 12/21/24 for 0700, 1200, or 1700. On 1/15/25 at 11:00 AM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D what a blank box on MAR would mean, LPN D said he didn't know as he had never seen that before. On 1/15/25 at 11:24 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how often should Medicare charting be completed, DON B said daily. Surveyor asked DON B what format is used for Medicare charting, DON B stated a template, Medicare Charting template or Clinical Follow Up template. Surveyor asked DON B what the Clinical Follow Up template entails, DON B explained that it is a focused template for the issue at hand. On 1/15/25 at 1:29 PM, Surveyor interviewed LPN D. Surveyor asked LPN D how often Medicare charting is to be completed, LPN D said once a day. Surveyor asked LPN D what format is used for Medicare charting, LPN D stated template. On 1/15/25 at 3:06 PM, Surveyor interviewed DON B. Surveyor asked DON B what a blank box on MAR would mean, DON B stated she was unsure, she would need to see what was being referenced. Surveyor showed DON B on MAR. Surveyor asked DON B if that could mean that the order wasn't done, DON B replied possibly. Surveyor asked DON B if staff should follow Physician orders as written, DON B stated yes.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 1 of 10 residents (R3) reviewed for abuse. R3's POA (Power of Attorney) voiced concerns and possible neglect during R3's stay from 11/1/24-11/4/24. NHA A (Nursing Home Administrator) initiated investigation, followed up with R3 and POA, but failed to interview other residents to ensure there were no other allegations or concerns. Evidence by: The facility policy, Abuse Neglect, Exploitation and Misappropriation Prevention Program, dated 2021, states, in part; .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property . R3 was admitted to the facility 11/1/24 with a diagnoses of respiratory failure, heart disease, kidney failure, major depressive disorder, weakness, diabetes, and difficulty in walking. R3 has an activated power of attorney. Facility self-report to state agency, states, in part; .date discovered 11/7/24 .resident was admitted from hospital on 11/1 and returned to hospital on 11/4. On 11/7 facility received a report from the hospital that resident's daughter had made an allegation of neglect. Upon investigation, no evidence of neglect was found, and when asked for a statement, resident's daughter stated that she only called it neglect because she felt like her mother was not getting enough attention. Vitals remained stable during patients stay. NHA was in frequent contact with daughter over the weekend in question with no concerns of neglect. Patient remained at baseline during her stay. Allegation is unsubstantiated with no negative outcomes .NHA visited resident at least twice during the weekend from 11/1 to 11/4. Resident made no complaints of neglect and seemed generally satisfied Resident was sent to hospital on 11/4 and has not returned . On 1/14/25 at 2:40PM, POA C (Power of Attorney) indicated she had talked with NHA A in regards with her concerns with R3's stay. POA C indicated she emailed concerns as well. POA C indicated she did talk with the NHA A the weekend of 11/1/24 and then further on 11/7/24 when he called to ask further questions about neglect. POA C indicated she didn't realize that by her saying neglect there would be an investigation, but she did have concerns with her mother's stay. POA C indicated she would send the Surveyor the email she sent NHA A with the concerns. POA C indicates staff told her that they were short staffed and doing the best they could do that weekend. POA C indicated her mother will never go back to the nursing home. POA C indicated she expected her mother to receive the very basic level of care, and she did not feel she received that while at the facility. POA C indicated the NHA A did not follow up further with her concerns and allegation of neglect. Surveyor reviewed POA C's list of concerns that was sent to the NHA A on 11/8/24 .states, in part; .When the doctors asked me what happened over the weekend, I told them what I observed. I called it neglect as a person that can't move their arms nor legs and can't even push an alert button needs more attention and I don't believe she received that. Plus, she said herself that she was neglected thus her comment on being miserable . On 1/15/25 at 1:45PM, NHA A (Nursing Home Administrator) indicated NHA A reviewed hospital notes on 11/7/24 indicating R3's POA voiced concern with neglect at the facility when R3 was there on 11/1/24-11/4/24. NHA A contacted R3's POA and NHA A indicated that POA stated she did not mean neglect and that she was concerned with R3 not getting attention from staff. NHA A stated he then asked for a written statement from R3's POA. NHA A reported possible neglect to State Agency and initiated investigation. NHA A collected written statements from staff that had worked on 11/2/24. NHA A indicated he also saw R3 in bedroom being assisted with eating and staff assisting her on 11/2/24. NHA A indicated he had multiple texts with POA on 11/2/24 and 11/3/24. NHA A indicated he did not interview other residents regarding concerns with neglect because R3's POA indicated she did not mean neglect. NHA A indicated he did receive written statement from POA. Surveyor asked NHA A if he reviewed the written statement. NHA A found written statement in his emails and stated that he wouldn't have done anything further because the POA indicated she did not mean neglect when he followed up with her on 11/7/24 and she did not voice neglect when he talked to throughout the weekend of 11/1/24. NHA A indicated moving forward he will interview a sample of residents while working through an investigation. The facility failed to ensure all alleged violations of abuse, neglect, exploitation, or mistreatment, are thoroughly investigated to ensure safety of all residents.

Based on interview and record review the facility did not ensure residents are free of any significant medication errors for 1 of 3 residents (R1) reviewed for medications. R1 had 8 medications not administered for a duration of time in December and January that could lead to significant negative outcome. This is evidenced by: The facilities Policy and Procedure entitled Administering Medications dated April 2019, documents, in part: .4. Medications are administered in accordance with prescriber orders, including any required time frame . The facilities Policy and Procedure entitled Adverse Consequences and Medication Errors dated February 2023, documents, in part: .Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include: a. Omission- a drug is ordered but not administered .3. A significant medication-related error is defined as .b. Requiring hospitalization , or extending a hospitalization .e. Resulting in cognitive deterioration or impairment f. Life threatening . The facilities Policy and Procedure entitled Charting and Documentation dated July 2017 documents, in part: .2. The following information is to be documented in the resident medical record .Medications administered . Example R1 admitted to the facility 12/20/24. R1 has the following diagnoses: cellulitis of left lower limb (soft tissue infection), hyperlipidemia (high cholesterol), paroxysmal atrial fibrillation (irregular heartbeat), type 2 diabetes mellitus with diabetic neuropathy, epilepsy (seizure disorder), chronic pain, essential (primary) hypertension (high blood pressure), portal vein thrombosis (narrowing or blocking of the portal vein (to liver) by a blood clot), benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), personal history of transient ischemic attach (TIA) (brief stroke-like attack) and cerebral infarction without residual deficits (stroke), and secondary gout (form of arthritis). R1's Discharge Medication List to the facility included: Insulin Glargine 20 units daily for diabetes mellitus Semaglutide 14 mg (milligrams) daily for diabetes mellitus Zonisamide 300 mg daily for seizure Apixaban 5 mg twice daily for paroxysmal atrial fibrillation Levetiracetam 1750 mg twice daily for seizures Mycophenolate 180 mg twice daily for antirejection of organ transplant Tacrolimus 1 mg twice daily for antirejection of organ transplant Ursodiol 500 mg twice daily for liver transplant recipient/bile flow Atorvastatin 10 mg (milligrams) daily for hyperlipidemia Baclofen 10 mg daily for muscle spasms Colchicine 0.6 mg daily for gout Gemtesa 75 mg daily for BPD Nystatin cream daily for yeast Miralax 17 G (grams) daily for constipation Terazosin 2 mg daily for BPH Acyclovir 400 mg twice daily for herpes simplex Penicillin V potassium 500 mg twice daily related to ankle hardware Pregabalin 100 mg three times per day for chronic pain R1's MAR (Medication Administration Record) documents the following: Of note, per chart codes 9= other/see progress notes Insulin Glargine: 9- 12/21/24 Semaglutide: 9- 12/21/24, 12/22/24, 12/23/24, 12/26/24, 12/27/24, 12/28/24 Zonisamide: 9- 12/21/24, 1/5/25 Apixaban: blank- 2000 (8 PM)- 12/20/24; 9 0800 (8 AM)- 12/21/24, 2000- 12/22/24, 12/23/24, 12/25/24, 12/26/24 Levetiracetam: blank- 2000- 12/20/24; 9- 0800- 12/21/24, 12/22/24, 12/23/24, 2000- 12/22/24, 12/23/24 Mycophenolate: blank- 2000- 12/20/24; 9- 0800- 12/21/24 Tacrolimus: blank- 1600 (4 PM)- 12/20/24; 9- 0800- 12/21/24, 12/23/24, 1600- 12/21/24, 12/22/24, 12/23/24 Ursodiol: blank- 2000- 12/20/24; 9- 0800- 12/21/24, 12/22/24, 12/23/24, 12/24/24, 1600- 12/21/24, 12/22/24, 12/24/24, 12/25/24, 12/27/24, 12/30/24 Of note, per chart codes 5= hold/see progress notes, 9= other/see progress notes Atorvastatin: blank- 12/20/24; 9- 12/22/24, 12/23/24, 12/25/24 Baclofen: blank- 12/20/24; 9- 12/25/24, 12/26/24 Colchicine: 9- 12/21/24, 12/24/24 Gemtesa: 9- 12/21/24 Nystatin: 9- 12/21/24, 12/23/24 Miralax: 9- 12/22/24 Terazosin: blank- 12/20/24; 9- 12/25/24 Acyclovir: blank- 2000 (8 PM)- 12/20/24; 9- 0800 (8 AM)- 12/21/24, 2000- 12/25/24 Penicillin V potassium: blank- 2000- 12/20/24; 9- 0800- 12/21/24, 12/22/24, 12/23/24, 2000-12/22/24, 12/23/24, 12/25/24 Pregabalin: blank- 1600 (4 PM)- 12/20/24, blank- 2000- 12/20/24; 9- 0800- 12/21/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 1600- 12/21/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 2000- 12/21/24, 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24; 5- 1600- 12/22/24 It is important to note that none of the above medications were administered to R1 on the date and times listed and there was no Physician notification made regarding this. Adverse reactions R1 could experience by not receiving these medications include, but not limited to: Insulin glargine and semaglutide- elevated blood sugars, diabetic ketoacidosis (blood sugar gets so high that your blood become acidic), etc. Zonisamide and Levetiracetam- seizures, suicidal ideations, etc. Abixaban- increased risk for blood clots, increase risk of stroke, etc. Mycophenolate, Tacrolimus, and Ursodiol- increased risk of organ rejection, graft organ could fail, etc. On 1/15/25 at 11:00 AM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D what 9 means on MAR, LPN D stated wasn't given and reason documented in progress note. Surveyor asked LPN D if 9 is documented should there be a progress note, LPN D replied there should be one. Surveyor asked LPN D what a blank box on MAR would mean, LPN D said he didn't know as he had never seen that before. On 1/15/25 at 11:15 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what 9 means on MAR, DON B said other/see progress note. Surveyor asked DON B if 9 is documented should there be a progress note, DON B said reason should be in progress note, but with Agency here, I'm just not sure, and there's another number that means something similar. Of note, Surveyor reviewed chart codes 5 says hold/see progress notes. On 1/15/25 at 3:06 PM, Surveyor interviewed DON B. Surveyor asked DON B what a blank box on MAR would mean, DON B stated she was unsure, she would need to see what was being referenced. Surveyor showed DON B on MAR. Surveyor asked DON B if that could mean that the order wasn't done, DON B replied possibly. Surveyor asked DON B if staff should follow Physician orders as written, DON B stated yes. Surveyor asked DON B should medications be given as ordered, DON B stated yes. Surveyor asked DON B if a medication isn't available what would you expect the nurses to do, DON B explained the nurse should check the automatic dispensing unit and give from there. Surveyor asked DON B what if the medication is not in the automatic dispensing unit, DON B said then they would need to call pharmacy and administer it when it was delivered. Surveyor asked DON B what if the automatic dispensing unit doesn't have it and neither does the pharmacy, DON B explained that the pharmacy would give the facility a paper about the medication and the facility would send that to the Physician. Surveyor asked DON B if medications not administered would be medication errors, DON B stated yes.

Based on observation, staff interview, and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect all 14 residents residing in the facility. Cook (CK)-F did not wear an appropriate hair covering. Raw meat was stored in a manner that had the potential to cross-contaminate other food items. Findings include: The Wisconsin Food Code documents at Hair Restraints 2-402.11 Effectiveness: (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils and linens; and unwrapped single-service and single-use articles. The facility's Hair Restraints policy, with a revision date of 7/13/24, indicates: Hair must be pulled back and properly restrained when working with exposed food, clean equipment, utensils, linens, and unwrapped single service and single-use articles .Hair nets, bouffant caps, or bandana style hair coverings may be used for long or full hair not completely restrained by a hat. The Wisconsin Food Code documents at Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (a) Using separate equipment for each type, or (b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented, and (c) Preparing each type of food at different times or in separate areas. The facility's Food Storage policy, with a revision date of 5/1/24, indicates: Uncooked and raw animal products and fish are stored on drip-proof pans under ready-to-eat foods, dairy, and produce. On 9/16/24 at 9:45 AM, Surveyor conducted a tour of the kitchen accompanied by Dietary Manager (DM)-D and Dietetic (DT)-E who indicated the facility followed the Wisconsin Food Code. Upon entering the kitchen, Surveyor observed CK-F in the food preparation area with a hat and hair net that covered the top of CK-F's head to CK-F's earlobes. CK-F had long hair that extended past the center of CK-F's back which was not covered by a hair restraint. On 9/16/24 at 10:10 AM, Surveyor interviewed DM-D who confirmed CK-F's hair should be covered. DM-D retrieved a larger hair net and provided the hair net to CK-F. On 9/16/24 at 10:15 AM, Surveyor entered the walk-in cooler which contained a rack of four shelves that were not solid. The bottom shelf contained a cardboard box of raw ground hamburger that was thawed and wrapped in plastic. Next to the box of raw hamburger was a cardboard box of thawed boneless chicken breasts in an open plastic bag. The shelf above contained a cardboard box of thawed raw chicken thighs in an open plastic bag. Sweet potatoes were stored on the same shelf as the raw chicken. None of the boxes of raw meat contained equipment to prevent cross-contamination from dripping below or adjacent to the raw meat. Surveyor observed a sign on the walk-in cooler door with a diagram of the shelving unit that indicated how to store food. The sign indicated: Top-Ready to eat. Next down-Any food that will be hot held not in other categories. Next down-Whole seafood, beef, pork, veal, lamb, roasts, shell eggs. Next down-Ground, injected, tenderized meats. Bottom-All poultry-chicken, turkey, duck, fowl. On 9/16/24 at 10:16 AM, Surveyor interviewed DM-D who indicated kitchen staff usually place a sheet pan under foods that are thawing. DM-D confirmed the raw meat should be placed in a different arrangement to prevent cross-contamination. DM-D moved the raw chicken to the bottom rack and the raw hamburger up one rack and above the raw chicken. DM-D placed the sweet potatoes at the top of the shelving unit. DM-D confirmed the raw chicken should have been stored on the bottom shelf.

Based on observation, staff interview, and record review, the facility did not ensure medications were accurately labeled for 2 residents (R) (R10 and R3) of 2 residents observed during medication administration. In addition, the facility did not ensure medications for 4 (R2, R6, R120, and R1) residents in 1 of 1 medication cart were disposed of when beyond the expiration date. During observations of medication administration, Licensed Practical Nurse (LPN)-G administered open and undated medication to R10 and R3. The facility's medication cart contained open and undated medications for R2, R6, R120, and R1. Findings include: The facility's Administering Medications policy, dated 4/2019, indicates: Medications are administered in a safe and timely manner, and as prescribed .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. The facility's Medication Labeling and Storage policy, dated 2/2023, indicates: The facility stores all medication and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys .Medication Labeling: .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 1. On 9/17/24 at 8:20 AM, Surveyor observed LPN-G prepare insulin lispro and glargine pens for R10. At 9:07 AM, Surveyor observed LPN-G prepare an insulin glargine pen for R3. Surveyor noted the pens did not contain open dates. Surveyor interviewed LPN-G who verified the insulin pens should have open dates and were good for 28 days after opening. 2. On 9/17/24 at 1:20 PM, Surveyor observed the medication cart and noted the following: ~ An insulin glargine pen for R2 with no open date. Manufacturer recommendations indicate: Store open vials/pens in the refrigerator or at room temperature up to 86 F (Fahrenheit) (30 C (Celsius)) for up to 28 days. Throw away all opened vials after 28 days of use, even if there is insulin left in the vial. ~ A bottle of latanoprost eye drops for R6 with no open date. Manufacturer recommendations indicate: Protect from light. Store unopened bottle(s) under refrigeration at 2 to 8 C (36 to 46 F). During shipment to the patient, the bottle may be maintained at temperatures up to 40 C (104 F) for a period not exceeding 8 days. Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks. ~ A Stiolto inhaler for R120 with no open date. Manufacture recommendations indicate: After assembly, the Stiolto Respimat inhaler should be discarded at the latest 3 months after first use or when the locking mechanism is engaged, whichever comes first. ~ A bottle of calcitonin nasal spray for R1 with no open date. Manufacturer recommendations indicate: After opening, store the bottle in an upright position for up to 30 days at 68 to 77 F (20 to 25 C). Excursions permitted to 59 F to 86 F (15 to 30 C). On 9/17/24 at 1:50 PM, Surveyor interviewed LPN-G who verified the unlabeled medication in the medication cart. On 9/18/24 at 8:09 AM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should have dated the medications when they opened the medications.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R2) of 5 sampled residents was monitored for adverse reactions or side effects of a high-risk medication. R2 was prescribed lamotrigine (an anticonvulsant medication), and oxycodone (an opioid medication). R2's plan of care did not contain monitoring for adverse reactions or side effects of lamotrigine and oxycodone. Findings include: The facility's Medication Therapy policy, dated April 2007, indicates: Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks .Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether: .d. potential or suspected side effects are present. According to Medlineplus.gov: lamotrigine may cause side effects including, but not limited to, loss of balance or coordination, double vision, blurred vision, uncontrollable movements of the eyes, difficulty thinking or concentrating, difficulty speaking, headache, drowsiness, dizziness, diarrhea, constipation, loss of appetite, weight loss, heartburn, nausea, vomiting, dry mouth, stomach, back, or joint pain, swelling, itching, or irritation of the vagina, uncontrollable shaking of a part of the body, swelling of the face, throat, tongue, lips, and eyes, difficulty swallowing or breathing, seizures, fever, stiff neck, sensitivity to light, unusual bleeding or bruising, rash, swollen lymph nodes, yellowing of the skin or eyes, painful or bloody urination, pink eye, racing heartbeat, shortness of breath, and fainting. According to Medlineplus.gov: oxycodone may cause side effects including, but not limited to, dry mouth, stomach pain, drowsiness, flushing, headache, mood changes, changes in heartbeat, agitation, hallucinations, fever, sweating, confusion, shivering, severe muscle stiffness or twitching, loss of coordination, diarrhea, nausea, vomiting, loss of appetite, weakness, or dizziness, chest pain, rash, itching, hives, difficulty breathing or swallowing, swelling of the face, mouth, tongue, lips, throat, hands, feet, ankles, or lower legs, and seizures. Between 9/16/24 and 9/18/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including spondylosis without myelopathy or radiculopathy, lumbosacral region, and bipolar disorder. R2's Minimum Data Set (MDS) assessment, dated 9/4/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. R2's physician orders included lamotrigine 200 milligrams (mg) by mouth at bedtime, lamotrigine 150 mg once daily for bipolar disorder, and oxycodone 5 mg every 4 hours as needed for pain. R2's medical record did not indicate staff monitored R2 for adverse reactions or side effects of the medications. On 9/18/24 at 10:05 AM, Surveyor interviewed Corporate Registered Nurse (CRN)-C who stated the facility did not have side effect monitoring in place for R2's opioid or anticonvulsant medication. CRN-C stated CRN-C expects monitoring to be in place in R2's Medication Administration Record (MAR) or care plan.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R14) of 1 resident reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R14 was transferred to the hospital 8/10/24. The facility did not provide R14 or R14's emergency contact with a bed hold notice. Findings include: The facility's Bed-Holds and Returns policy, dated October 2022, indicates: Residents and/or their representatives are informed in writing of the facility and state bed hold policies. The bed hold addresses holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. well in advance of any transfer, and b. at the time of transfer (or, if the transfer was an emergency, within 24 hours). On 9/18/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including acute kidney injury, adjustment disorder with depressed mood, unspecified fall, and pulmonary embolism. R14's Minimum Data Set (MDS) assessment, dated 8/10/24, did not indicate R14 was assessed for cognition. R14 did not have an activated Power of Attorney (POA). R14's medical record indicated R14 was transferred to the hospital on 8/10/24. R14's medical record did not indicate R14 and/or R14's emergency contact were provided with a bed hold notice. On 9/18/24 at 11:17 AM, Surveyor interviewed Corporate Registered Nurse (CRN)-C who stated the facility did not issue a bed hold notice for R14's hospital transfer. CRN-C indicated a bed hold notice should have been provided prior to R14's transfer.

Based on observation, staff and resident interview, and record review, the facility did not ensure a continuous positive airway pressure (CPAP) machine was cleaned per the facility's policy for 1 resident (R) (R7) of 1 sampled resident. R7 used a CPAP machine for obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Staff did not clean the CPAP machine per the facility's policy. Findings include: The facility's CPAP/BiPAP (bievel positive airway pressure) Support Policy and Procedure, with an issue date of 3/2015, indicates: .7. Masks, nasal pillows, and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. From 9/16/24 to 9/18/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses including COVID-19, Clostridium difficile, dysphagia, and failure to thrive. R7's Minimum Data Set (MDS) assessment, dated 8/31/24, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R7 had severely impaired cognition. R7 had an activated Power of Attorney for Healthcare (POAHC). R7's care plan, dated 8/27/24, contained an intervention to Ensure CPAP/BiPAP is in good working condition, cleaned regularly, and maintains a good fit. On 9/16/24 at 10:59 AM, Surveyor observed a CPAP machine on a table near R7's bed and noted the face mask contained film and condensation. On 9/16/24 at 10:59 AM, Surveyor interviewed R7 who did not recall seeing staff clean the face mask since R7 was admitted . On 9/17/24 at 2:48 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who indicated Certified Nursing Assistants (CNAs) cleaning residents' CPAP machines. On 9/17/24 at 2:51 PM, Surveyor interviewed CNA-H who indicated PM shift CNAs apply the CPAP for residents and AM shift CNAs clean the CPAP mask and equipment. On 9/18/24 at 9:57 AM, Surveyor interviewed CNA-I who indicated CNA-I removes the CPAP mask and places it on a paper towel on the bedside table next to the bed. CNA-I indicated CNA-I does not clean the mask and stated a nurse normally does so. On 9/18/24 at 10:12 AM, Surveyor interviewed LPN-J who indicated LPN-J does not do anything with CPAP machines or equipment. On 9/18/24 at 11:38 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B could not speak to the cleaning of CPAP machines and equipment but expects staff to follow the facility's policy.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R14) of 1 resident reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R14 was transferred to the hospital on 8/10/24. Neither R14 or R14's emergency contact were provided with a written transfer notice. Findings include: On 9/18/24, Surveyor review R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including acute kidney injury, adjustment disorder with depressed mood, unspecified fall, and pulmonary embolism. R14's Minimum Data Set (MDS) assessment, dated 8/10/24, did not indicate R14 was assessed for cognition. R14 did not have an activated Power of Attorney (POA). R14's medical record indicated R14 was transferred to the hospital on 8/10/24. R14's medical record did not indicate R14 or R14's emergency contact were provided with a written transfer notice. On 9/18/24 at 11:17 AM, Surveyor interviewed Corporate Registered Nurse (CRN)-C who stated the facility did not have a transfer notice for R14's hospital transfer. CRN-C stated a written transfer notice should have been provided prior to R14's transfer.