Every finding on record at St Ann Health and Rehabilitation Center

Based on observations, interviews, record review, and policy review, the facility failed to ensure that quarterly safety evaluations accurately identified and documented the use of elopement-prevention devices, that care plans were developed for residents utilizing wander guards, and that Minimum Data Set (MDS) assessments reflected the presence of these safety devices for three of three residents (Resident (R)3, R8, and R45) reviewed for elopement. As a result of this deficient practice, staff did not recognize wander guards as a safety device to ensure all needed interventions were implemented.re respiratory equipment was stored in a sanitary manner for one of one resident (Resident (R) 15) reviewed for respiratory care out of a total sample of 17. This had the potential to expose the resident to infection. Findings include:1. Review of R3's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/07/25 with medical diagnoses including vascular dementia with severe anxiety and major depressive disorder.Review of the Elopement assessment dated [DATE], under the Evaluations tab in the EMR, documented R3 was a high risk for elopement.Review of the physician's orders for R3, located in the EMR under the Orders tab, documented an order on 05/13/25, Wander Guard to Right Ankle. Check function daily. Update nurse if any malfunction.Review of R3's quarterly Safety Evaluation assessment dated [DATE], under the Evaluations tab in the EMR, lacked documentation of a safety device, wander guard, in place.Review of R3's quarterly MDS, located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/31/25, revealed a Brief Interview for Mental Status (BIMS) could not be completed because the resident was rarely/never understood. The assessment lacked documentation of the presence of a wander guard.Review of R3's Treatment Administration Record (TAR), located in the EMR under the Orders tab, documented from May 2025 to March 2026 the presence of a wander guard functioning daily. Review of R3's Care Plan, under the Care Plan tab in the EMR, lacked documentation of a focus for elopement or wander guard.An observation on 03/03/26 at 2:43 PM in R3's room revealed a wander guard in place on the right ankle. 2. Review of R8's admission Record, located in the EMR under the Profile tab, revealed an admission date of 08/06/25 with medical diagnoses including vascular dementia, major depressive disorder, and developmental and epileptic encephalopathy. Review of the physician's orders for R8, located in the EMR under the Orders tab, documented an order on 08/27/25, Wander Guard to Left Ankle. Check function daily. Update nurse if any malfunction.Review of R8's Care Plan, under the Care Plan tab in the EMR, documented a focus for elopement and wander guard placement, initiated on 09/25/25, with interventions to monitor functionality and skin assessment daily.Review of R8's quarterly Safety Evaluation assessment dated [DATE], located under the Evaluations tab in the EMR, lacked documentation of a safety device, wander guard in place.Review of R8's quarterly MDS, located in the EMR under the MDS tab with an ARD of 12/18/25, revealed a BIMS score of 10 out of 15, indicating R8 was moderately cognitively impaired. The assessment lacked documentation of a wander guard.Review of R8's TAR, located in the EMR under the Orders tab, from August 2025 to March 2026 documented the presence of a wander guard functioning daily. 3. Review of R45's admission Record, located in the EMR under the Profile tab, revealed an admission date of 02/09/22 with medical diagnoses including Wernicke's encephalopathy (acute neurological condition) and Alzheimer's disease.Review of R45's Care Plan, under the Care Plan tab in the EMR, documented a focus area for elopement and wander guard placement initiated 05/10/22 with interventions to monitor functionality and skin assessment daily.Review of the physician's orders for R45, located in the EMR under the Orders tab, documented an order on 01/13/24, Wander Guard to Left Ankle. Check function daily. Update nurse if any malfunction.Review of R45's quarterly Safety Evaluation assessment dated [DATE], under the Evaluations tab in the EMR, lacked documentation of a safety device, wander guard in place.Review of R45's TAR from January 2024 to March 2026 documented the presence of a wander guard functioning daily. Review of R45's quarterly MDS assessment with ARD of 03/03/26, located in the EMR under the MDS tab, lacked documentation of the presence of a wander guardDuring an interview on 03/04/26 at 3:15 PM, Certified Nursing Assistant (CNA) 2 confirmed R3, R8, and R45 wore wander guard anklets that set off the elevator alarm when R3, R8 or R45 were near the elevator when it opened.During an interview on 03/05/26 at 10:31 AM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) verified the safety devices quarterly assessments and quarterly MDS assessments lacked documentation of a device in use for R3, R8, and R45 and confirmed the devices were in use and needed to be documented as such. The DON confirmed R3 had been in the facility since May of 2025, with a wander guard in place without a care plan for elopement and wander guard. The DON and ADON confirmed they had not considered a wander guard anklet as an assistive device.Review of the facility's policy titled Accidents and Supervision, implemented 10/08/24, revealed, The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). j, implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring effectiveness and modifying interventions when necessary . Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. Various sources provide information about hazards and risks in the resident environment. d. These sources may include, but are not limited to: . MDS/Care Area Assessments (CAA) data . Individual observation . This information is to be documented and communicated across all disciplines . Implementation of interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment- The process includes . Communicating the interventions to all relevant staff.

Based on observation, policy review, record review, and interview, the facility failed to ensure that a resident was transferred in a dignified manner for one resident (Resident (R) 24) out of a total of 17 sampled residents reviewed. This failure has the potential to negatively impact a resident's dignity and psychological well-being. Findings include:Review of R24's Face Sheet, located in the Profile tab of electronic medical record (EMR), revealed R24 was admitted on [DATE] with diagnoses of legal blindness, mild cognitive impairment, major depressive disorder, muscle weakness, difficulty walking, and need assistance with personal care. Review of R24's quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 03/04/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated R24 had moderate cognitive impairment. The MDS also indicated R24 ambulated with a wheelchair, and she was dependent on staff for toilet hygiene.Review of R24's Care Plan Report, located in the Care Plan tab of the EMR, revealed a focus, revised on 12/15/25, which indicated R24 had ADL (Activities of Daily Living) self-care performance deficits and exhibited new onset of decreased strength, decrease in functional mobility, reduced functional activity tolerance, and reduced static and dynamic balance. An intervention, revised on 12/25/25, advised staff that R24 required minimum assistance of two staff members for toilet transfers using a stand to sit assistance device. During an observation on 03/02/26 at 2:10 PM, Certified Nurse Aide (CNA) 1 transferred R24 from the restroom to R24's personal room on a stand to sit device. R24's room was directly across the hall from the restroom. While being transferred, R24 was observed with her black pants around her ankles exposing her in a brief while being transferred. During an interview on 03/03/26 at 9:42 AM, CNA1 confirmed she transferred R24 with her pants around her ankles, exposing R24 in only her brief. She stated she should not have done that, and she did it because R24's room was right across the hall. She stated it was a dignity issue, and she should have made sure she was completely dressed before she was transferred to her room. During an interview on 03/05/26 at 9:41 AM with the Director of Nursing (DON), she stated no resident should be transferred in that manner. All residents should be fully dressed if they are in any common area. The DON added that it is dignity issue and should never happen. Review of the undated facility policy titled, [NAME] of Resident Rights, specified, We will promote your right to receive care and treatment in a manner and in an environment that maintains or enhances your dignity and respect in full recognition of your individuality.

Based on observation, staff interview, record review, and the Resident Assessment Instrument (RAI) Manual review, the facility failed to ensure three of three residents (Resident (R) 3, R8, and R45) reviewed for wander guard placement had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly can lead to inaccurate federal reimbursement and inaccurate assessment and care planning for the residents.Findings include: 1. Review of R3's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/07/25 with medical diagnoses including vascular dementia with severe anxiety and major depressive disorder.Review of the physician's orders for R3, located in the EMR under the Orders tab, documented an order on 05/13/25, Wander Guard to Right Ankle. Check function daily. Update nurse if any malfunction.Review of R3's quarterly MDS assessment with an Assessment Reference Date (ARD) of 12/31/25, located in the EMR under the MDS tab, lacked documentation of the presence of a wander/elopement alarm.An observation of R3 on 03/02/2026 at 11:33 AM, R3 was in her room with a wander guard on her right ankle.2. Review of R8's admission Record, located in the EMR under the Profile tab, revealed an admission date of 08/06/25 with medical diagnoses including vascular dementia, major depressive disorder, and developmental and epileptic encephalopathy. Review of the physician's orders for R8, located in the EMR under the Orders tab, documented an order on 08/27/25, Wander Guard to Left Ankle. Check function daily. Update nurse if any malfunction.Review of R8's quarterly MDS assessment with an ARD of 12/18/25, located in the EMR under the MDS tab, lacked documentation of the presence of a wander/elopement alarm.An observation on 03/02/2026 at 1:59 PM, R8 had a wander guard on his left ankle while sitting in a wheelchair during activity in the activity room on the second floor.3. Review of R45's admission Record, located in the EMR under the Profile tab, revealed an admission date of 02/09/22 with medical diagnoses including Wernicke's encephalopathy (an acute neurological condition) and Alzheimer's disease.Review of the physician's orders for R45, located in the EMR under the Orders tab, documented an order on 01/13/24, Wander Guard to Left Ankle. Check function daily. Update nurse if any malfunction.Review of R45's quarterly MDS assessment with an ARD of 03/03/26, located in the EMR under the MDS tab, lacked documentation of the presence of a wander/elopement alarm.Observation on 03/03/26 at 10:45 AM, R45 was ambulating in the hallway on the second floor with the wander guard visible on her right ankle.During an interview on 03/04/36 at 3:15 PM, Certified Nursing Assistant (CNA) 2 confirmed R3, R8, and R45 wear wander guards that set off the elevator alarm when they were near the elevator when it opened. During an interview on 03/04/26 at 12:48 PM, the MDS Coordinator confirmed that R3, R8, and R45 had wander guards and were not coded on the MDS when they should have been coded as having a wander/elopement alarm in place. The MDS Coordinator confirmed using the RAI Manual as guidance for completing the MDS assessments for the residents.During an interview on 03/04/26 at 3:30 PM, the Director of Nursing (DON) confirmed the MDS assessments were to be accurate, and the facility used the RAI Manual guidelines for accuracy.Review of the RAI Manual, dated 10/01/25 and located at https://www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf, indicated, '' . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [interdisciplinary team] completing the assessment .''

Based on observation, interview, record review, and policy review, the facility failed to ensure a care plan was developed for one of three residents (Resident (R) 3) reviewed for wander guard placement to prevent elopement. This deficient practice increases the risk of inconsistent staff responses and elopement.Findings include:Review of R3's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/07/25 with medical diagnoses including vascular dementia with severe anxiety and major depressive disorder.Review of the Elopement assessment dated [DATE], located under the Evaluations tab in the EMR, documented R3 was a high risk for elopement.Review of the physician's orders for R3, located in the EMR under the Orders tab, documented an order on 05/13/25, Wander Guard to Right Ankle. Check function daily. Update nurse if any malfunction.Review of R3's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/31/25, revealed a Brief Interview for Mental Status (BIMS) was unable to be completed because the resident was rarely/never understood. Review of R4's Care Plan, under the Care Plan tab in the EMR, lacked documentation of a care focus for elopement and wander guard.An observation on 03/03/26 at 2:43 PM in R3's room revealed a wander guard on the resident's right ankle. During an interview on 03/04/36 at 3:15 PM, Certified Nursing Assistant (CNA) 2 confirmed R3 wore a wander guard that set off the elevator alarm if R3 was near the elevator when it opened.During an interview on 03/04/26 at 3:15 PM, Registered Nurse (RN) 1 verified R3 had a wander guard. Nursing documented skin condition under, and functioning of, the wander guard. RN1 confirmed there was no care plan in place for R3 for elopement or a wander guard.During an interview on 03/05/26 at 10:31 AM, the Director of Nursing (DON) verified that R3 had a wander guard in place since admission in May 2025 and there was no care plan in place. The DON stated a care plan should have been there to ensure needed interventions were in place.Review of the facility's policy titled, Comprehensive Care Plans, revised 05/05/25, documented The comprehensive care plan will describe at a minimum the following: . resident specific interventions that reflect the resident's needs .

Based on observations, interviews, record review, and policy review, the facility failed to ensure respiratory equipment was stored in a sanitary manner for one of one resident (Resident (R) 15) reviewed for respiratory care out of a total sample of 17. This had the potential to expose the resident to infection. Findings include:Review of R15's Face Sheet, located in the Profile tab of electronic medical record (EMR), revealed R15 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), malignant neoplasm of unspecified right bronchus or lung, and acquired absence of lung. Review of R15's Care Plan Report, located in the Care Plan tab of the EMR, revealed a focus, revised on 04/04/25, which indicated R15 had PRN (as needed) oxygen therapy due to end of life and lung cancer. A focus, revised on 04/17/25, indicated R15 had altered respiratory status or difficulty breathing due to lung cancer and COPD. Review of R15's quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/22/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R15 was cognitively intact.Review of R15's Physician Orders, located in the Orders tab of the EMR, revealed the following order dated 01/27/26: Albuterol sulfate inhalation nebulization solution 2.5mg [milligram]/3 ml [milliliter] 0.083% 1 inhalation every 6 hours as needed for shortness of breath [SOB] or wheezing.During an observation and interview on 03/02/26 at 10:46 AM, R15's nebulizer mask was propped up next to the nebulizer machine. R15's stated the mask was never stored in a bag; he confirmed it was propped up next to the machine. He added his last treatment was the night before. During an observation on 03/03/26 at 12:00 PM, R15's nebulizer mask was propped up next to the machine with a blue liquid in the reservoir of the mask. During an interview on 03/03/26 at 12:05 PM, Registered Nurse (RN) 3 stated breathing treatment masks should be cleaned once the treatment is complete. Masks were rinsed off and left to dry on a paper towel. She stated for infection control purposes, the mask should be stored in a bag once they have completely dried. RN3 confirmed the mask was not stored in anything. She also indicated that the mask was dirty and there was treatment solution still in the mask reservoir. During an interview on 03/05/26 at 9:41 AM with the Director of Nursing (DON) and the Infection Preventionist, the DON stated the mask needed to be stored in a bag after it was cleaned and dried. Review of the National Institutes of Health article titled, How to Use a Nebulizer, dated 10/2021 and located at https://www.nhlbi.nih.gov/sites/default/files/publications/How-to-Use-a-Nebulizer-21-HL-8163.pdf, revealed, . store nebulizer parts in a dry, clean plastic storage bag . Review of the facility's policy titled, Nebulizer Therapy, dated 04/09/25, specified It is the expectation of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions . Care of Equipment . once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag.

Based on observation, interviews, record review, and policy review, the facility failed to ensure that resident (Resident (R)13) received medications in the correct dosage and as ordered. This resulted in two medication errors out of 32 opportunities, yielding a medication error rate of 6.25%. These errors had the potential to reduce the effectiveness of the prescribed treatment due to underdosing.Findings include:1. Review of R13's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 08/26/22 and readmission date of 09/12/25 with medical diagnoses that included major depressive disorder and chronic (diastolic) congestive heart failure (CHF).Review of R13's quarterly Minimum Data Set (MDS) assessment, under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/11/25, revealed R13 used antidepressant and diuretic medications, and review of her drug regimen revealed no significant issues.Review of the March 2026 Medication Administration Record (MAR), located under the Orders tab of the EMR, revealed an order dated 03/03/26 for Prozac Oral capsule 10 milligrams [mg] [fluoxetine HCL]. Give 30 mg by mouth one time a day related to major depressive disorder, recurrent and an order dated 09/19/25 for furosemide Oral Tablet 20 mg. Give 2 tablet by mouth one time a day for edema.During a medication administration observation on the first floor with Registered Nurse (RN) 2 on 03/04/26 at 8:52 AM, RN2 pulled the medication card out of the medication cart for R13 that contained Prozac 10 mg tablets. RN2 placed one tablet into the medication cup, along with other ordered medications. RN2 then counted the number of oral medications (pills) to be administered and confirmed there were 16 pills in the medication cup to be administered. RN2 entered R13's room and administered the medications.Upon review of the March 2026 MAR and review of the medication cards, the number of oral medications (pills) to be administered should have been 19, not 16.During an interview on 03/04/26 at 10:28 AM, RN2 confirmed that one 10 mg tablet of Prozac was administered and confirmed the order on the MAR in the resident's record was for 30 mg to be administered or three 10 mg tablets. RN2 confirmed the medication furosemide 40 mg was not administered. The medication card for furosemide contained 40 mg doses to be administered. RN2 confirmed there should have been 19 pills administered and verified the missing pills were two 10 mg Prozac and one 40 mg furosemide that were not administered and should have been, confirming the errors.During an interview on 03/04/26 at 11:03 AM, the Director of Nursing (DON) confirmed medications ordered should be given using the correct dosage and following all the orders for medication administration. Review of the facility's policy titled Medication Administration, revised 04/09/25, revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Review MAR to identify medication to be administered, . Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, and f. Right documentation.

Based on observation and interviews, the facility did not ensure each resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 2 (R1 and R2) of 3 Residents reviewed for dignity.*On 2/11/26, Surveyor observed Certified Nursing Assistants (CNA) C and D standing, while feeding R1 and R2 their meals. CNA-C was also observed feeding two residents interchangeably at the same time. Findings Include:The facility Meal Supervision and Assistance reviewed/revised 10/29/24 documents:Guideline:.The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes:1.Identifying hazard(s) and risk(s)2.Evaluating and analyzing hazard(s) and risk(s)3.Implementing interventions to reduce hazard(s) and risk(s)4.Monitoring for effectiveness and modifying interventions when necessary.Compliance Guidelines:.14. Provide a relaxing, enjoyable environment during mealtime.1.) R1 was admitted to the facility on [DATE] with diagnoses of Spastic Hemiplegia Affecting Unspecified Side (one side of body experiences muscle stiffness and weakness), Paraplegia(paralysis of lower half of body), Aphasia (a language disorder caused by brain damage, typically from a stroke or injury, affecting speech production, comprehension, reading, and writing), Protein-Calorie Malnutrition Moderate (significant, but not severe, deficiency in nutrient intake),Colostomy Status (opening connecting large intestine (colon) to the skin), and Seizures (sudden, uncontrolled bursts of electrical activity in the brain that cause temporary, varying disturbances in awareness, sensation, behavior, and muscle control).R1's Quarterly Minimum Data Set (MDS) completed 1/5/26 assesses R1 has both short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R1's MDS assesses R1 has range of motion (ROM) impairment on both sides of upper and lower extremities. R1's MDS assesses R1 as dependent for eating, hygiene, mobility, transfers, showers, and toileting.R1's care card instructing CNAs on how to care for R1 as of 2/11/26 documents:Eating/Nutrition*Eating: maximum assist times one, does well with finger foodsR1's comprehensive care plan documents the intervention: maximum assist times one for eating, does well with finger foodsInitiated 9/25/21Revised 7/3/242.) R2 was admitted to the facility on [DATE] with diagnoses of Encephalopathy (group of conditions that cause brain dysfunction), Chronic Kidney Disease (progressive damage and loss of function in the kidneys),Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar), Adult Failure to Thrive (decline in overall health in older adults), Alzheimer's (progressive disease that destroys memory and other important mental functions),Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Depression (mood disorder that causes persistent feelings of sadness and loss of interest), and Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities).R2's Quarterly Minimum Data Set (MDS) completed 12/4/25 assesses R2 has both short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R2's MDS assesses R2 does not have range of motion (ROM) impairment on both sides of upper and lower extremities. R2's MDS assesses R2 is dependent for eating, hygiene, mobility, transfers, showers, and toileting.R2's care card instructing CNAs on how to care for R2 as of 2/11/26 documents:Eating/Nutrition*Eating: R2 is totally dependent on one staff for eating.R2's comprehensive care plan documents, R2, is totally dependent on one member of staff for eating.Initiated 9/10/25On 2/11/26, at 8:29 AM, Surveyor observed nine residents in the dining room. Per CNA-D, five of the nine residents require assistance with eating.On 2/11/26, at 8:35 AM, Surveyor observed CNA-D standing and feeding R1 breakfast. At 8:38 AM, CNA-D left R1.On 2/11/26, at 8:39 AM, CNA-C approached R1 and started feeding R1 breakfast while standing to the right of R1. Surveyor observed R2 on CNA-C's other side. R2 appeared to be sleeping, and small bowel of eggs was sitting in front of R2. At this time, CNA-C attempted to wake up R2.On 2/11/26, at 8:50 AM, Surveyor observed CNA-C standing feeding both R1 and R2 at the same time.On 2/11/26, at 9:00 AM, Surveyor observed CNA-C continued to feed breakfast to both R1 and R2 while standing.Surveyor also observed the lunch meal on 2/11/26, at 12:20 PM. During this meal, Surveyor observed CNA-C standing and feeding R2 protein pudding. At that time, CNA-C began to feed R1 lunch from R1's right side. Surveyor observed CNA-C is standing between R1 and R2.On 2/11/26, at 12:36 PM, Surveyor continued to observe CNA-C standing between R1 and R2; alternating feeding R1 and R2 at the same time. On 2/11/26, at 12:40 PM, Surveyor observed CNA-D approach R1 on the R1's left side. CNA-D started feeding R1 the rest of their lunch while standing over R1. CNA-C remained on R2's left side, feeding R2 the rest of R2's lunch while standing.On 2/11/26, at 1:45 PM, Surveyor interviewed CNA-D and asked why CNA-D was standing and feeding residents. CNA-D stated, I didn't see any seats. Surveyor then interviewed CNA-C and asked the same question. CNA-C informed Surveyor that the residents needed assistance. Sometimes not enough seats, I just didn't see one.On 2/11/26, at 1:51 PM, Surveyor interviewed Director of Nursing (DON)-B and asked what the expectation for CNAs are when feeding residents. DON-B stated to follow the resident care card and confirmed that CNAs should be sitting when feeding residents. Surveyor shared the observations of CNA-C and CNA-D feeding R1 and R2 breakfast and lunch and that they remained standing during the whole meal. DON-B understood the concerns.

Based on interview, record review, and facility document review, the facility failed to ensure known resident behaviors of kicking, hitting, grabbing, rejection of care, et cetera (etc., other similar things) were addressed, to include the development and implementation of interventions, for 1 (Resident #2) of 5 sampled residents reviewed for behaviors. Findings included:An admission Record revealed the facility initially admitted Resident #2 on 04/09/2024 and most recently admitted the resident on 10/31/2024. According to the admission Record, the resident had a medical history that included diagnoses of encephalopathy (disease in which the functioning of the brain is affected); epilepsy (seizure disorder); hemiplegia (complete paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side; unspecified dementia, moderate, with other behavioral disturbance anxiety disorder; insomnia; and need for assistance with personal care. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident exhibited physical and verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others, and rejection of care during one to three days of the seven-day assessment look-back period. Per the MDS, Resident #2 was dependent upon staff for rolling left and right in bed. A quarterly MDS, with an ARD of 07/17/2025, revealed Resident #2 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident exhibited physical and verbal behavioral symptoms directed towards others during four to six days of the seven-day assessment look-back period and other behavioral symptoms not directed towards others during one to three days of the seven-day assessment look-back period. Per the MDS, Resident #2 was dependent upon staff for rolling left and right in bed. Behavior Symptoms documentation for the timeframe from 07/02/2025 through 07/31/2025 revealed Resident #2 exhibited yelling/screaming during 15 out of 30 days, kicking/hitting during 11 out of 30 days, grabbing during 15 out of 30 days, and rejection of care during seven out of 30 days.Resident #2's Care Plan revealed a focus area addressing the potential for Resident #2 to be physically aggressive was not initiated until 07/19/2025. In addition, interventions directing staff how to respond should the resident become agitated were not initiated until 07/19/2025. A Nurses Note, documented by Licensed Practical Nurse (LPN) B with an effective date of 07/19/2025 at 2:59 PM, indicated LPN B was called to Resident #2's room during the morning by a certified nursing assistant (CNA). Per the note, the CNA reported that while turning the resident, the resident's head hit the wall. The note indicated the resident's right eye was swollen, and there was a 1-centimeter (cm) laceration above the resident's right eye. Documentation of an interview conducted by the facility with CNA A and copies of text message communications between the CNA and Administrator, dated 07/19/2025, revealed CNA A reported that while trying to provide care to Resident #2, the resident became combative and punched her. CNA A reported the resident was fighting and was in a rage, and when CNA A turned the resident on their side, the resident's face hit the wall.On 08/01/2025 at 8:02 AM, 9:11 AM, and 2:49 PM, the surveyor attempted to conduct a telephone interview with CNA A; a voicemail message was left, and no return call was received. During an interview on 07/31/2025 at 4:46 PM, the Administrator stated Resident #2 had anxiety and required one-person assistance prior to the incident on 07/19/2025. During a follow-up interview on 07/31/2025 at 5:39 PM, the Administrator stated the root cause analysis conducted as a result of the 07/19/2025 incident revealed Resident #2 was being aggressive. The Administrator further stated Resident #2's behaviors were hit or miss and were mostly related to the resident's diagnosis of anxiety. During a phone interview on 08/01/2025 at 12:21 PM, the Director of Nursing (DON) stated her expectation was that CNA A should have walked away and gotten help.During an interview on 08/01/2025 at 12:23 PM, the Administrator stated if the resident was agitated, her expectation was that staff would remove themselves and reapproach the resident to give the resident space to calm down.Resident #2's care plan focus area addressing the potential for physically aggressive behaviors, initiated 07/19/2025, was not updated to include an intervention that directed staff to walk calmly away, and approach later when the resident became aggressive until after this incident on 07/19/2025.

Based on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety for 46 of 48 residents that receive food from the kitchen. * In the facility's main kitchen, observations of partially used and undated food were made in the walk-in and wall freezers/coolers. Several food items were observed in one of the facility's main kitchen wall coolers uncovered open to air and undated. * [NAME] restraints were not being utilized by a kitchen staff working in the main kitchen area. * Temperatures were not completed on all required food items prior to serving the food to residents. Findings include: The facility policy titled Food Safety Requirements, date reviewed 04/29/2024 documents: Policy Explanation and Compliance Guidelines: 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Subsection iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and Subsection v. Keeping foods covered or in tight containers. 4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards. Subsection d. Holding-staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold temperatures are maintained. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Subsection d. Dietary staff must wear hair restraints (e.g. hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Food Storage Observations: On 02/04/25, at 08:55 AM, Surveyor observed in the main kitchen freezers labeled 1, 2, and C, the following items previously opened and partially used: 1 bag of corn, 1 bag of hash browns, 1 bag of pepperoni, 1 bag of hamburger patties, 1 bag of shredded potatoes, 1 bag of peas, 2 bags of pizza crusts, and 1 package of buns in the walk-in freezer. On 02/04/25, at 08:55 AM, Surveyor observed in the main kitchen coolers the following items that were opened and partly used: 1 large jar of mayonnaise, 2 cheese packages, 1 package of cheese slices, 1 gallon of milk, 1 carton of Lactaid milk, and 1 used whip cream squeeze bag with whip cream on outside of bag. Surveyor noted that all of these food items were not labeled or dated with an open or use by date. On 02/04/25, at 10:15 AM, Surveyor interview Food Service Director (FSD)-C and Cook-E about food storage and delivery. Surveyor asked FSD-C if they usually placed dates on food items after opening and placing the item in the refrigerator or freezer. FSD-C informed Surveyor that it is the facility's practice to place use by dates on food items when they are opened. On 02/05/25, at 03:21 PM, Surveyor observed in the main kitchen freezers labeled 1, 2, and C, the following items previously opened and partially used: 1 bag of hash browns, 1 bag of cookie dough, 1 loaf of bread, 1 bag of omelets, and 1 package of buns in the walk-in freezer. Surveyor observed in the main kitchen wall coolers:1 large jar of mayonnaise, 1 package of cheese slices, 1 gallon of milk, 1 loaf of bread, 2 open to air uncovered Jell-O cups, and 1 used whip cream squeeze bag with whip cream on outside of bag. Surveyor noted that these items were not labeled or dated with an open or use by date. Food Temperature Observations: Surveyor asked FSD-C about the process of taking food from the main kitchen to the kitchenettes on the units. FSD-C informed Surveyor the food comes from the main kitchen and is then delivered to the kitchenette in covered pans and carts. Surveyor asked Cook-E when temperatures are taken on the food. Cook-E informed Surveyor temperatures are taken right away when the food comes out of the oven or heating source. Surveyor asked FSD-C when temperatures are taken on the food delivered to the kitchenettes on the unit. FSD-C told Surveyors that temperatures are taken after arrival to the unit warming station and prior to serving residents. On 02/04/25, at 12:18 PM, Surveyor observations of staff doing kitchenette point of service food temperatures prior to serving residents in the dining area. Surveyor observed Dietary Aide (DA)-G take temperatures on soup, vegetables, pureed meat, pureed vegetables. Surveyor observed DA-G did not take a temperature on the potatoes and gravy. Surveyor asked DA-G if a temperature should be taken on the potatoes and gravy. DA-G told Surveyor that DA-G only takes temperatures on the puree and regular items not the gravy and potatoes. On 02/04/25, at 12:25 PM, Surveyor observed DA-G serving a resident the gravy and potatoes without taking a temperature prior to serving the gravy and potatoes. Hair Restraint Observations: On 02/04/25, at 11:51 AM, Surveyors observed Dietary Aide (DA)-F had no beard restraint or cover on beard while working in the main kitchen. On 02/05/25, at 03:43 PM, Surveyors informed Nursing Home Administrator (NHA)-A of the above findings. No additional information was provided as to why the facility did not ensure that food was stored and served in accordance with professional standards for food service safety.

Based on observation and interview, the facility failed to maintain 1 (R14) of 12 residents reviewed their right to personal privacy and confidentiality of his or her personal and medical records. * R14's protected health information was left on a computer screen unattended in a common area. R14's medication administration record was displayed on the computer screen in full view of residents and staff that were in and around the common area. Findings include: 1.) R14 was admitted on [DATE] with diagnosis that included Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD), Depression and Alzheimer's Disease. R14's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 12/4/24, documents a Brief Interview for Mental Status (BIMS) score of 12, indicating that R14 has moderate cognitive impairment. Section GG documents that R14 uses wheelchair for mobility. On 02/05/25, at 09:28 AM, Surveyor observed Registered Nurse (RN)-D passing medication from the medication cart. RN-D was observed to walk away from the medication cart while R14's medication administration record remained open on the computer screen in view of a unit common area. Surveyor observed RN-D walk down the hall into a room to give medications. Surveyor noted that while RN-D was giving medications, the computer on the medication cart was out of RN-D's line of sight and displayed R14's medication administration record. Surveyor observed 4 people walk by in close proximity of the medication cart computer screen while R14's medication record was in plain view on the computer screen. On 02/06/25, at 09:27 AM, Surveyor interviewed R14 about privacy and resident rights in the facility. Surveyor asked R14 if R14's medical information was left open on a computer screen and someone could read it that shouldn't read it, would it bother R14. R14 informed Surveyor yes that would really bother me. R14 stated to Surveyor wouldn't it bother you. R14 informed Surveyor that R14 wouldn't like it at all. On 02/06/25, at 09:47 AM, Surveyor informed Nursing Home Administrator (NHA)-A the concern about RN-D leaving an unattended medication cart computer with R14's medication administration record open and visible to the unit common area. Surveyor informed NHA-A that Surveyor observed 4 people in close enough proximity to view R14's protected health information while the medication cart computer was unattended. No additional information was provided as to why the facility did not ensure that R14's medical record remained private and confidential.

Based on interview and record review the facility did not ensure 1 (R12) of 12 residents who were reviewed for a change of condition received a comprehensive assessment. * On 10/6/24, R12 experienced a change in condition and RN (registered nurse)-H did not complete a comprehensive assessment prior to sending R12 to the hospital via ambulance. Findings include: 1.) R12 was admitted to the facility with diagnoses of atrial fibrillation, morbid obesity, hypertension and congestive heart failure. The nurses note dated 2/5/25 documents Resident initially c/o (complain of) stomach pain to CNA (certified nursing assistant) around 3am. Went into room to see resident--laying flat, and in the middle of having a bowel movement. Resident c/o stomach cramping and nausea. PRN (as needed) medication offered for GI discomfort-declined. Education provided. Water at bedside. Resident encouraged to push fluids and alter diet to prevent constipation. Basin retrieved by CNA in case of emesis. Resident then requested to see me again later during the shift, via CNA. CNA reports resident communicating at baseline. I told the CNA that I would be in to see resident shortly, and bringing down her scheduled medication which was due. Before I could retrieve medication, CNA came back to office and reported rapid change in condition. I immediately went in to see resident. Resident was foaming at the mouth, was not verbally responsive, pupils fixed and deep labored breathing. Pulse checked--intact. Bell ambulance contacted immediately. ADON (assistant director of nursing)/DON (director of nursing)/Husband updated while in room. MD notified when back to office. RN-H completed an SBAR (situation, background, assessment and recommendation) evaluation dated 2/5/25 documents: Hypotension, remained in room with resident during emergency-vitals not obtained. Paramedics report that resident was hypotensive. The SBAR did not have any vital signs documented from the moment of the change in condition. On 2/6/25 at 8:16 a.m. Surveyor interviewed RN-H. RN-H states around 3 a.m. the CNA told her R12 was complaining of stomach ache. RN-H stated R12 was laying flat and was having a bowel movement. RN-H stated she asked R12 if she wanted something for her nausea and R12 told her no. RN-H stated R12 is constantly eating snacks and is normal for R12 to complain of stomach ache. RN-H stated R12 remained at baseline. RN-H stated around 5 a.m. CNA told her R12 is complaining of stomach pain again. RN-H stated she was in the medication room and was getting ready to pass early morning medications. RN-H stated she told CNA that she would go see R12 with her early morning medications. RN-H stated CNA immediately came back and stated to RN-H that R12 was not looking good. RN-H stated she left the medication room and went to R12's room. RN-H stated she saw R12 with her eyes wide open and wasn't responding. RN-H stated she was having deep labored breathing and foaming from the mouth. RN-H stated she checked her pulse and R12 had a pulse so she pulled her phone out and called 911. Surveyor asked RN-H if she obtained vital signs from R12. RN-H stated she did not have any of her equipment with her. RN-H stated the equipment was down the hall in the medication room. RN-H stated she did not want to leave R12 alone so she stayed with R12 instead of getting the equipment she needed to obtain vital signs. On 2/6/25 at 9:50 a.m. Surveyor interviewed DON-B. Surveyor asked if facility had a policy regarding the expectations of nurses when a resident has a change in condition. DON-B handed Surveyor a policy explaining circumstances requiring notification of change but nothing explaining expectations of nurses during a change in condition. DON-B stated the facility does not have a policy that explains nursing expectation regarding residents experiencing a change in condition. On 2/6/25 at 10:15 a.m. Surveyor interviewed DON-B, NHA-A and ADON-I. Surveyor explained the concern RN-H did not complete an accurate assessment when R12 experienced the change in condition. Surveyor explained RN-H did not obtain vital signs for a complete assessment. DON-B agreed this is concern and will be conducting education. No additional information was provided.

Based on observation, resident interview, staff interview, and record review, the facility failed to ensure menus were followed and served as posted and on the dietary tray cards. The failure placed any of the 45 facility residents receiving meals from the kitchen at risk of dissatisfaction with their meals. Findings include: During an interview on 10/17/24 at 12:40 PM, Resident (R) 6 complained that at least once a day the meal varies from what they are supposed to have. R6 pointed to a covered dish on her tray stating, That's not a chocolate peanut butter bar. The cover was lifted to reveal a confetti cake with a whipped type topping dollop. When asked what the menu tray card said, R6 showed the paper slip which showed Choc [Chocolate] Peanut Butter Bar. Review of R6's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/13/24 showed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicative of being cognitively intact. Review of the menu for 10/17/24 showed 1 [one] sq [square] Chocolate Peanut Butter Bar. During an interview on 10/17/24 at 2:45 PM regarding the difference in the posted menu versus the observation of the confetti cake served, the Food Service Director (FSD) stated, She [the cook] does not speak English. I give her the recipes, she uses her translator on her phone, I turn around and find she cooked something different. The FSD continued on to explain that when she does the ordering / receives the order if something is unavailable, she will substitute and change the posted menu. Review of the undated facility policy titled Menus and Adequate Nutrition revealed, Policy: The purpose of this policy is to ensure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. Policy Explanation and Compliance Guidelines: . 3. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods with comparable nutritive value.

Based on observation, record review, and interview, the facility did not ensure adequate supervision and assistance devices were provided to prevent falls for 2 (R3 and R4) of 3 residents reviewed for accidents. * R3 did not have fall interventions in place per care plan to prevent a fall out of bed on 1/24/2024 and fall interventions were observed not to be in place to prevent future falls. * R4 was not transferred as per care plan resulting in a fall on 2/21/2024. R4's care plan indicated R4 required moderate assist of 2 staff members with the use of a sit-to-stand lift. On 2/21/2024, R4 was pivot transferred with the assist of 1 staff member instead of 2 staff members with the use of a sit-to-stand, resulting in R4 being lowered to the ground. Findings: 1. R3 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease, peripheral vascular disease, amputation of right and left lower limbs above the knees, cerebrovascular disease, and chronic atrial fibrillation. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R3 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 and had an activated Power of Attorney. R3's Mobility Care Plan indicated R3 needed maximum assistance with bed mobility and used a Hoyer lift for transfers. R3's Risk for Falls Care Plan was initiated on 7/14/2023 and the following interventions were in place on 1/24/2024: -Body pillow to the right side of the bed to aid in defining the perimeter of the bed. -Body pillow to the left side of the bed. -Bedside table to be within arm's reach - fall mat not to be used. -Reminder signs to the room to prompt R3 to request assistance. -Body pillow to be placed in the fitted sheet to ensure they do not come off the edge of the bed. -Anticipate and meet R3's needs. -Encourage R3 to ask for assistance. -Fall assessment to be completed upon admission, after falls, quarterly, with significant change of condition and as needed. -Follow therapy recommendations for transfers and mobility. -Place call light within reach. -Review information on past falls and attempt to determine cause of falls. -Update physician as needed. On 1/24/2024 at 12:30 AM in the progress notes, nursing charted R3 was lying supine on the floor mat next to the low bed. R3 was alert and verbally responsive with no apparent injury. Incontinence care was provided after getting R3 back into bed with a Hoyer lift. Nursing charted fall interventions were in place per plan of care. (Surveyor noted the fall interventions were not documented as to what was in place at the time of the fall.) A body pillow was placed along the left side of the bed for positioning. R3's Risk for Falls Care Plan was revised on 1/24/2024 with the following interventions: -Bolstered mattress to be used instead of body pillows. -Check and change on strict every two hour schedule and as required for incontinence. On 1/26/2024 at 9:31 PM in the progress notes, Director of Nursing (DON)-B charted the Interdisciplinary Team (IDT) met to review R3's fall on 1/24/2024. R3 was found lying on the back parallel to the bed on the fall mat. (Surveyor noted R3's Risk for Falls Care Plan indicated a fall mat was not to be used.) R3 did not have any apparent injuries or complaints of pain and range of motion was within normal limits. R3 had a call light within reach but not turned on for assistance. R3 was unable to recall specifics of the incident or give a description of the factors leading to the fall. R3 had baseline memory issues, confusion at times and had an activated POA. R3 was incontinent of bladder when found post fall. Incontinence cares were provided upon return to bed with the assist of two and the Hoyer lift. R3 did not have gripper socks/non-skid footwear as R3 had bilateral above the knee amputations. The root cause of the fall: R3 with baseline incontinence of bowel and bladder with the inability to sense the need to void at all times in combination with memory issues/confusion/time of night. New immediate intervention: adjustment of check and change to strict every 2 hours and as needed with incontinence cares as necessary. (Surveyor noted this intervention was added to the Risk for Falls Care Plan on 1/24/2024.) On 3/13/2024 at 12:15 PM, Surveyor observed R3 sitting in a wheelchair in R3's room. The mattress on R3's bed was a regular mattress. Surveyor asked R3 if R3 had any falls recently. R3 stated R3 had about five falls when R3 first got to the facility but no falls since then. On 3/13/2024 at 3:42 PM, Surveyor observed R3 lying in bed. A body pillow was observed to be in a chair next to the door. No body pillow was in R3's bed. R3 stated the staff put a pillow on the side of the bed so R3 does not fall out. Surveyor pointed to the body pillow in the chair and asked R3 if that was the pillow staff would put on the side of the bed. R3 laughed and said yes. R3 said it was not doing any good sitting in the chair. R3 stated R3 has a hard time seeing the TV with the pillow on the side of the bed. Surveyor observed R3 did not have a bolstered mattress in place as per care plan. In an interview on 3/14/2024 at 12:38 PM, Surveyor asked Assistant Director of Nursing (ADON)-C if ADON-C was familiar with R3 and R3's fall on 1/24/2024. ADON-C stated yes, ADON-C worked with R3 frequently. Surveyor shared with ADON-C the confusion of R3's Risk for Falls Care Plan intervention of not having a fall mat if R3 had frequent falls. ADON-C stated R3 had a fall mat on the floor, but R3 would continually reach for water on the bedside table and with the fall mat in place, the table could not be reached causing R3 to fall out of bed. ADON-C guessed that was why the care plan stated the fall mat should not be in place; without the fall mat, the table could be pushed up to the side of the bed. ADON-C stated R3's room was rearranged at the end of 2023, either in November or December, and with the bed moved to a different position, the fall mat and bedside table could both be next to the bed. ADON-C stated R3's care plan must not have been updated after the room was rearranged. Surveyor shared with ADON-C the observation that R3 did not have a bolstered mattress as per care plan. ADON-C stated the bolstered mattress was ordered and when it arrived, it was the wrong size. ADON-C stated the mattress takes a couple weeks to arrive and since the first one had to be returned, they must still be waiting for the right mattress to arrive. Surveyor noted the bolstered mattress was added to the care plan on 1/24/2024, seven weeks ago. Surveyor asked ADON-C if seven weeks was a long time to be waiting for an ordered specialty mattress. ADON-C stated it can take a couple of weeks for the mattress to arrive but agreed that it had been a long time since the mattress had been ordered. Surveyor asked ADON-C what the expectation was for staff since the care plan said to have a bolstered mattress and that was not in place. ADON-C stated the body pillows should still be in use until the bolstered mattress arrives. On 3/14/2024 at 1:50 PM, Surveyor observed R3 in bed. No fall mat was on the floor. No body pillows were in the bed and the bolstered mattress was not in place. The bedside table was observed to be on the other side of the room from R3 in bed not within reach and R3's cell phone was ringing. The bed was observed to be at hip height, not in low position. In an interview on 3/14/2024 at 1:55 PM, Surveyor asked Certified Nursing Assistant (CNA)-F, who frequently works with R3, what measures are put in place to keep R3 safe when in bed. CNA-F stated R3 should have pillows on the sides of R3, the bed should be low, and there should be a cushion on the floor. Surveyor noted none of these interventions were currently in use while R3 was in bed. On 3/14/2024 at 2:12 PM, Surveyor met with Nursing Home Administrator (NHA)-A. Surveyor asked what the status was on R3's bolstered mattress. NHA-A stated NHA-A had been reviewing emails with the supply company and was able to find a reply from an email NHA-A had sent regarding the initial order for the bolstered mattress. NHA-A stated the reply from the supply company came on 1/18/2024. Surveyor noted this email came six days prior to R3's fall from bed. NHA-A stated the bolstered mattress was delivered on 1/19/2024 but it was the wrong size. NHA-A stated the mattress that was delivered was 36 inches wide when they had ordered a mattress that was 42 inches wide. NHA-A stated NHA-A was asked to reorder the mattress, but NHA-A forgot to place the order so when Surveyor asked about the bolstered mattress, NHA-A ordered the mattress today. Surveyor shared with NHA-A the concern interventions were not in place per care plan when R3 fell out of bed on 1/24/2024, such as the body pillows to the bed, and observations made on 3/13/2024 and 3/14/2024 when R3 was in bed with no interventions in place including the bolstered mattress, body pillows to the bed, or the bedside table within R3's reach. No further information was provided at that time. 2. R4 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, diabetes, epilepsy, bipolar disorder, and schizoaffective disorder. R4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R4 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R4's Impaired Mobility Care Plan was initiated on 9/12/2023 indicating R4 transfers with moderate assistance with two people using a Sit-to-Stand lift. On 2/21/2024 at 7:24 PM in the progress notes, nursing charted R4 was lowered to the floor by Certified Nursing Assistant (CNA)-D after CNA-D was transferring R4 from the toilet to the wheelchair. Nursing charted R4 did not hit the head and had no complaints of pain; R4 did not have any injuries from the fall. On 2/27/2024 at 10:48 AM in the progress notes, Assistant Director of Nursing (ADON)-C charted the Interdisciplinary Team (IDT) reviewed R4's fall on 2/21/2024 and determined the root cause of the fall to be R4 was transferred not using two CNAs and the Sit-to-Stand lift. The intervention to prevent future falls was to ensure the Sit-to-Stand with the assistance of two staff was used for all transfers unless working with therapy. On 3/13/2024 at 12:46 PM, R4 was observed to be eating lunch in the dining room. R4 wheeled the wheelchair using R4's arms away from the table without finishing eating. R4 stated the food did not have any flavor. Surveyor asked R4 if R4 had any falls while at the facility. R4 stated R4 when being transferred in the shower. Surveyor asked R4 if R4 was wet and slippery when R4 fell . R4 stated no, R4 was fully clothed and just slipped down. In an interview on 3/14/2024 at 12:46 PM, Surveyor asked ADON-C about R4's fall on 2/21/2024. ADON-C stated R4 had been working with therapy on slide board transfers and stand and pivot transfers. ADON-C stated R4 and CNA-D decided between the two of them that R4 could be transferred with the pivot transfer because R4 was feeling strong enough to transfer that way. ADON-C stated halfway through the transfer, R4 could not sustain their weight and R4 and CNA-D decided to lower R4 to the ground and get help. ADON-C stated R4 has been trying to be able to get back to the group home and needs to be able to transfer without a mechanical lift. ADON-C stated ADON-C educated CNA-D about following the care plan and having therapy determine any changes in transfer status. On 3/14/2024 at 1:59 PM, Surveyor asked CNA-E how R4 transfers. CNA-E stated R4 uses a Sit-to-Stand lift with assistance of two people. On 3/14/2024 at 2:12 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R4 was transferred by CNA-D and had a fall due to CNA-D not using the Sit-to-Stand lift as per care plan. NHA-A agreed CNA-D should have used the Sit-to-Stand lift. No further information was provided at that time.

Based on observation and interview, the facility did not ensure the cleaning and disinfecting of a Glucometer which was being shared between 8 residents. The Glucometer was being disinfected with a 70% isopropyl alcohol wipe rather than with a disinfectant bleach wipe in order to kill blood bourne pathogens. *On 11/9/23 Surveyor observed RN (Registered Nurse)-G administer blood glucose testing for R40. RN-G did not clean and disinfect the facility's shared Glucometer with a disinfectant wipe which kills blood borne pathogens. This deficient practice had the potential to affect 8 residents residing on the 2nd floor who utilize . Findings include: The facility policy dated 2023, entitled, Glucometer Disinfection reads: .1) The facility will ensure blood Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use . 3) The Glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. On 11/9/23 at 7:20 AM, Surveyor observed the medication administration task on the facility's 2nd floor. At this time, the 2nd floor had 1 Glucometer on the medication cart which was being shared between 8 residents at the time of observation. The Glucometer were not cleaned according to the facility policy. On 11/9/23 at 8:35 AM, Surveyor observed R40 at the dining room table eating breakfast. R40 had completed approximately 50 % of their breakfast at this time. Surveyor observed RN-G approach R40 and proceed to check R40's blood sugar at the dining room table. Surveyor noted RN-G using an alcohol prep wipe containing 70% isopropyl alcohol to wipe down the surface of the Glucometer for 15 seconds prior to testing R40's blood sugar. Surveyor noted RN-G utilizing a fresh alcohol prep wipe containing 70% isopropyl alcohol to wipe down the surface of the Glucometer for 15 seconds after testing R40's blood sugar. At this time, Surveyor asked RN-G what the facility's policy is for using shared Glucometers. RN-G responded they thought all the residents used to have their own Glucometers for testing but is unsure why the other Gucometers are not on the cart. Surveyor asked if there were any disinfectant wipes on the medication cart for cleaning medical equipment. RN-G responded, I use the alcohol wipes to clean the machine. Surveyor conducted record review to confirm no residents who use the 2nd floor Glucometer had blood borne pathogens at the time of survey. On 11/9/23 at 11:20 AM, Surveyor conducted interview with ADON (Assistant Director of Nursing)-C in the presence of DON (Director of Nursing)-B. Surveyor asked ADON-C what the facility's policy and procedure is for disinfection of Glucometers. ADON-C responded that Glucometers should be cleaned with a disinfectant bleach wipe to kill blood borne pathogens. Surveyor informed ADON-C of observations of RN-G utilizing alcohol wipes to clean the 2nd floor Glucometer and that no disinfectant bleach wipes had been noted on the medication cart at the time of medication pass observation. ADON-C told Surveyor that they would go to the 2nd floor to find the individual Glucometers for each resident and provide education to RN-G regarding proper Glucometer usage and disinfection of Glucometers. On 11/9/23 at 3:10 PM at the daily exit meeting, Surveyor informed NHA-A of the observations of RN-G not cleaning the 2nd floor Glucometer in accordance with facility's policy and procedure while administering blood glucose checks. ADON-C told Surveyor that the facility has now ensured each individual resident on the 2nd floor has their own Glucometer for personal use.

Based on observation and interview, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, to include the expiration date when applicable for 4 of 10 (R7, R17, R19 and R25) resident insulin's observed. * Residents' insulin, which was open and used, was not dated when opened and insulin was observed to be beyond the expiration date. Findings include: The facility policy titled: Insulin Pen which was not dated, documents (in part) . .It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Policy Explanation and Compliance Guidelines: 1. Insulin pens contain multiple doses of insulin but are used for a single resident only. 2. Insulin pens must be clearly labeled with the residents name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. 9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. 11. Procedure: e. Check the expiration date on the pen. Discard if expired. The facility policy titled: Labeling of Medications and Biological's which was not dated, documents (in part) . .All medications and biological's used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 4. Labels for individual drug containers must include: h. The expiration date when applicable. 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured); b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. On [DATE] at 3:29 PM Surveyor observed the 2nd floor medication room refrigerator. Surveyor located a Levemir Insulin Flex pen belonging to R19, which was open and used, but not dated when opened. Surveyor asked Licensed Practical Nurse (LPN)-D when the insulin pen was opened. LPN-D looked at the insulin pen and could not find a date when opened. LPN-D stated: They're supposed to be dated when opened, I always do. It's not supposed to be in the refrigerator, we only keep pens that are not opened in there. The problem is, if we throw this out, pharmacy probably won't send another one because she's not due for a refill. On [DATE] at 3:40 PM Surveyor observed the 1st floor medication cart. Surveyor located the following insulin's: Humalog Lispro vial belonging to R7 which was opened and used, but not dated when opened. Humalog Lispro vial belonging to R25 which was dated opened [DATE] and two vials of Lantus insulin belonging to R25 which were opened and used, but not dated when opened. Two vials of Aspart insulin belonging to R17 which were opened and used, but not dated when opened and a Levemir insulin Flex pen dated opened ?[DATE]. Surveyor asked LPN-E how long insulin is good for once opened. LPN-E stated: I think 28 days. Surveyor showed LPN-E all the above insulin's found in the medication cart. LPN-E confirmed R25's insulin dated [DATE] and R17's insulin dated ?[DATE] were both past 28 days. LPN-E confirmed all the other insulin's were opened and used, but not dated when opened. LPN-E stated: I guess they're all not good anymore. Surveyor review of the residents' medical records confirmed the following current Physician Orders: R7 Humalog Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale: If ,d+[DATE] = 2 units; ,d+[DATE] = 4 units; ,d+[DATE] = 6 units; ,d+[DATE] = 8 units call provider if BS (blood sugar) is above 350, subcutaneously before meals related to Type 2 Diabetes Mellitus - dated [DATE]. R17 Novolog FlexPen Solution Pen-injector 100 unit/ml (Insulin Aspart) Inject as per sliding scale: If ,d+[DATE] = 3 units; ,d+[DATE] = 5 units; ,d+[DATE] = 7 units; ,d+[DATE] = 9 units; ,d+[DATE] = 11 units, subcutaneously before meals and at bedtime for monitoring diabetic Call MD if <70 or >400 - dated [DATE]. Levemir Solution (Insulin Detemir) Inject 32 unit subcutaneously at bedtime for DM - dated [DATE]. R19 Insulin Detemir (Levemir) Subcutaneous Solution 100 unit/ML (milliliter) (Insulin Detemir) Inject 20 unit subcutaneously at bedtime for DM (Diabetes Mellitus). Notify MD (Medical Doctor) if blood sugar over 350 or under 70 - dated [DATE]. R25 Humalog Solution (Insulin Lispro) Inject as per sliding scale: If ,d+[DATE] = 4 ,d+[DATE] = 8 units ,d+[DATE] = 10 units; ,d+[DATE] = 12 units; ,d+[DATE] = 12 units if over 400 call MD, subcutaneously before meals for DM 2 - dated [DATE]. Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine) Inject 50 unit subcutaneously in the morning for diabetes hold for BS under 70 and contact MD - dated [DATE]. On [DATE] at 11:27 AM Surveyor advised Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-D of the observed concern regarding residents' insulin's that were opened and used, but not dated when opened and expired insulin's observed. DON-B reported all the observed insulin's have been replaced and dated. No additional information was provided.

Based on observation, interview and record review the facility did not ensure residents were free from significant medication errors for 3 (R51, R40 and R20) of 12 residents reviewed for medications. *R51 was admitted to the facility on [DATE] with an order for Augmentin (antibiotic) twice a day until 8/10/23. The facility incorrectly transcribed the order as Augmentin twice a day every 11 days. The incorrect transcription resulted in R51 receiving the Augmentin/antibiotic for two days (or 4 doses) instead of 11 days (or a total of 27 doses). R51's gangrene progressed resulting in a right lower extremity amputation (above the knee amputation). Vascular Surgery Registered Nurse (RN)- L informed Surveyor on 8/10/23 everything was looking good and that RN-L could not located documentation that vascular surgery was aware R51 did not receive the correct amount of Augmentin and had the NP who saw R51 on 8/10/23 been made aware of the missed doses of the Augmentin they may have ordered something different. Registered Nurse (RN)-M informed Surveyor the facility contacted RN-M on 8/14/23 and was made aware of the antibiotic transcription error. RN-M understood R51 to have at least received a total of 11 doses of the antibiotic on the PM shift and did not realize R51 had only received a total of 4 doses. RN-M stated had she been made aware of R51 receiving only 4 doses, she would have done something different such as prescribing additional antibiotics According to Medical Director (MD)-N and Vascular Surgeon (MD)-K, R51 had horrible blood flow with multiple failed endovascular attempts and with a failed stent that was not enough to establish blood flow to R51's foot resulted in the amputation of the right lower foot. Both MD-N and MD-K indicated the lack of antibiotics would not have mattered since there was a lack of blood flow to R51's foot. On 8/31/23, R51 went to an appointment with the vascular surgeon and was sent directly to the hospital from the vascular appointment for a right leg amputation. *R40 received insulin after R40 had already consumed 50% of their breakfast meal. R40 did not receive their insulin before their meal. *R20's Keppra was observed to be crushed during medication pass. Keppra is a medication that should not be crushed. Findings include: Facility policy, which is not dated, entitled Medication Administration, documented, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Policy Explanations and Compliance Guidelines: .14. Administer medications as ordered in accordance with manufacturer specifications . c.Crush medications as ordered. Do not crush medications with do not crush instructions . Example guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive. Medications requiring administration on empty stomach: .Insulin 1. R51 was admitted to the facility on [DATE] and had diagnoses including complete traumatic amputation of right great toe, atherosclerosis of the native artery with wet gangrene, protein calorie malnutrition and deep vein thrombosis. On 06/14/23, prior to hospitalization which led to placement at the facility, R51 had a right sided angiogram and revascularization of the anterior tibial and balloon angioplasty within the superficial femoral artery. R51 went to a vascular appointment on 08/31/23 and was sent to an acute care hospital for a right lower extremity amputation. R51 did not return to the facility. R51's admission Minimum Data Set Assessment (MDS), dated [DATE], documented R51 had an infection of the foot and a surgical wound but did not document antibiotic use. R51's care plan, initiated on 11/13/23 and revised on 11/13/23 document, Resident has potential for/Actual infection r/t (related to) right lower extremity amputation and wound; 7/28/23 Atherosclerosis of Native Artery of RLE (right lower extremity) with Wet gangrene S/P (Status post) Amputation and Surgical Intervention-Resolved 08/01/23; 08/25/23-right foot surgical site; and had interventions including, Administer antibiotics per physician order Amoxicillin ordered upon admission (7/28/23)-stop date 08/10/23; Doxycycline 100mg (milligrams) PO (by mouth) BID (twice a day) x (for) 10 days-stop on 09/08/23; 08/31/23-vascular appointment-sent to acute care hospital for amputation of the right lower extremity due to vascular insufficiency . (Surveyor noted R51's care plan date of 11/13/23 to be the date when Surveyor asked for the care plan to be printed. Surveyor noted all R51's care plans to have the same date of 11/13/23. Surveyor did not note the date until after Survey exit; however Surveyor did review R51's care plan prior to 11/13/23 and noted the same information to be in the care plan.) Surveyor reviewed R51's Electronic Health Record (EHR) and noted the following physician orders: Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG (Augmentin) Give 1 tablet by mouth two times a day every 11 day(s) for foot infection. This order had a start date of 07/29/23 and was discontinued on 08/01/23. Surveyor reviewed R51's Electronic Medication Administration Record (EMAR) and noted R51 received the Amoxicillin twice on 07/29/23, the Amoxicillin was not scheduled on 07/30/23 or 07/31/23 and the Amoxicillin was discontinued on 08/01/23. Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG (Augmentin) Give 1 tablet by mouth two times a day every 11 day(s) for foot infection until 08/10/2023. This order had a start date of 08/01/23 and was documented as completed on 08/10/23. Surveyor reviewed R51's EMAR and noted R51 received the Augmentin twice on 08/01/23. The Augmentin was not scheduled to be administered again due to order being transcribed as give twice a day every 11 days with a completed date of 08/10/23. Surveyor noted both above orders were transcribed to give the Augmentin twice a day every 11 days. Surveyor reviewed R51's hospital after visit summary, dated 07/28/23, and noted the following medication order: Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG (Amoxicillin & Pot Clavulanate), give one tablet every 12 hours for 27 doses, EOT (End of Therapy) 08/10/23. Surveyor noted the hospital discharge instructions documented to take the Augmentin twice a day until 08/10/23; however, the facility transcribed the order as Augmentin twice a day once every 11 days. Instead of R51 receiving the full 27 doses as ordered by the hospital, R51 only received four doses. The previous Director of Nursing (DON)-J wrote a late entry note dated 08/01/23, with a created date of 08/23/23, which documented, Resident was a new admission to facility on 7/28/23 with orders for Amoxicillin due to foot wound/infection. Recent hospitalization due to atherosclerosis of native artery of RLE with wet gangrene. Nursing called infectious disease to clarify antibiotic order with resident receiving 2 doses since admission to facility. Infectious diseases stated okay to discontinue as of this date and after admission to facility. Orders and care plan updated. On 11/13/23 at 10:00 AM, Surveyor interviewed DON-J. Surveyor asked DON-J about the above progress note. Per DON-J, she was not aware of the antibiotic transcription error until the middle of the month around 8/14/23. DON-J informed Surveyor she did not contact infectious disease until 08/14/23. Per DON-J, the above progress note was documentation from closing out her infection control tasks for the month of August. Surveyor noted from 08/01/23 to 08/10/23 the facility documented weekly wound assessments and changed the wound vac as scheduled. The facility did not document any changes to R51's wound. R51 went to a vascular wound appointment on 08/10/23 and returned with the following instructions for the facility, Wound has increased necrotic tissue in the base needs to break down tissue, foot is swollen; Orders: vac on hold for 2 weeks; RTC [sic] in 10 days; Adaptic over bone in upper parts of the wound; Dakin's 1/4 strength to Amputate Site daily-pack into wound undermining & cover-ace wrap to right foot daily; call with concerns or questions; wear post op shoe at all times. Surveyor noted this order was transcribed appropriately. On 8/14/2023 at 6:18 PM, DON-J documented in progress notes, called infectious disease to provide update on ABT (Antibiotic therapy) and see if future orders are needed - waiting for call back at this time. On 8/15/2023 at 11:02 AM, a nurse documented, Infectious disease clinic from Froedtert. New orders to discontinue current Augmentin therapy noted. Surveyor noted R51 was not on any antibiotics on 08/15/23 and had not received any antibiotics since 08/01/23. From 08/10/23 to 08/21/23 the facility continued with daily wound care. On 08/21/23, the following is documented in progress notes, Upon treatment of right foot surgical wound writer noted a deterioration in condition with increased purulent drainage and eschar now present. Resident, [name of Power of Attorney] MD (medical doctor), Surgeon, RD (Registered Dietician) notified of change in condition. Labs ordered for 8/22/23 and follow-up appointment with Vascular Surgery made for 8/24/23. On 8/24/2023 at 6:02 PM, a nurse documented, Resident returned from hospital wound care appointment at 1800 (6:00 pm) in stable condition. Copy of follow up apps (appointments) given to scheduler for transportation set up. New orders are as follows: Betadine to R (right) 3rd toe and skin edges daily. Continue with Dankins damp to dry daily and cover. Doxycycline monohydrate (antibiotic) 100mg BID x 14 days. Follow up app (appointment) with MD in 1 week . Orders updated . Surveyor noted the following order transcribed in R51's physician's orders: Doxycycline Monohydrate Oral Tablet 100 MG (Doxycycline Monohydrate), Give 1 tablet by mouth two times a day for treatment/prevention of infections for 14 Days. This order had a start date of 08/25/23 and a stop date of 09/08/23. On 08/31/23, R51 had an appointment with the vascular surgeon. Per documentation R51 was sent to the hospital directly from the vascular appointment for a right leg amputation. Per hospital documentation, the amputation was related to chronic limb ischemia and worsening gangrene. On 11/09/23 at 2:50 PM, Surveyor interviewed [name of hospital] Infectious Disease Registered Nurse (RN)-M via phone. Per RN-M, R51 had an Infectious Disease (ID) consultation while in the hospital and upon discharge orders were given for R51 to take Augmentin (Amoxicillin-Pot Clavulanate Oral Tablet 875-125) twice a day for 11 days. Per RN-M, the facility contacted ID on 08/14/23 to clarify antibiotic orders. RN-M stated this was the first time ID was aware that R51 did not receive the correct amount of antibiotics. Per RN-M, the antibiotic order was transcribed incorrectly by the facility. RN-M stated ID spoke with a nurse at the facility who informed them (ID) R51 had received the Augmentin daily on second shift but could not confirm if R51 had received the antibiotic on day shift. RN-M informed Surveyor the facility wanted to know if the antibiotics should be continued. RN-M stated she contacted the ID physician and pharmacist, who reviewed R51's labs and decided R51 most likely received enough Augmentin if it was given once a day. Per RN-M, ID was under the impression R51 received the Augmentin once a day for 11 days (11 doses total) instead of twice a day. Surveyor explained per facility documentation, R51 only received four doses. RN-M was not aware of that information and stated to Surveyor if ID had known R51 only received four doses instead of 11 doses, they (ID team) would have done something different, such as prescribe additional antibiotics. On 11/09/23 at 3:19 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C, DON-B and Regional Nurse Consultant (RN)-O. Surveyor asked what antibiotic orders R51 admitted with. Per ADON-C, R51 was admitted with two toes amputated and had gangrene. R51 had a wound vac and limited arterial blood supply. Per ADON-C, the wound vac was trialed to see if R51's foot was salvageable. ADON-C stated he was certain about R51's antibiotic orders. ADON-C informed Surveyor R51 was on something but it was canceled when R51 admitted to the facility. Surveyor asked about R51's Augmentin orders which were transcribed for twice a day every 11 days, but the hospital discharge information documented Augmentin twice a day for 11 days. ADON-C reviewed R51's EHR, and informed Surveyor he was uncertain because he did the wound care but the previous DON, DON-J, did the infection control aspect. ADON-C stated he was relatively new to the facility when R51 admitted and the current DON, DON-B was not at the facility when R51 was a resident. Surveyor relayed the concern of the antibiotic transcription error and asked when did the facility recognize the error and when was it reported to ID? Surveyor asked how many doses R51 actual received of the Augmentin? Surveyor relayed the information received from ID that R51 received 11 doses. Surveyor asked for clarification because according to R51's EMAR, R51 only received four doses total. ADON-C stated he was uncertain but would look into it and get back to Surveyor. On 11/13/23 at 8:33 AM, surveyor interviewed DON-B and ADON-C. DON-B provided Surveyor with a timeline of R51's admission. ADON-C informed Surveyor he had spoken with the facility's Medical Director (MD)-N. Per ADON-C, the MD-N was going to provide Surveyor with a signed statement documenting R51's right leg amputation was due to failed revascularization attempts and not related to the antibiotic transcription error. On 11/13/23 at 9:15 AM, Surveyor interviewed ADON-C. Per ADON-C, he did not personally speak with ID, but he had reviewed R51's EMAR/EHR and could only verify R51 received four doses of the Augmentin. Per ADON-C, he had spoken with MD-N and MD-N stated antibiotics are great if they are getting to where they need to go, but R51's stent had failed and R51 had major perfusion issues. ADON-C stated he would provide Surveyor with MD-N's signed statement as soon as he received it. On 11/13/23 at 10:00 AM, Surveyor interviewed DON-J via phone. Per DON-J, she thought ID was aware of how many Augmentin doses R51 had received. DON-J stated the facility had at least three nurses contact ID to discuss R51's antibiotic orders. Surveyor relayed the information received from ID that R51 received 11 doses of Augmentin and Surveyor asked if DON-J knew how many doses R51 received. DON-J stated she thought she saw that in a progress note but could not speak for certain and did not want to give Surveyor incorrect information. Per DON-J, the bigger issue with R51 was the lack of blood flow to the leg, not the missed antibiotics. On 11/13/23, Surveyor received a copy of MD-N's signed statement which documented in part, .Despite all efforts to salvage R51's limb with underlying necrotic tissue and gangrene, multiple wound care evaluations, as well as failed revascularization attempts by vascular surgery this patient had unavoidable amputation of toe. The missed antibiotic doses did not cause the decline in the wound to the foot rather the stent that was placed ultimately failed leading to lack of blood perfusion and unfortunately leading to AKA (Above the knee amputation). On 11/13/23 at 11:02 AM, Surveyor interviewed Vascular Surgery RN-L via phone. RN-L reviewed R51's notes and informed Surveyor R51 was seen by Vascular Surgery on 08/10/23 and everything was looking good. Per RN-L, the Nurse Practitioner (NP) that saw R51 on 08/10/23 documented R51 should be finishing ABT (antibiotic therapy) today. RN-L could not locate documentation they (vascular surgery) were aware that R51 did not receive the correct amount of Augmentin. Per RN-L, the NP that saw R51 on 08/10/23 may have ordered something different if they had been aware of the missed antibiotic doses. On 11/13/23 at 1:24 PM, Surveyor interviewed Vascular Surgeon, MD-K. MD-K was listed as R51's vascular surgeon. Per MD-K, R51 had horrible blood flow with multiple failed endovascular attempts. MD-K stated the stent was not enough and no matter what vascular surgery did, they could not establish blood flow to R51's foot. MD-K informed Surveyor the lack of antibiotics would not have mattered since there was a lack of blood flow to R51's foot. MD-K stated R51 either needed to have the RLE amputation or needed hospice care, which the family did not want. On 11/13/23 at 1:30 PM, Surveyor relayed the above information to ADON-C, and DON-B. 42037 2. R40 was admitted to the facility on [DATE] with diagnoses of Type Two Diabetes Mellitus, Hypertension and Dementia. R40's Annual MDS (Minimum Data Set) assessment dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. R40 was noted by surveyor to be non-interviewable at the time of this survey due to cognitive status. On 11/9/23 at 7:20 AM, Surveyor began to conduct the medication administration task to observe residents receiving their morning medications. Surveyor observed RN (Registered Nurse)-G throughout the medication administration task. On 11/9/23 at 8:35 AM, Surveyor observed R40 at the dining room table eating breakfast. R40 had completed approximately 50 % of their breakfast at this time. After checking R40's blood sugar, RN-G proceeded to draw up R40's morning insulin. Surveyor observed RN-G drawing up 14 units of Humulin 70/30 insulin in a syringe. Surveyor then observed RN-G drawing up 2 units of Novolog insulin into a separate syringe. Surveyor verified insulin dosing with RN-G at this time. RN-G administered R40's insulin at this time. On 11/9/23 at 8:40 AM, Surveyor conducted an interview with RN-G. Surveyor asked what the procedure would be for administering insulin to residents regarding meal intake. RN-G responded to Surveyor that R40 was not ready for their insulin and it is hard to stay in compliance and give R40 their insulin prior to meal times per physician order. On 11/9/23 at 11:20 AM, Surveyor conducted interview with ADON (Assistant Director of Nursing)-C in the presence of DON (Director of Nursing)-B. Surveyor asked ADON-C if procedures such as insulin administration should be provided after a resident eats their meal. ADON-C confirmed that residents should always receive their insulin medication prior to meals. Surveyor informed ADON-C of observations of RN-G administering R40's insulin after R40 had already consumed 50% of their breakfast meal. On 11/9/23 at 3:10 PM at the daily exit meeting, Surveyor informed NHA (Nursing Home Administrator)-A of the observations of RN-G administering R40's morning insulin after R40 had consumed 50% of their breakfast. The facility did not provide any additional information to the Survey team at this time. 3. R50 was admitted to the facility on [DATE] with diagnoses of alcohol abuse, epilepsy and hypertension. R50's admission Minimum Data Set, dated dated dated [DATE] notes R50 with a Brief Interview for Mental Status score of 12, indicating R50 has mild cognitive impairment. Surveyor attempted to conduct an interview with R50 at the time of Survey. R50 did not wish to speak Surveyor at this time as they were tired and preferred to rest in their room. On 11/9/23 at 7:20 AM, Surveyor began to conduct the medication administration task to observe residents receiving their morning medications. Surveyor observed RN-G throughout the medication administration task. On 11/9/23 at 8:35 AM, Surveyor observed R50 at the dining room table eating breakfast. Surveyor watched RN-G prepare R50's morning medications including Keppra (an extended release seizure medication) 750 mg. RN-G proceeded to crush R50's medications and combine with applesauce before administration to R50. On 11/9/23 at 8:40 AM, Surveyor conducted interview with RN-G. Surveyor asked RN-G if delayed release or extended release medications should be crushed before administrating to residents. RN-G did not have a response for Surveyor at this time. On 11/9/23 at 11:20 AM, Surveyor conducted interview with ADON-C in the presence of DON-B. Surveyor asked ADON-C if delayed release or extended release medications should be crushed before administrating to residents. ADON-C told Surveyor it would be contraindicated to crush extended release medications. Surveyor reported to ADON-C that RN-G administered R50's morning dosage of Keppra extended release to R50 after crushing the medication. ADON-C told Surveyor that they would look into this matter and see if any medications could be administered in a liquid form instead. On 11/9/23 at 3:10 PM at the daily exit meeting, Surveyor reported observations of RN-G administrating Keppra extended release to R50 after crushing their medications. No additional information was provided by the facility at this time.

Based on observation, interview and record review, the facility did not ensure the medication error rate was below 5%. During medication pass, surveyors observed 6 errors out of 32 opportunities with a medication error rate of 18.75%. 3 (R40, R20, and R50) of 6 residents observed during the medication administration task did not receive their medication as ordered. *R40 received their scheduled morning insulin (Humulin and Novolog) after eating 50% of their breakfast. *R20 received their scheduled Omeprazole - extended release reflux medication after eating 25% of their breakfast meal. According to the Assistant Director of Nursing (ADON)-C Omeprazole should be administered on an empty stomach. Surveyor informed ADON-C of observations of RN-G administering Omeprazole after R20 had began eating their breakfast meal. *R50 received their scheduled extended release reflux medication Omeprazole after eating 50% of their breakfast meal. R50 also received extended release seizure (Keppra) and pain medication (Tylenol). Surveyor observed all 3 of these medications crushed prior to administration. Assistant Director of Nursing (ADON-C) informed Surveyor the Omeprazole should be administered on an empty stomach and it would be contraindicated to crush extended release (Omeprazole, Keppra, and Tylenol) medications. Findings include: 1. R40 was admitted to the facility on [DATE] with diagnoses of Type Two Diabetes Mellitus, Hypertension and Dementia. R40's Annual MDS (Minimum Data Set) assessment dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. R40 was noted by surveyor to be non-interviewable at the time of this survey due to cognitive status. On 11/9/23 at 7:20 AM, Surveyor began to conduct the medication administration task to observe residents receiving their morning medications. Surveyor observed RN (Registered Nurse)-G throughout the medication administration task. On 11/9/23 at 8:35 AM, Surveyor observed R40 at the dining room table eating breakfast. R40 had completed approximately 50 % of their breakfast at this time. After checking R40's blood sugar, RN-G proceeded to draw up R40's morning insulin. Surveyor observed RN-G drawing up 14 units of Humulin 70/30 insulin in a syringe. Surveyor then observed RN-G drawing up 2 units of Novolog insulin into a separate syringe. Surveyor verified insulin dosing with RN-G. RN-G administered R40's insulin at this time. On 11/9/23 at 8:40 AM, Surveyor conducted interview with RN-G. Surveyor asked what the procedure would be for administering insulin to residents regarding meal intake. RN-G responded to Surveyor that R40 was not ready for their insulin and it is hard to stay in compliance and give R40 their insulin prior to meal times per physician order. On 11/9/23 at 11:20 AM, Surveyor conducted an interview with ADON (Assistant Director of Nursing)-C in the presence of DON (Director of Nursing)-B. Surveyor asked ADON-C if procedures such as insulin administration should be provided after a resident eats their meal. ADON-C confirmed that residents should always receive their insulin medication prior to meals. Surveyor informed ADON-C of observations of RN-G administering R40's insulin after R40 had already ate 50% of their breakfast meal. On 11/9/23 at 3:10 PM at the daily exit meeting, Surveyor informed NHA (Nursing Home Administrator)-A of the observations of RN-G administering R40's morning insulin after R40 had eaten 50% of their breakfast. The facility did not provide any additional information to the Survey team at this time. 2. R20 was admitted to the facility on [DATE] with diagnoses of Dementia, Malnutrition and Epilepsy. R20's Quarterly Minimum Data Set assessment dated [DATE] indicates a Brief Interview for Mental Status score of 06, indicating severe cognitive impairment. R20 was noted by surveyor to be non-interviewable at the time of this survey due to cognitive status. On 11/9/23 at 7:20 AM, Surveyor began to conduct the medication administration task to observe residents receiving their morning medications. Surveyor observed Registered Nurse (RN)-G throughout the medication administration task. On 11/9/23 at 8:22 AM, Surveyor observed R20 at the dining room table eating breakfast. R20 had completed eating approximately 25% of their breakfast at this time. Surveyor observed RN-G approach R20 and proceed to administer R20's morning dose of Omeprazole 20mg. On 11/9/23 at 8:40 AM, Surveyor conducted interview with RN-G. Surveyor asked RN-G if residents should be receiving Omeprazole with meals or on an empty stomach. RN-G did not have a response for Surveyor at this time. On 11/9/23 at 11:20 AM, Surveyor conducted interview with Assistant Director of Nursing (ADON)-C in the presence of Director of Nursing (DON)-B. Surveyor asked ADON-C if Omeprazole should be administered with meals or on an empty stomach. ADON-C responded that Omeprazole should be administered on an empty stomach. Surveyor informed ADON-C of observations of RN-G administering Omeprazole after R20 had began eating their breakfast meal. On 11/9/23 at 3:10 PM at the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A of the observations of RN-G administering R20's Omeprazole after eating 25% of their breakfast meal. No additional information was provided by the facility at this time. 3. R50 was admitted to the facility on [DATE] with diagnoses of alcohol abuse, epilepsy and hypertension. R50's admission Minimum Data Set, dated dated dated [DATE] notes R50 with a Brief Interview for Mental Status score of 12, indicating R50 has mild cognitive impairment. Surveyor attempted to conduct an interview with R50 at the time of Survey. R50 did not wish to speak Surveyor at this time as they were tired and preferred to rest in their room. On 11/9/23 at 7:20 AM, Surveyor began to conduct the medication administration task to observe residents receiving their morning medications. Surveyor observed Registered Nurse (RN)-G throughout the medication administration task. On 11/9/23 at 8:35 AM, Surveyor observed R50 at the dining room table eating breakfast. R50 had completed eating approximately 50% of their breakfast of this time. Surveyor observed RN-G approach R50 and speak with them. R50 complained of wrist pain at the time of RN-G's assessment. Surveyor watched RN-G prepare R50's morning medications including Keppra (an extended release seizure medication) 750 mg, Omeprazole delayed release 20 mg and Tylenol extended release 650 mg. RN-G proceeded to crush these medications and combine with applesauce before administration to R50. On 11/9/23 at 8:40 AM, Surveyor conducted an interview with RN-G. Surveyor asked RN-G if residents should be receiving Omeprazole with meals or on an empty stomach. RN-G did not have a response for Surveyor at this time. Surveyor asked RN-G if delayed release or extended release medications should be crushed before administrating to residents. RN-G did not have a response for Surveyor at this time. On 11/9/23 at 11:20 AM, Surveyor conducted interview with Assistant Director of Nursing (ADON)-C in the presence of Director of Nursing (DON)-B. Surveyor asked ADON-C if Omeprazole should be administered with meals or on an empty stomach. ADON-C responded that Omeprazole should be administered on an empty stomach. Surveyor asked ADON-C if delayed release or extended release medications should be crushed before administrating to residents. ADON-C told Surveyor it would be contraindicated to crush extended release medications. Surveyor informed ADON-C of observations of RN-G administering Omeprazole after R20 had began eating their breakfast meal. Surveyor reported observations of RN-G administrating Omeprazole delayed release, Keppra extended release and Tylenol extended release to R50 after crushing the 3 medications. ADON-C told Surveyor that they would look into this matter and see if any medications could be administered in a liquid form instead. On 11/9/23 at 3:10 PM at the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A of the observations of RN-G administering R50's Omeprazole after eating 50% of their breakfast meal. Surveyor reported observations of RN-G administering delayed release Omperazole, extended release Keppra and extended release Tylenol to R50 after crushing the 3 medications. No additional information was provided by the facility at this time.

Based on observation, interview and record review the facility did not ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 (R35) residents reviewed. R35 did not have a rolled up washcloth in his right hand per his care plan and therapy recommendations. Findings include: R35 admitted to the facility on [DATE] and has diagnoses that include Cerebral Palsy, quadriplegia, convulsions, Neuromuscular Scoliosis, Angelman Syndrome, Adult Failure to Thrive and muscle spasm. Surveyor noted R35 has contractures of bilateral upper and lower extremetities documented since admission. R35's Quarterly Admission/Readmission/Routine Head-to-toe Evaluation dated 10/19/23 documents: Musculoskeletal: Does the resident have contractures? Yes. Bilateral lower and upper extremities. Resident has severe contractures of upper and lower extremities due to Cerebral Palsy. R35's Quarterly Minimum Data Set (MDS) dated [DATE] section GG0115, Functional Limitation in Range of Motion documents: Upper extremity (shoulder, elbow, wrist, hand) Lower extremity (hip, knee, ankle, foot) impairment both sides. R35's Care Plan Focus area documents: Self care deficit r/t (related to) cognitive deficits, disease process/progression r/t congenital Cerebral Palsy and Angel syndrome- initiated 7/16/21. Interventions include: - Splint or brace assistance: Apply rolled up wash cloth in right hand between thumb web space for contracture/skin integrity management (resident's Mom made colorful washcloths that resident appears to like) Wear for 4 hours as tolerated (resident occasionally releases washcloths on his own) ask resident if he wants to keep it before reapplying it - initiated 1/9/23. On 11/8/23 at 9:55 AM Surveyor observed R35 lying in bed as a staff member entered his room with a Hoyer lift. On 11/8/23 at 10:08 AM Surveyor observed R35 sitting up in his wheelchair in his room. The TV was on and R35 had pillows for positioning behind his head, on his left side, under his feet and between his knees. Surveyor noted R35's left wrist was bent and his hand was slightly open. R35's right hand was contracted in a fist. Surveyor noted R35 did not have a rolled washcloth in his right hand as per his care plan. On 11/8/23 at 11:59 AM Surveyor observed R35 lying in bed on his back. Surveyor observed R35's left hand to be open and his right hand in a fist. R35 did not have a rolled washcloth in his right hand as per his care plan. On 11/9/23 at 7:10 AM Surveyor observed R35 lying in bed on his back, slightly to the left side. Surveyor noted R35 did not have a rolled washcloth in his right hand as per the care plan. On 11/9/23 at 11:40 AM Surveyor observed R35 lying in bed on his back, there was no rolled washcloth in his right hand as per the care plan. Surveyor spoke with Registered Nurse (RN)-G. Surveyor asked if R35 has splints for his hands. RN-G stated: No. He's pretty contracted, has been for a long time. Surveyor asked RN-G if R35 wears palm protectors or anything else in his hands. RN-G stated: No. I guess they could put a rolled washcloth or towel, but he's pretty contracted. On 11/9/23 at 12:00 PM Surveyor spoke with Certified Nursing Assistant (CNA)-H who reported she usually works the unit and is familiar with R35. Surveyor asked CNA-H if R35 has splints or anything for his hand contractures, to which CNA-H stated: No. Surveyor asked if R35 wears palm protectors or anything else in his hand. CNA-H stated: No, not that that I know of. On 11/9/23 at 1:10 PM Surveyor spoke with Therapy Director-I regarding when R35 was last seen in therapy and what were the recommendations. Therapy Director-I reported on 1/6/23 therapy recommendations were to place a rolled washcloth in his right hand and range of motion exercises. Therapy Director-I reported R35 does not have splints because he is not able to tolerate them. Surveyor review of Therapy Recommendations dated 1/6/23 document: Splint or brace assistance - apply rolled up wash cloth in pt's (patients) right hand between thumb web space for contracture/skin integrity management. *Pt's Mom made colorful washcloths that pt appears to like. *wear for 4 hours as tolerated - pt occasionally releases wash cloth on his own; ask pt if he wants to keep it before reapplying it. On 11/9/23 at 1:27 PM Surveyor advised Nursing Home Administrator (NHA)-A of Surveyors observations while on survey R35 did not have rolled up washcloth in his right hand per therapy recommendations and care plan. Surveyor advised NHA-A of interviews with staff indicating they were not aware of the care plan interventions of the rolled washcloth to his right hand. Surveyor noted R35's weekly skin checks dated 11/5/23 and 11/12/23 documented skin intact. On 11/13/23 at 10:13 AM Surveyor observed R35 lying in bed, dressed with a Hoyer sling under him. Surveyor observed a rolled washcloth in his right hand. Surveyor observed CNA-H outside the room with Hoyer lift. CNA-H reported she was waiting for help to get him up. Surveyor advised CNA-H that I noticed he has a rolled washcloth in his hand today. CNA-H stated: Yes, I put it in this morning. Surveyor asked CNA-H if she was aware of any colored ones R35's mother made. CNA-H stated: No, but she'll be in today, so I'll ask her about it. Surveyor asked CNA-H how she knew to put a rolled washcloth in R35's right hand. CNA-H stated: I looked at his care plan. Surveyor asked to observe R35's right hand which revealed intact skin with no signs or symptoms of breakdown.

Based on observation, interviews and record review the facility did not ensure that residents are free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms and document ongoing re-evaluation of the need for restraints for 1 of 1 (R35) residents reviewed for restraints. R35 had a seat belt restraint in use on his wheelchair (w/c). There was no physician's order, careplan, consent or monitoring of the restraint. Findings include: The facility policy titled Restraint Free Environment which is not dated, documents (in part) . .It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definitions: Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: - Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising. Compliance Guidelines: 1. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms. 2. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by practitioner, unless the resident has previously made a valid refusal of the treatment in question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of physical restraints. 4. A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use restraint. 5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: a. How the use of restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released, c. The type of direct monitoring and supervision that will be provided during use of the restraint. 6. Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. R35 admitted to the facility on [DATE] and has diagnoses that include Cerebral Palsy, Quadriplegia, convulsions, Neuromuscular Scoliosis, Angelman Syndrome, muscle spasms and Adult Failure to Thrive. R35's Annual Minimum Data Set (MDS) dated [DATE] section P0100, Physical Restraints documents: Trunk restraint - not used. R35's Quarterly MDS dated [DATE] section P0100, Physical Restraints documents: Trunk restraint - not used. Section GG0115, Functional Limitation in Range of Motion documents: Upper extremity (shoulder, elbow, wrist, hand) - impairment both sides. On 11/8/23 at 10:08 AM Surveyor observed R35 sitting in his wheelchair in his room. The TV was on and R35 had positioning pillows behind his head, left side, under his feet and between his knees. Surveyor observed a seat belt connected around his waist. On 11/8/23 at 11:59 AM Surveyor observed R35 lying in bed on his back. Surveyor observed a seat belt strap hanging on the right side of the wheelchair. Surveyor review of R35's medical record revealed no Physician's order, care plan, consent or ongoing monitoring of the seat belt restraint. Review of R35's medical record revealed a Quarterly Safety Device Audit Assessment Tool dated 1/17/23. Surveyor noted this was the first audit assessment tool completed by the facility in R35's medical record. The form documented: Does the Device Restrict Movement, Does the Device Prevent resident from performing a movement they would otherwise be capable of performing, Does the device assist in the improvement in the resident's functional status - NO. Can the resident independently AND on command remove device - NO. Device for this resident is considered (check mark) restraint. Comments: Resident does not have enabler bars due to dependent with bed mobility. Resident does have seat belt on wheelchair. Consent signed by POA (Power of Attorney). Surveyor located an Admission Safety Device Audit Assessment Tool dated 3/6/23 which documented: Does the Device Restrict Movement - YES. Does the Device Prevent resident from performing a movement they would otherwise be capable of performing - YES. Can the resident independently AND on command remove device? NO On 11/8/23 at 3:18 PM During the daily exit meeting with the facility, Surveyor asked for R35's Safety Device Audit Assessment Tools and evidence of consent signed by R35's POA. Surveyor advised the facility of concern R35's medical record does not contain a Physician's order, Care Plan or consent for the seat belt restraint and there is no evidence of ongoing monitoring of the restraint on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). On 11/9/23 at 8:51 AM Surveyor spoke with Director of Nursing (DON)-B. DON-B advised Surveyor she did an audit on everyone in the facility and R35 is the only resident with a restraint. DON-B reported R35 has Cerebral Palsy and has muscle spasms and body flailing at times. DON-B stated: I did see that he did not have a physician order or care plan, so I did call for an order and updated his care plan. He's had the seat belt since admission. I completed a new audit assessment tool and I talked to his mother, she said he's had the seat belt for years prior to admission. We completed a risk/benefit tool as well. On 11/9/23 at 1:02 PM Surveyor spoke with MDS-F and advised R35's annual and quarterly MDS' do not document the seat belt (restraint). MDS-F stated: I knew he had a seat belt at one point, I didn't know they were still using it, that's why it's not on the MDS. After Surveyor identified concern, Surveyor noted the following: Physician order dated 11/9/23 - Use w/c belt while up in w/c for safety and positioning. Document every shift for w/c belt placement and proper positioning. R35's care plan was updated: The resident uses physical restraints (belt on w/c) r/t (related to) cerebral palsy and quadriplegia, has spastic movements - date Initiated: 11/8/23. Interventions include: - Discuss and record with the resident/family/caregivers, the risks and benefits of the restraint, when the restraints should/will be applied, routines while restrained and any concerns or issues regarding restraint use. - Document every shift when up in w/c on placement and proper positioning of w/c lap belt. - Ensure the resident is positioned correctly with proper body alignment while restrained. - Risk and benefits explained to responsible party. Resident could have a seizure and slide down in chair and choke, could fall out of chair and cause injury up to and including death. TAR: Use w/c belt while up in w/c for safety and positioning. Document on placement and proper positioning q (every) shift. Every shift for w/c belt placement and proper positioning - start date 11/9/23. Consent obtained from residents Mother (Guardian) 11/8/23. On 11/9/23 at 3:00 PM during the daily exit meeting, Surveyor advised Nursing Home Administrator (NHA)-A and DON-B of concern the facility was using a seat belt restraint on R35 in the w/c without a physician's order, care plan or consent and there was no evidence of ongoing monitoring of the restraint. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure that 2 (R40, R20) of 12 residents were provided with personal privacy during medical treatment with the administration of medications (insulin and tear drops) and obtaining testing R40's blood sugar. * On 11/9/23, R40 was not provided with personal privacy during the administration of insulin and when R40's blood sugar was tested while in the dining room. * On 11/9/23, R20 was not provided with personal privacy when her tear drop medication was administered while in the dining room. Findings include: 1. R40 was admitted to the facility on [DATE] with diagnoses of Type Two Diabetes Mellitus, Hypertension and Dementia. R40's Annual MDS (Minimum Data Set) assessment dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. R40 was noted by surveyor to be non-interviewable at the time of this survey due to cognitive status. On 11/9/23 at 7:20 AM, Surveyor began to conduct the medication administration task to observe residents receiving their morning medications. Surveyor observed RN (Registered Nurse)-G throughout the medication administration task. On 11/9/23 at 8:35 AM, Surveyor observed R40 at the dining room table eating breakfast. R40 had completed approximately 50 % of their breakfast at this time. Surveyor observed RN-G approach R40 and proceed to check R40's blood sugar at the dining room table with 4 other residents present in the dining room. After checking R40's blood sugar, RN-G proceeded to draw up R40's morning insulin. Surveyor observed RN-G drawing up 14 units of Humulin 70/30 insulin in a syringe. Surveyor then observed RN-G drawing up 2 units of Novolog insulin into a separate syringe. Surveyor verified insulin dosing with RN-G at this time. RN-G proceeded to lift R40's shift up at this time, exposing their bare abdomen at the dining room table. RN-G administered both insulin injections at this time into R40's abdomen at the dining room table. On 11/9/23 at 8:40 AM, Surveyor conducted interview with RN-G. Surveyor asked what the procedure would be for administering insulin to residents regarding meal intake. RN-G responded to Surveyor that R40 was not ready for their insulin and it is hard to stay in compliance and give R40 their insulin prior to meal times. Surveyor asked RN-G if it was a common occurrence to administer blood glucose testing or insulin administration in the dining room. RN-G did not have a response for Surveyor at this time. On 11/9/23 at 11:20 AM, Surveyor conducted interview with ADON (Assistant Director of Nursing)-C in the presence of DON (Director of Nursing)-B. Surveyor asked ADON-C if procedures such as blood glucose testing and insulin administration should be provided in the facility's dining rooms. ADON-C responded that these procedures should always be performed with residents receiving privacy, typically in resident rooms. Surveyor informed ADON-C of observations of RN-G administering blood glucose testing in the dining room in front of other residents and staff. Surveyor informed ADON-C that RN-G had administered R40's insulin in the dining room into R40's exposed abdomen in front of other residents and staff. ADON-C confirmed that RN-G should have provided R40 with privacy during blood glucose testing and insulin administration. On 11/9/23 at 3:10 PM at the daily exit meeting, Surveyor informed NHA (Nursing Home Administrator)-A of the observations of RN-G administering blood glucose testing in the dining room in front of other residents and staff. Surveyor also informed NHA-A of the observations of RN-G administering R40's insulin in the dining room into R40's exposed abdomen in front of other residents and staff. The facility did not provide any additional information to the Survey team at this time. 2. R20 was admitted to the facility on [DATE] with diagnoses of Dementia, Malnutrition and Epilepsy. R40's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. R20 was noted by surveyor to be non-interviewable at the time of this survey due to cognitive status. On 11/9/23 at 7:20 AM, Surveyor began to conduct the medication administration task to observe residents receiving their morning medications. Surveyor observed Registered Nurse (RN)-G throughout the medication administration task. On 11/9/23 at 8:22 AM, Surveyor observed R20 at the dining room table eating breakfast. Surveyor observed RN-G approach R20 and proceeded to administer artificial tear drops to R20 at the dining room table with 4 other residents present in the dining room. On 11/9/23 at 8:40 AM, Surveyor conducted interview with RN-G. Surveyor asked RN-G if it was a common occurrence to administer eye drops to residents in the dining room. RN-G did not have a response for Surveyor at this time. On 11/9/23 at 11:20 AM, Surveyor conducted interview with Assistant Director of Nursing (ADON)-C in the presence of Director of Nursing (DON)-B. Surveyor asked ADON-C if a resident's eye drop administration should be provided in the facility's dining rooms. ADON-C responded that eye drops should be administered in private, typically in resident rooms. Surveyor informed ADON-C of observations of RN-G administering R20's eye drops in the dining room in front of other residents and staff. ADON-C confirmed that RN-G should have provided R20 with privacy during eye drop administration. On 11/9/23 at 3:10 PM at the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A of the observations of RN-G administering R20's eye drops in the dining room in front of other residents and staff. The facility did not provide any additional information to the Survey team at this time.