Every finding on record at The North Shore Estates LLC

Based on interview and document review, the facility failed to ensure allegations of potential verbal abuse and rough handling were immediately reported to the administration and State agency (SA) for 1 of 4 residents (R2) reviewed. A nursing assistant (NA) roughly handled R2 and made demeaning comments to him on 6/20/26 which were observed by another staff member; however, these allegations were not reported to the administrator until several days later; nor were they ever reported to the SA. Findings include: R2's admission Minimum Data Set (MDS), dated [DATE], identified R2 was non-verbal, had cognitive impairment, and demonstrated behaviors which placed himself and others at significant risk of harm or injury. R2's care plan, dated 6/30/26, identified R2 as a categorically vulnerable adult (VA) due to residing in the care center. R2 had decreased cognition, reduced physical abilities, and was non-verbal using mostly sign language or photo boards to communicate. Further, the care plan outlined R2 had impaired mobility and used a Hoyer with assistance of two staff to complete transfers. During interview on 7/7/26 at 12:05 p.m., nursing assistant (NA)-A stated they had worked with R2 and described him as a resident who repeatedly causes issues with other residents due to his behaviors. R2 did not speak, liked to pick at people, and at times would get super upset and strike at others or himself. NA-A stated they just recently had given a statement to the director of nursing (DON) about R2 and some concerning events during cares they had observed happen with NA-E present. NA-A explained they felt NA-E was provoking the crap out him [R2] on 6/20/26 as cares were completed. NA-A stated they both were in R2's room and needed to place the mechanical lift sling underneath R2, and R2 was resistive to it and not allowing it, but then NA-E suddenly grabbed R2's head and pulled it down like super hard against his will. NA-A stated aloud, I don't think you should do that. NA-E then proceeded with help with cares and transfer while making verbal comments to R2 like calling him crazy and telling R2 that NA-E hopes he gets a brain aneurysm [due to his behavior]. NA-A stated they had never seen NA-E treat another resident like that before and felt it was abusive adding, You never keep aggravating somebody. NA-A stated they did not immediately report these concerns to the nurse working or administration as they were reluctant to speak out against NA-E. NA-A stated they spoke about the situation with their family member and then decided to report it to the DON. NA-A stated they reported it they thought on the Friday after it happened (6/26). NA-A stated there had been no follow-up about it since then or any re-education about reporting provided adding, I haven't heard anything since I've given my statement. During interview on 7/7/26 at 12:42 p.m., licensed practical nurse (LPN)-A stated they had worked with NA-E prior and tried to keep them out of R2's room whenever able as they seemed to butt heads with each other. LPN-A stated they were aware of something recently which happened between R2 and NA-E which involved something inappropriate being said to R2. LPN-A stated NA-E seemed to make comments which were weird often and gave an example of telling someone to run after something even though they (NA-E) knew the person was unable to physically run. LPN-A stated several residents had voiced concerns about NA-E and didn't want them to provide care for them. LPN-A had never seen NA-E be purposefully abusive to a resident, however, stated NA-E seemed to have just one of those senses of humor. The staff were trying to always do a cares in pairs with R2 now. When told about comments potentially said to R2 by a staff member (as explained by NA-A), LPN-A stated those comments were not OK and would be considered verbally abusive. The Centers for Medicare and Medicaid (CMS) iQEIS system, used to track complaint investigations and facility-reported incident (FRI) reports, was reviewed on 7/7/26. It lacked evidence that the allegations witnessed and reported to DON by NA-A were submitted to the SA. Further, R2's medical record was reviewed and lacked evidence of these allegations or what, if any, actions were taken to address them (i.e., reported, investigated). On 7/7/26 at 3:35 p.m., a group interview was held with licensed practical nurse unit manager (LPN)-B, the DON, and the administrator. It was explained that NA-E was awkward at times but overall was never intending to harm a resident or someone to their knowledge. DON verified that NA-A had come and reported some concerns about NA-E and R2 but was unable to recall the exact date when. DON stated they were unable to remember exactly what had been reported but recalled it was during placement of a mechanical lift sling and NA-E had pulled [R2] forward. DON reiterated, I don't recall exactly what was said to me [reported]. DON stated they had maybe written some notes and would look for them and provide, if located. The administrator stated they were made aware of the concerns right after the DON was and then called some of the other staff members who had worked on the same shift that day. None of the other staff saw or had anything reported to them about it. They called NA-E who denied the comments being said in that manner but rather in a manner like, You're going to give yourself an aneurysm [if he kept doing the behaviors]. The team verified if an NA witnessed something potentially abusive it should be immediately reported to them which did not happen with this situation. The administrator stated, That's the expectation. The team also acknowledged that comments as reported by NA-A would be credible allegations of potential verbal abuse. The administrator stated they did not report the allegation to the SA as they were able to gather enough evidence to unsubstantiate the allegation before the window to report (i.e., two hours) was through after they were made aware. It was a he said, she said allegation and NA-E denied making the comments or being rough with care. Later, at 4:44 p.m., the administrator provided their investigation into the allegations (SEE F610) and the DON provided their notes about the allegation they had made. The administrator stated they had up to 24 hours to report an allegation if they suspected abuse had happened and had two hours to report if the allegations were 100% abuse [known to have occurred]. The administrator reiterated they did not report the allegations to the SA as they investigated it and felt they had enough evidence to determine that the allegations were not credible. A notebook sheet, dated 6/30/26, (provided by DON) identified handwritten items on it. Both NA-A and NA-E's name were on top along with writing which read, [NA-E] - rude & agressive [sic] to residents. Pulled [R2] head forward. I hope you get a brain anneurysm [sic] a brain bleed. [NA-E] was restricting him. [R2] stating - unable to make statement. The facility Abuse Prohibition/Vulnerable Adult Policy, dated 11/2025, identified all staff were responsible for reporting any situation that would be considered abuse or neglect. The supervisor would evaluate the situation and take actions to protect residents. The administrator was to be immediately notified for any instances of abuse, both alleged and suspected. Further, the policy identified abuse (including verbal abuse) should be reported to the SA not later than two hours after the suspicion of abuse was identified.

Based on interview and document review, the facility failed to ensure allegations of physical and verbal abuse were thoroughly investigated and adequate follow up to prevent ongoing abuse for 1 of 4 residents (R2) reviewed. A nursing assistant (NA) had allegedly roughly handled R2 and made demeaning comments to him on 6/20/26 which were observed by another staff member; however, these allegations were not reported to the administrator until several days later nor thoroughly investigated to determine if abuse had occurred. Further, the delay in reporting allowed the alleged perpetrator (NA-E) to continue working unsupervised with other residents despite the allegations. Findings include: R2's admission Minimum Data Set (MDS), dated [DATE], identified R2 was non-verbal, had cognitive impairment, and demonstrated behaviors which placed himself and others at significant risk of harm or injury. R2's care plan, dated 6/30/26, identified R2 as a categorically vulnerable adult (VA) due to residing in the care center. R2 had decreased cognition, reduced physical abilities, and was non-verbal using mostly sign language or photo boards to communicate. Further, the care plan outlined R2 had impaired mobility and used a Hoyer with assistance of two staff to complete transfers. During interview on 7/7/26 at 12:05 p.m., nursing assistant (NA)-A stated they had worked with R2 and described him as a resident who repeatedly causes issues with other residents due to his behaviors. R2 did not speak, liked to pick at people, and at times would get super upset and strike at others or himself. NA-A stated they just recently had given a statement to the director of nursing (DON) about R2 and some concerning events during cares they had observed happen with NA-E present. NA-A explained they felt NA-E was provoking the crap out him [R2] on 6/20/26 as cares were completed. NA-A stated they both were in R2's room and needed to place the mechanical lift sling underneath R2, and R2 was resistive to it and not allowing it, but then NA-E suddenly grabbed R2's head and pulled it down like super hard against his will. NA-A stated aloud, I don't think you should do that. NA-E then proceeded with help with cares and transfer while making verbal comments to R2 like calling him crazy and telling R2 that NA-E hopes he gets a brain aneurysm [due to his behavior]. NA-A stated they had never seen NA-E treat another resident like that before and felt it was abusive adding, You never keep aggravating somebody. NA-A stated they did not immediately report these concerns to the nurse working or administration as they were reluctant to speak out against NA-E. NA-A stated they spoke about the situation with their family member and then decided to report it to the DON. NA-A stated they reported it they thought on the Friday after it happened (6/26). NA-A stated there had been no follow-up about it since then or any re-education about reporting provided adding, I haven't heard anything since I've given my statement.During interview on 7/7/26 at 12:42 p.m., licensed practical nurse (LPN)-A stated they had worked with NA-E prior and tried to keep them out of R2's room whenever able as they seemed to butt heads with each other. LPN-A stated they were aware of something recently which happened between R2 and NA-E which involved something inappropriate being said to R2. LPN-A stated NA-E seemed to make comments which were weird often and gave an example of telling someone to run after something even though they (NA-E) knew the person was unable to physically run. LPN-A stated several residents had voiced concerns about NA-E and didn't want them to provide care for them. LPN-A had never seen NA-E be purposefully abusive to a resident, however, stated NA-E seemed to have just one of those senses of humor. The staff were trying to always do a cares in pairs with R2 now. When told about comments potentially said to R2 by a staff member (as explained by NA-A), LPN-A stated those comments were not OK and would be considered verbally abusive. R3's quarterly MDS, dated [DATE], identified R3 had intact cognition and demonstrated no delusional thinking or hallucinations. On 7/7/26 at 1:05 p.m., R3 was interviewed after they yelled into the hallway for the surveyor to come into their room. R3 stated there was a NA who worked on the evening shifts which they heard was rough with cares from other residents. R3 identified NA-E by name and stated they seem to get rough with residents more who aren't normal [cognitively impaired]. R3 stated NA-E will help others and she could hear audible screams and yells from the closed door to their rooms which was very concerning. R3 stated NA-E had never abused her, but R3 reiterated a concern for other residents about NA-E adding, It needs to be dealt with though.R4's quarterly MDS, dated [DATE], identified R4 had intact cognition and demonstrated no delusional thinking. When interviewed on 7/7/26 at 1:25 p.m., R4 stated they had been cared for by NA-E and [didn't] like the way he handled me. R4 explained she had been hospitalized and when returned, NA-E wouldn't physically help her but rather just stood there and kept saying, You can do it. R4 stated she was exhausted and weak from being hospitalized and NA-E not helping her then made her upset adding, I find [NA-E] to be pretty much heartless. R4 stated they had seen the same thing happen with other residents, too, where NA-E would tell people who cannot stand up that they'd have to stand up to get help. R4 stated there had been an [AGE] year old resident on the unit prior who would wait in the dining room and yell, Help me, out loud but NA-E would just let the resident sit there and wait which R4 felt was rude and poor care. R4 added, [NA-E] would help everyone else and just let her sit there [despite yelling for help]. R4 stated NA-E had never been verbally or physically abusive to her, however, had heard other residents voice they felt NA-E was abusing to people. R4 added, I hear that [NA-E] is mean to some people. On 7/7/26 at 1:49 p.m., a telephone call was placed the LPN-D who was listed as the nurse for the shift NA-E worked on 6/20/26. However, a return call was not received. R2's medical record was reviewed and lacked evidence the allegations of potential abuse were acted upon, investigated or what, if any, measures were taken to protect R2 from continued abuse since 6/20/26, when the allegations were witnessed by NA-A. No completed incident reports about the allegation were located. On 7/7/26 at 3:35 p.m., a group interview was held with licensed practical nurse unit manager (LPN)-B, the DON, and the administrator. It was explained that NA-E was awkward at times but overall was never intending to harm a resident or someone to their knowledge. DON verified that NA-A had come and reported some concerns about NA-E and R2 but was unable to recall the exact date when. DON stated they were unable to remember exactly what had been reported but recalled it was during placement of a mechanical lift sling and NA-E had pulled [R2] forward. DON reiterated, I don't recall exactly what was said to me [reported]. DON stated they had maybe written some notes and would look for them and provide, if located. The administrator stated they were made aware of the concerns right after the DON and then called some of the other staff members who had worked on the same shift that day. None of the other staff saw or had anything reported to them about it. They called NA-E who denied the comments being said in that manner but rather in a manner like, You're going to give yourself an aneurysm [if he kept doing the behaviors]. The team verified if an NA witnessed something potentially abusive it should be immediately reported to them which did not happen with this situation. The administrator stated, That's the expectation. The team also acknowledged that comments as reported by NA-A would be credible allegations of potential verbal abuse. The administrator stated the allegation was a he said, she said situation and NA-E denied making the comments or being rough with care. The administrator stated they recalled taking some notes about their investigation and would provide those. DON and administrator verified NA-E was not removed from the schedule or assigned any direct supervision despite the allegations as they felt the allegation was not credible given their investigation immediately after being told of the allegations by NA-A. There had also been no corrective actions done for NA-E as there was no proof it happened. Later, at 4:44 p.m., the administrator provided their investigation into the allegations and the DON provided their notes about the allegation they had made. A notebook sheet, dated 6/30/26, (provided by DON) identified handwritten items on it. Both NA-A and NA-E's name were on top along with writing which read, [NA-E] - rude & agressive [sic] to residents. Pulled [R2] head forward. I hope you get a brain anneurysm [sic] a brain bleed. [NA-E] was restricting him. [R2] stating - unable to make statement. A printer sheet, undated, identified typed wording which recorded R2 had lived at the care center since 4/2026 and was primarily non-verbal but could nod yes-or-no for responses. The sheet had several statements typed which identified NA-A reported on 6/30/26, that on 6/20/26 they had been caring for R2 with NA-E. R2 did not want to move his upper body forward, so NA-E pulled R2's head forward to place a sling underneath him. R2 was then hitting himself in the head which was not uncommon. NA-A reported NA-E made a comment to R2, I hope you hurt yourself. NA-E was interviewed at 12:43 p.m. (6/30) and denied pulling on R2's head. NA-E told R2 to stop hitting himself or he would hurt himself. NA-E denied the comments reported by NA-A and stated R2 could be challenging to work with. LPN-B was interviewed at 1:15 p.m. and denied having concerns reported about NA-E by NA-A on the 6/20/26 shift. Two other NA(s) were interviewed and denied knowledge of the incident. The note recorded, [R2] asked if [NA-E] hurt him. [R2] shook his head no. The note concluded, Please note, [DON], worked as CNA 6/21/2026, with [NA-E] and had no concerns. She assisted with taking care of [R2] and there were no concerns, or skin issues. The investigation lacked any recorded interviews with other residents to help determine if concerns with NA-E's care were present on the same shift or since; it lacked evidence of what corrective actions the facility had completed with NA-A or NA-E about this incident and the late reporting of it; and it further lacked evidence of what, if any, protections were placed for R2 while these items were being investigated or since the allegations. The interview continued, and administrator stated they had up to 24 hours to report an allegation if they suspected abuse had happened and had two hours to report if the allegations were 100% abuse. The administrator reiterated they did not report the allegations to the SA as they first investigated it and felt they had enough evidence to determine that the allegations were not credible within those two hours after being notified of them. The administrator verified they interviewed no other residents who had received care from NA-E on 6/20/26 as part of their investigation. DON was asked how they determined R2 did not feel abused by the verbal comments made to him and responded by saying they had asked R2 if anyone had hurt them to which R2 did a head nod in a 'no' response. DON verified they did not use any sign language or other communication attempts to interview R2 (despite a potential misunderstanding being possible of 'hurt' [i.e., physically abused] versus told demeaning comments [i.e., verbal abuse]).When interviewed on 7/7/26 at 4:31 p.m., NA-E stated they had worked at the care center for several years and typically worked on the evening shift. NA-E was asked about the events from 6/20/26 while helping R2 and expressed they were unable to recall ever pulling R2 by his head or neck to place a sling underneath him. NA-E adamantly denied making comments such as calling R2 crazy and responded aloud, I never said anything like that! NA-E stated the administrator had called them about a week ago and asked about the comments made to which NA-E denied making them. NA-E stated they were never removed from the schedule or placed on supervised care since the allegation and remained working their assigned shifts. NA-E stated they were told by leadership to basically steer clear of R2 as much as able was all for follow-up. NA-E wondered why someone would wait for so long to report concerns like that to administration if they saw it happen and felt it was likely just someone who didn't like NA-E at the care center making those accusations. NA-E verified they had been given training by the care center on abuse and reporting. NA-E was unable to recall when they had last completed it but felt it was discussed at a team meeting within the last month or so. NA-E stated allegations of abuse should be reported to leadership within 24 hours and reiterated their denial of treating R2 rough or verbally abusing him. The facility's daily schedules, dated 6/20/26 through 7/7/26, were provided and had no markings on the sheets to demonstrate any restrictions on NA-E's workload. NA-E was listed as working on the PM shift for the following dates: 6/21/26, 6/24/26, 6/25/26, 6/29/26, 6/30/26, 7/1/26, 7/3/26, 7/4/26, and 7/5/26. The facility Abuse Prohibition/Vulnerable Adult Policy, dated 11/2025, identified all staff were responsible for reporting any situation that would be considered abuse or neglect. The supervisor would evaluate the situation and take actions to protect residents. If the suspected perpetrator was a staff member, they would be immediately suspended until the investigation was completed. The administrator was to be immediately notified for any instances of abuse, both alleged and suspected, and abuse (including verbal abuse) should be reported to the SA not later than two hours after the suspicion of abuse was identified. The policy section labeled, Investigation/Protection, identified the investigation would begin immediately and staff would take action to prevent further abuse. Incident reports would be reviewed, and the investigation may include interviews with staff, other residents, and witnesses.

Based on observation, interview, and document review, the facility failed to ensure behaviors, including behaviors which were bothersome to other residents, were comprehensively assessed and interventions developed to ensure a consistent, therapeutic approach was done for 1 of 4 residents (R2) reviewed. R2 demonstrated physical and verbal behaviors with care and others which were not assessed to develop consistent interventions the staff could attempt or use while providing care. Findings include: R1's quarterly MDS, dated [DATE], identified R1 had intact cognition and demonstrated no delusional thinking. On 7/7/26 at 11:07 a.m., R1 was interviewed outside the nursing home main entrance. R1 stated he had lived at the care center for several years and liked the place except for some issues with another resident. R1 stated he was being bothered by another resident, R2, and had even been hit by him a few times describing the hitting as both with a closed fist but also a slapping motion. R1 stated they were not sure if R2 was intending or hurt him with the repeated slaps and hits but expressed the repeated altercations with R2 were a real strainer mentally, and R1 was fearful he was going to strike R2 back if they continued. R1 stated he felt always on guard when out of his room due to R2 being around and his behaviors. R2's admission Minimum Data Set (MDS), dated [DATE], identified R2 as non-verbal and demonstrated no delusional thinking or hallucinations during the review period. R2 had multiple medical conditions including aphasia (neurological brain disorder which impairs speaking) and cerebral palsy (permanent movement disorder). R2 demonstrated behaviors which placed himself and others at risk of harm and interfered with care. R2's corresponding Behavioral Symptoms Care Area Assessment (CAA), dated 4/30/26, identified an actual problem existing for behavior as R2 had multiple documented episodes of hitting/kicking during the look-back period. R2 was non-verbal and staff reported deficits in both short and long-term memory. A PHQ-9 was completed which identified mild depression. The CAA identified behavioral concerns would be care-planned with an objective to minimize decline and risk. The CAA added, IDT will continue to follow resident care plan and refer additional services as needed. However, the CAA lacked any further data or analysis of the behavioral incidents (i.e., time of day happened, events immediately prior which could have triggered it, staff working with him when happened, other residents involved, etc.). On 7/7/26 at 12:02 p.m., R1 was observed seated in an electric wheelchair next to the nurses' station on the second floor. R2 wheeled out to the same area from the dining room and stopped right next to R1. Neither of them interacted with the other. No staff attempted to separate them. R1 then turned to the left and visited with nursing assistant (NA)-A who was standing at the desk. R1 then left the area. Following, on 7/7/26 at 12:05 p.m., NA-A stated R1 had voiced frustrations with R2 recently as R2 was a resident who repeatedly causes issues and at times would bother people. R2 liked to pick at people and go into others' rooms and take things. R2 was non-verbal and R1 had reported that R2 would try to hit me [him]. NA-A stated they had never actually seen R2 physically hit R1 or any other resident, but R2 did strike out at staff with cares. NA-A stated the nurses were aware of R2's behavior and the NA staff to try to keep an eye on [R2] as best able. NA-A stated there were no formal safety checks or anything for R2, rather it was just trying to make sure staff know his location and check on him when able adding, It's when I have time. NA-A stated there was not really any direction to do that from the nurses rather it was just a more personal thing I started on my own. When interviewed on 7/7/26 at 12:23 p.m., NA-D stated they worked with R2 and were aware R1 was bothered by R2. R1 had reported being able to only put up with so much before he took action himself with R2. NA-D stated R2 did, at times, strike staff members during cares and NA-D felt it was all about the approach with R2 as they'd never really had issues with him like the other staff report. NA-D stated R2 was, at times, on cares in pairs and felt that might be causing some behavior as it was too stimulating for R2. R2 seemed to accept care better from certain staff members than others but there were no consistent staffing attempts (i.e., just have same people work with him) with R2 to NA-D's knowledge.R2's progress notes, dated 4/29/26 to 7/7/26, identified multiple episodes of behaviors. These included:On 6/20/26, an eMAR note identified, Was a behavior observed? YES. The note lacked any further information on what the specific behavior was or what staff did to reduce/improve it.On 6/21/26, an eMAR note identified, Was a behavior observed? YES. However, again, the note lacked any further information on what the specific behavior was or what staff did to reduce/improve it.On 6/27/26, R2 was sent to the hospital for having exacerbated behaviors . hit one other resident and while trying to get him to bed he hit two staff members. R1 returned the next morning from the ED with orders to adjust the psychotropic medications. On 6/29/26, R2's psychotropic medication was increased after consent was given by the guardian. When interviewed on 7/7/26 at 12:42 p.m., licensed practical nurse (LPN)-A stated R2 came to the nursing home from a smaller group home but was unable to return there due to his poor mobility status now. Management was aware of R2's behaviors and were trying to find him a better location to get care. LPN-A stated they had noticed R2 seemed to purposely go behind R1 and target him a little more than others for whatever reason. LPN-A stated they thought R2 was maybe just bored as it was hard to get him focused on activities. The staff attempted multiple things like using his tablet, calling his family and playing movies but the effectiveness was usually short-lived. LPN-A stated R2 did hit out at staff during cares and LPN-A reiterated a smaller setting for R2 was needed in their opinion. LPN-A stated any assessment or care planning for behavioral interventions would be done by the nurse manager team and reported there were no other interventions for R2 aside from the things mentioned adding, Nothing that come to the top of my head. LPN-A stated they had noticed that R2 seemed to enjoy soda pop so staff would, at times, buy one and reward him with pop for good behavior or allowing cares. LPN-A stated it wasn't something told to them to try but rather something the staff had identified as something that makes him happy. On 7/7/26 at 1:18 p.m., a call was placed to trained medication aide (TMA)-A for interview. A return call was received on 7/8/26 at 11:37 a.m., and TMA-A explained R2 was bothersome to R1 to the point R1 had asked them (TMA-A) to make a grievance and place it in the director of nursing (DON) mailbox on the outside of her office door. R1 was upset and felt management was acting on R2 to do anything about the situation. TMA-A stated they felt R2 was more aware of his actions than people believed as R2 seemed to circle R1 like he's looking for a reaction. TMA-A added, I do believe [R2] is culpable [with some of the issues]. TMA-A stated they had only ever been told observe R2 and report issues, if noticed. TMA-A stated they were unaware R2 enjoyed soda pop, and nobody had ever mentioned trying to use that to better get R2 to cooperate with cares. R2's behavior care plan, dated 6/2/26, identified R2 had an alteration in mood and behavior due to ongoing adjustment to placement at the care center. R2's medical conditions were listed and the plan identified R2 had a history of restlessness, agitation, withdrawing, and attempting to hit staff. R2 had a history of previously attempting to inappropriately touch staff during cares. R2 was noted to hit himself and bite himself at times and would holler out when brought to his room. A goal was listed which read, Resident's mood/behavioral state will remain stable. The plan listed several interventions which included communicating clearly with R2 on cares to be provided and giving him a fidget gadget during physical care, giving R2 reminders of upcoming care prior to starting them, offering to call family members or play music, and monitoring target behaviors per protocol. However, the plan lacked any evidence of the interventions the floor staff had identified as being effective with R2 including using soda pop as incentive or having the same, consistent staff providing direct care whenever able as they seemed to have more success with care than others. R2's Treatment Administration Record (TAR), dated 7/2026, identified the current treatments being done for R2 by the nursing staff. These included, Target Behavior Monitoring . restless . agitation . withdrawn, and listed non-pharmacological interventions to be attempted and recorded if behavior was witnessed. The interventions included re-direction, ambulation, activities, and repositioning. The effectiveness of the interventions would then be recorded in the progress notes. The TAR recorded no behaviors being displayed or interventions done for R2 for the period. R2's medical record was reviewed and lacked evidence the IDT had comprehensively assessed R2 for his behaviors to determine what, if any, patterns were identified or how they arrived at the interventions listed on the care plan. The record lacked evidence that the IDT had reviewed or considered the interventions the floor staff determined to be helpful in getting R2 to show improved behavior or allow cares, such as soda pop or consistent staff members being assigned to him. The record also lacked evidence that the resident-to-resident interactions which were bothersome to others had been evaluated or had interventions assigned to address them. On 7/7/26 at 2:17 p.m., a call was placed to R2's identified guardian. However, they were not reached.On 7/7/26 at 2:36 p.m., a group interview was held with the DON, licensed practical nurse unit manager (LPN)-B, and social services director (SSD). The administrator joined the interview at 2:40 p.m. SSD explained when someone admitted to the care center, that staff would try to learn behaviors and the IDT would adjust the care plan accordingly. The social workers reviewed progress notes and then a target behavior monitoring form would be completed in the medical record. SSD reviewed the record and stated R2 might not have one yet as it wasn't a full quarter since he had admitted . The TAR was reviewed, and the group verified only three items were being tracked for R2 including restlessness, agitation, and withdrawn behavior. The administrator stated they were actively seeking other placement options for R2 but had not secured anything so far due to family wanting to keep him in the Duluth area. The group expressed R2 was not always hitting people but rather would grab them or tap them to get attention due to being non-verbal. The staff could use the tablet to distract or occupy R2 if needed. They acknowledged being aware R1 did not like R2's presence and the corresponding issues between them. R1 was being addressed with a possible room change and seeing psychiatry to help with emotions. The administrator explained behaviors were discussed and tracked in the morning meeting using a spreadsheet which was not part of the medical record. SSD stated the completion of the assessment (i.e., target behavior form) was only done quarterly as that was policy, and if staff don't communicate with them (IDT) on interventions they see work, then the care plan wouldn't get updated with that information. The administrator stated they would review the medical record for the IDT assessment process of R2's behaviors and provide it, if located. SSD stated it was important to assess behaviors and care plan the interventions to show what actions had been taken, what worked or did not work, and that the center was not ignoring the issue. No further information was received.A facility policy on behavioral assessment was requested; however, none was received.

Based on observation, interview, and document review the facility failed to ensure the following infection prevention measures occurred: utilization of proper isolation signage, handwashing, appropriate utilization of personal protective equipment (PPE) by staff, proper handling of laundry to prevent bacteria growth, and proper hand sanitization during meal tray pass to residents in their rooms. These deficient practices had the potential to impact all residents who resided at the facility. Isolation Signage and PPE Usage R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was cognitively intact with diagnoses of hypertension, acute kidney failure, bipolar, and schizophrenia. R35 quarterly MDS dated [DATE], indicated R35 was cognitively intact with diagnoses of end stage renal disease with dialysis, diabetes and hypertension. R56's comprehensive MDS dated [DATE], indicated R56 was cognitively intact with the diagnoses of heart failure, acute kidney failure, and diabetes. The facility document Residents Currently on Precautions sent on 2/10/26, identified 34 residents on precautions including: R9: contact and droplet precautions for cough, runny nose congestion, negative influenza, covid and RSV. R35: enhanced barrier precautions for dialysis and wound and contact and droplet precautions for human metapneumovirus. R56: contact and droplet precautions for human metapneumovirus. Facility isolation signs from the Centers for Disease Control and Prevention (CDC) instructed staff to do the following: -Droplet Precautions: everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Picture of face mask and eye protection. Remove face protection before exit. -Contact Precautions: Everyone must clean their hands before entering and when leaving the room. Providers must also put on gloves before entry and discard gloves before room exit. Put on gown before room entry and discard gown before exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable medical equipment. Clean and disinfect reusable equipment before use on another person. -Enhanced barrier precautions: everyone must clean their hands including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing lines, providing hygiene, changing briefs or assisting with toileting. Device care or use for: central line, urinary catheter, feeding tube, tracheostomy and wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. The CDC Appendix A Guidelines for Isolation Precautions last updated 9/2024, recommended Contact precautions plus standard precautions for mask use when caring for individuals with human metapneumovirus. During an observation on 2/9/26 at 12:53 p.m., the following signs were on the following resident doors door: -R9: contact and droplet precautions -R35: contact and droplet precautions -R56: contact and droplet precautions During an observation on 2/9/26 at 1:00 p.m., of the low two hundred wing it was noted the hallway did not have any wall mounted hand sanitizer dispensers. There were 9 isolation carts in the hallway. Only one cart was noted to have a small bottle of hand sanitizer on top of the cart. During an observation on 2/9/26 at 1:00 p.m., nursing assistant (NA)-B entered R9's room. Prior to entry NA-B did not sanitize hands, or apply gown, gloves, or a mask as the contact and droplet precautions signs on R9's door instructed. During a follow-up interview on 2/9/26 at 6:52 p.m., NA-B stated they believed they had a mask on, but if they were just bringing in food or something, then they would not put all the PPE (personal protection equipment) on. NA-A stated masks and PPE were important to wear for infection prevention reasons. During an observation on 2/9/26 at 6:45 p.m., registered nurse (RN)-Centered R9's room which now only had a droplet precautions sign on the door (the contact precautions sign was gone). RN-C exited the room with a standing transfer device and parked it in the hallway. Prior to entering the room RN-C did not sanitize hand, apply mask, gown, or gloves. At 6:47 p.m., RN-C applied gloves and used sanitizing wipes to clean the standing transfer device parked in the hallway. At 6:48 p.m., RN-C entered R35's room which now only had a droplet precautions sign on the door. Prior to entering the room RN-C did not apply mask, gown, or gloves. RN-C exited R35's room at 6:51 p.m. During an interview on 2/9/26 at 6:56 p.m., RN-C looked at R9's door and confirmed they saw the droplet sign and stated they should have put a mask on before they entered R9 and R35's room. In their mind the residents were on enhanced barrier precautions. RN-C stated it would be important to wear a mask for droplet precautions to prevent the spread of what the residents had. On 2/9/26 at 7:01 p.m., RN-C returned and stated they had checked, and R9 and R35 were probably done with isolation, but they needed to have their rooms deep cleaned before they could come off droplet precautions. During an observation on 2/10/26 at 9:50 a.m., R9 and R35 and R56's doors had droplet precautions signs on the door. During an observation on 2/11/2026 at 7:24 a.m., R9 and R25's rooms had droplet isolation signs on their doors. There were no contact isolation signs on the door. During an observation on 2/11/26 at 7:30 a.m., laundry aide (LA)-F knocked on resident door (with a contact precautions sign on the door) to deliver laundry. LA-F opened the top drawer of the isolation cart and then proceeded down the hallway checking several carts for hand sanitizer. NA-C instructed LA-F to look in the storeroom for hand sanitizer bottles. LA-F exited the storeroom without hand sanitizer and proceeded down the hallway checking carts. LA-F found a bottle of hand sanitizer, sanitized hands, applied gown, gloves and then entered the resident room. During an observation on 2/11/26 in the a.m., NA-C came down the hallway from the nursing station area, applied a mask only and entered R35's room. NA-C asked R35 if they would put a mask on, R35 stated they never had before, but agreed and placed a mask on before being wheeled down the hallway by NA-C for an outside appointment. During an interview on 2/11/26 at 2:15 p.m., NA-C stated staff went by the isolation signs on the door to know what PPE to wear and the night nurse had also given a rundown of what residents were in isolation for. NA-C confirmed R35 and R9's doors had droplet isolation signs only on them. NA-C stated they knew they should also gown and glove in addition to droplet precautions to go into those rooms because of shift hand off from the night nurse. During an interview on 2/11/26 at 3:40 p.m., the director of nursing stated (DON) the company infection prevention tool indicated droplet precautions should be used for residents with Human Metapneumovirus. The DON looked at the company tool and stated it did not cite any sources of information. The DON stated they had had contact and droplet precaution signs on R9 and R35's doors but due to an internal discussion on signage, the contact precaution signs must have been taken down by another staff member. During an observation with the DON on 2/12/26 at 8:27 a.m., the DON went through the isolation carts on the low 200 hallway. One of seven carts had a small bottle of hand sanitizer in the top drawer, the rest of the carts had none. The DON stated all the carts should be stocked with hand sanitizer and then asked health information manager (HIM)-H to stock all isolation carts with hand sanitizer. During an interview on 2/12/26 at 8:30 a.m., both the DON and an infection preventionist licensed practical nurse (LPN-A) were present. The DON stated they had reviewed CDC Appendix A and discovered their company reference tool was incorrect and needed to be updated. Contact precautions and masks should be used for human metapneumovirus, not just droplet precautions. LPN-A reviewed the facility isolation signs and confirmed the droplet precautions sign only instructed staff to wear face and eye coverings. The DON stated their original signage of contact and droplet precautions covered correct PPE but the current droplet signage for R9, R35, and R56 was not adequate. The DON confirmed enhanced barrier precautions should be continued for residents requiring additional precautions. Contact precautions would cover enhanced barrier precautions, but droplet precautions alone did not direct staff to wear appropriate PPE for resident cares. The DON listed expectations for the following isolation types: -Enhanced barrier precautions: staff should follow the direction on the sign and wear appropriate PPE based on task performed. -Contact precautions: staff are expected to always put on the PPE listed on the sign before they entered a contact precaution room for any reason. -Droplet: staff should be putting on PPE before entering the room even if they are just going in to ask a question. Regarding hand sanitization, the DON stated it was their expectation that staff would sanitize their hands either at a sink or with hand sanitizer before and after entering resident rooms. They also expected staff to keep each isolation cart stocked with hand sanitizer at all times. LPN-A stated they had done isolation and PPE education during a recent respiratory outbreak and during their September 2025, skills fair. During an observation on 2/12/26 at 9:36 a.m., all of the isolation carts in the low 200 hallway had hand sanitizer bottles. R9 and R35's doors had contact precautions signs on the door. The droplet precaution signs had been removed. There was no signage that indicated staff should wear face covering (mask). The facility Infection Prevention and Control Program dated 11/2024, included implementing appropriate isolation precautions when necessary and following established general and disease-specific guidelines such as those of the Centers for Disease Control as important facets of infection prevention. Laundry Department During an observation on 2/10/26 at 1:07 p.m., housekeeper (H)-A opened the laundry area door and stated the laundry staff were gone for the day. The second washing machine closest to the clean laundry side of the room had a load of laundry washing. During an interview on 2/11/26 at 9:44 a.m., LA-F confirmed they had put a load of laundry in at the end of their shift on 2/10/26. They had been told they could not leave the dryer running when they left for the day, but it was okay for them to put a load of laundry in at the end of the day to take care of in the morning. LA-F stated they were not aware of any infection prevention concerns with leaving laundry in the washing machine overnight. During an interview on 2/11/26 at 10:10 a.m., the house keeping supervisor (HS) stated they had been in their position about a year. In the training they had received, they were told it was okay to start a load at the end of the day to process in the morning, but it was not okay to leave the dryer running when staff left for the day. During an interview on 2/12/26 at 8:30 a.m. both the DON and LPN-A were present. The DON stated laundry should not be left in washing machines overnight because it gave mold and/or bacteria an opportunity to grow. If laundry got left over night, it should be re-washed before going into the dryer. Hand Hygiene and PPE Use R3's annual MDS dated [DATE], identified intact cognition and diagnoses of infection and inflammatory reaction of left knee prosthesis, a multidrug-resistant organism (MDRO), and direct infection of the right elbow. R3 was dependent with transfers, set-up assistance for eating, and partial to moderate assistance for dressing and grooming. R3's care plan identified a focus statement dated 1/12/26, identifying R3 had a current infection and included an intervention for isolation precautions. On 2/9/26, a focus statement for contact isolation precautions identified staff to follow isolation precautions, infection control precautions per protocol, sign on resident's door, and treatment for current infection per order. R3's provider order dated 1/12/26, identified an order for staff to follow contact precautions every shift. During an observation on 2/9/26 at 2:36 p.m., NA-H knocked and entered R3's room, which had a Contact Precautions sign on the outside of the door, and then exited shortly after with a water mug. At 2:38 p.m., NA-H returned with a water mug and went back into the room. NA-H stated the sign was there because R3 has had surgeries and incisions, a line and some wounds. NA-H explained you wouldn't need to wear a gown if you were just going in there. During an observation on 2/10/26 at 11:24 a.m., two unidentified NAs entered R'3 room with a mechanical sling lift. Neither NA donned PPE at the PPE station in the hallway outside R3's door. During an observation and interview on 2/11/26 at 7:23 a.m., trained medication aid (TMA)-A entered R3's room with a vitals stand and didn't don PPE. At 7:26 a.m., TMA-A stated R3 had wounds, so you had to gown up to do her wounds. During an interview on 2/12/26 at 12:05 p.m., RN-A, a nurse manager for the first floor, stated R3 was on contact precautions because she had methicillin-resistant staphylococcus auris (MRSA) in a wound and has had multiple surgeries. RN-A described contact precautions would be used any time you are coming in physical contact with their belongings or things in their room, but if you were just setting down a tray you wouldn't need to. On 2/9/26 at 4:55 p.m., the evening meal cart arrived on the second floor. The cart was brought to the East hallway. There were clothing covers on the top of the cart, no evidence of hand wipes. - at 4:58 p.m., nursing assistant NA-B brought a tray into R55's room and exited with a different tray. - at 4:59 p.m., NA-B wearing gloves exited R8's room carrying a tray and placed it on the bottom rack of the meal cart. NA-B, wearing the same gloves went back into R8's room carrying a different tray into the room. Upon exiting the room NA-B was still wearing gloves and pushed the cart further down the hall (no glove change or hand hygiene was performed). NA-B brought a tray into R25's room, exited the room still wearing gloves and placed the entrée cover on the bottom rack of the cart, next picked up two packets of sour cream and brought them into R25's room. NA-B was heard offering to open the sour cream packets, the response was no, NA-B exited the room with the sour cream packets and placed them back on the cart. NA-B, still wearing the same gloves, closed the cart and moved it down the hall. NA-B, wearing the same gloves, brought a tray into R53's room after knocking on the door. -at 5:05 p.m., NA-B still wearing the same gloves picked up a tray that was on a cart in the hallway, placed the tray in the food cart, closed the cart and moved it down the hallway. -at 5:06 p.m., NA-B removed the gloves they had been wearing and held them in their left hand. -at 5:07 p.m., NA-B answered R23's call light and adjusted their overbed table so they could eat their meal. During an interview on 2/9/26 at 5:08 p.m., NA-B stated they usually wore gloves when they delivered meal trays. NA-B verified they wore the same gloves while delivering new trays and when they picked up used trays. NA-B verified they did not perform hand hygiene after removing their gloves. During an interview on 2/12/26 at 3:53 p.m., the director of nursing (DON) verified staff should perform hand hygiene before and after delivering each resident tray. The DON verified she would expect staff to wear gloves if they were going to touch any food. The DON stated it was important to follow good hand hygiene to prevent infection and the spread of bacteria. The policy Handwashing dated 2/2024, identified proper hand-washing techniques should be used to protect the spread of infection. The policy identified hand washing should be completed before and after caring for someone who is sick.

Based on interview and document review, the facility failed to ensure allegations of abuse were reported within 24 hours to the State Agency (SA) for 1 of 1 resident (R11) reviewed for abuse.Findings include:R11's five-day Minimum Data Set (MDS) dated [DATE], identified R11 had diagnoses which included displaced intertrochanteric fracture of left femur with routine healing, paroxysmal atrial fibrillation (an irregular and often fast heart rhythm), insomnia, anxiety, and chronic pain. In addition, R11's MDS identified she was cognitively intact and received scheduled and as needed pain medications for frequent pain.A complaint was submitted to the state agency on 10/28/25, at 1:11 p.m., related to misappropriation of property. It was reported that R11 had stated she had slept through the night without any pain medication. The reporter noted pain medications had been signed out twice overnight for the resident.The facility was made aware of the allegation by the reporter on 10/20/25, the facility completed an investigation at the time but did not report the allegation to the SA.During an interview on 2/11/26 at 2:27 p.m., nurse practitioner (NP)-B recalled the reporter telling her about the concerns they had. NP-B gave the reporter the phone number to the SA and advised them to report their concerns. The NP-B recalled discussing the concern with the nurse manager and recalled the facility completed an investigation.During an interview on 2/11/26 at 2:58 p.m., registered nurse (RN)-A stated they could not recall any recent concerns related to a possible problem with narcotics.During an interview on 2/11/26 at 3:06 p.m., the administrator verified they completed an investigation related to potential narcotic diversion in October of 2025. The administrator verified they did not report the allegation to the SA.The Abuse Prohibition/Vulnerable Adult Policy dated 11/2025, identified the following, If the suspected Neglect, Exploitation, or Misappropriation of resident property did not result in serious bodily injury, the reports must be made within 24 hours.

Based on interview and document review the facility failed to ensure proper procedure, documentation and accounting procedures were followed for controlled substances reviewed for narcotic diversion. Findings include:During an interview on 2/11/26 at 12:46 p.m., trained medication aide (TMA)-A stated R11 had told them they were proud they had not taken any narcotics over the weekend. TMA-A looked in the narcotic book and saw there had been oxycodone (a strong prescription opioid analgesic) signed out to R11. TMA-A reported this to the facility on [DATE], and to R11's provider.During an interview on 2/11/26 at 2:27 p.m., nurse practitioner (NP)-B stated she recalled the TMA talking to her about their narcotic concerns, she advised them to report the concern, she discussed it with the facility and modified narcotic orders for residents to reflect what residents were using in regard to narcotics.During an interview on 2/12/26 at 8:37 a.m., the administrator stated the alleged perpetrator (AP)-B did not show any signs of impairment and administered a lot of pain medication because they worked a lot. The administrator stated they investigated the concern, but they did not report the allegation to the state agency.Narcotic book page 28 hydrocodone/APAP [acetaminophen] (a combination prescription opioid with a non-opioid pain reliever) 10-325 milligrams (mg) dated 8/25/25 at 0945 dropped on floor signed by AP-B, no second signature.Narcotic book page 105 oxycodone 15 mg dated 10/9/25 at 5:18 a.m., dropped signed by AP-B and second staff.Narcotic book page 146 hydrocodone (opioid pain medication)12/20/25 at 00:41 a.m., dropped on floor signed by AP-B, no second signature.Narcotic book page 57 lorazepam (short-acting benzodiazepine [central nervous system depressant])0.5 mg 11/10/25, no time documented, destroyed signed by AP-B and second staff.Narcotic book page 47 lorazepam 2 mg dated 12/25/25 at 3:45 p.m., med destroyed signed by AP-B and second staff.Narcotic book page 57 lorazepam dated 12/28/25 at 3:45 p.m., med destroyed signed by AP-B and second staff.A review of R45 progress notes dated11/10/25, 12/25/25, and 12/28/25, did not reveal any progress notes identifying why the lorazepam was destroyed on those dates.Narcotic book page 110 oxycodone 5 mg dated 1/25/26 at 7:49 a.m., number 3 pill missing from card.During an interview on 2/12/26 at 2:30 p.m., the administrator stated they did not know what number 3 pill missing meant.During an interview on 2/12/26 at 2:49 p.m., registered nurse (RN)-D stated when she discovered pill number 3 missing, she called the on call nurse to report the concern. RN-D stated the count at change of shift was totally unfocused, alarms were going off and they didn't notice there was a pill missing from the bubble pack. RN-D stated she heard later from AP-B that it had been taken care of, and the missing pill was found in the suboxone box.During an interview on 2/12/26 at 3:56 p.m., the director of nursing (DON) reviewed page 110 where the oxycodone pill number three was noted to be missing. The DON checked her text messages and verified she was informed about the missing medication. She was not able to recall anything else about the incident stating she believed she asked RN-D if she found it. She could not verify if the missing medication was investigated. Narcotic book page 71 morphine (a potent opioid analgesic) 15 mg dated 2/10/26at 6:00 p.m., not signed out, a sticky note was attached to the page, AP-B please sign for 2/10/26. The residents electronic medical record documented the time given as 4:13 p.m., two hours prior to the medication being signed out.A review of four narcotic books in use did not have any other staff wasting, destroying or dropping medications on the floor except for AP-B.During an interview on 2/12/26 at 12:52 p.m., R35 stated she could not recall any staff dropping medications, she stated she did not drop her medications either. R35 stated specifically AP-B, doesn't' drop anything.During an interview on 2/12/26 at 4:40 p.m., AP-B stated the process for wasting a narcotic was to have an RN witness the destruction. AP-B stated it was not part of the process to write a progress note explaining why a medication was destroyed and not given. For page 105 wrong card, they said they must not have followed the five rights of medication administration. AP-B stated for page 105 the resident would drop the medication on the floor. For page 146, they stated they did not know why there was not a second signature documented. For pages 7, 47, 57, said sometimes the resident would be sleeping and they couldn't wake them to give the medication again stating there was no protocol requiring a progress note but stated it would be good to document why a medication was not given. For page 28 was again not sure why there was not a second signature documenting the waste.During an interview on 2/12/26 at 3:35 p.m., the consultant pharmacist (CP)-J stated they had not been made aware of the facility's investigation of possible narcotic diversion. CP-J stated they should have been involved in the investigation.During an interview on 2/12/26 at 3:56 p.m., the DON stated a nurse should assess a resident prior to a TMA giving an as needed narcotic and there should have been a progress note documenting the assessment.The policy Disposal of Medications and Medication-Related Supplies dated 2025, identified the following, When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of [two licensed nurses], and the disposal is documented on the accountability record/book on the line representing that dose.IIA2: Discrepancies, loss and/or diversion of Medications dated 2025, identified this would be reported to the DON and CP immediately, a facility incident report would be filed, an investigation would occur, corrective action would be taken, and appropriate agencies would be notified. In addition, the policy identified the following, If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited.Preparation and General Guidelines dated 2025, identified the following, If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is [initialed and circled]. If electronic MAR is used, documentation of the unadministered dose is done as instructed by the procedures for use of the eMAR system. An explanatory note is entered on the reverse side of the record. If [XX consecutive doses] of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response.Addendum: Trained Medication Aide (TMA) dated 10/3/20, identified the following, Documents after administration the date, time, dosage and method of administration of all medications or reason for not administering the medication as ordered, including the signature of the nurse or physician who is authorized to administer.

Based on observation, interview, and document review the facility failed to ensure medications were properly stored and secured during medication pass. In addition, the facility failed to ensure floor stock melatonin, 3 milligrams (mg) administered to residents was pharmaceutical grade. These deficient practices had the potential to impact all residents on or who could access the second floor and/or receive melatonin 3 mg.Findings include:Med Pass:During an observation on 2/11/26 at 8:39 a.m., registered nurse (RN)-B stepped away from their medication cart located in the hallway and entered a resident room. The medication cart was unlocked. The following items were on top of the cart: inhaler, several bottles of eye drops, and two medication cups containing multiple pills. At 8:43 a.m., RN-B was back setting up medications at their medication cart.At 8:44 a.m., RN-B went into another resident room. The medication cart was left unattended and unlocked. The 2nd large cart drawer was partially open. The two cups of pills and the inhaler were still on top of the cart along with a card of pills. During an interview on 2/11/26 at 8:48 a.m., RN-B confirmed they had left the medication unattended with medications on the surface of the cart. RN-B stated they knew they were supposed to lock the medication when they walked away from it, but they didn't always do that when they were just running into a room. RN-B stated the medication cups had been set up to administer but one resident was still out and about and the other one didn't want to wake up yet to take their medications.During an interview on 2/11/26 at 3:40 p.m., the director of nursing (DON) stated medication carts should never be left unlocked and unattended, nor should medications ever be left on the surface of carts unattended. It was the medication nurse's responsibility to make sure medications were properly secured at all times to prevent unauthorized individuals such as other residents or visitors from accessing resident medications.The facility policy Medication Storage in the Facility dated 6/2022, directed Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.The facility policy Preparation and General Guidelines dated 2025, section Preparation and General Guidelines Number 16 instructed: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.Melatonin:During a review of a first-floor medication cart on 2/12/26 at 12:45 p.m., trained medication aide (TMA)-A removed two sealed and one open bottle quantity 60 of Basic Brands melatonin 3 mg from the cart. TMA-A confirmed the bottles did not have an expiration date; the bottles only had a manufacture date of 6/2024. TMA-A called health information manager (HIM-H) over. HIM-H stated they ordered the stock medications, and the bottles came loose. HIM-H confirmed the bottles did not have an expiration date on them. At 1:02 p.m., the administrator walked up, looked at the bottle and confirmed there was not an expiration date.During the review of a second-floor medication cart on 2/12/26 at 1:43 p.m., RN-B removed a bottle of melatonin 3 mg from the cart and confirmed the bottle did not have an expiration date.During an interview on 2/12/26 at 3:50 p.m., the consultant pharmacist (CP) stated all pharmaceutical grade medications and supplements had to have an expiration date. When a medication bottle like melatonin or vitamins did not have an expiration date it meant they were being treated as a food product or supplement. These products were not intended to be used as medications because they did not undergo the same quality control processes as pharmaceutical grade medications. The facility should not be administering melatonin without an expiration date; the melatonin should be replaced with pharmaceutical grade melatonin.On 2/12/26 at 4:13 p.m., the administrator reported the following quantities of melatonin 3 mg with manufacture date 6/2024, in each medication cart:1 [NAME] - 46 tabs in open bottle, 60 in unopened bottle1 East - 32 tabs in open bottle, 60 in unopened bottle2 [NAME] - 27 tabs2 East - 19 tabsA list of residents who received floor stock melatonin 3 mg was also requested but not received.The facility policy Medication Storage in the Facility dated 6/2022, directed no expired medications will be administered to residents. The nurse will check the expiration date of each medication before administering it. Nursing staff should consult with the dispensing pharmacist for any questions related to medication expiration dates.

Based on observation and interview, the facility failed to serve food that remained at palatable temperatures through delivery of the food to the residents for 2 of 2 residents (R3, R61) reviewed for food quality concerns.Findings include:R3:R3's admission minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses included methicillin susceptible staphylococcus aureus (MRSA, a type of bacterial infection causing infections which are resistant to many antibiotics) infection, acquired absence of right leg below the knee, infection and inflammatory reaction due to internal left knee prosthesis and rheumatoid arthritis. R3 was independent with eating and dependent for transfers.R3's care plan dated 10/17/24, identified a focus statement for alteration in nutritional status related to current increased caloric needs due to wound status and healing purposes and included interventions of assisting with set up of meals as needed, culinary director to consult as needed, record nutritional intakes per facility protocol, and R3 kept snacks in her room.R3's provider's order dated 2/5/26, identified an order for a two-gram sodium diet with regular texture and thin liquids.During an interview on 2/9/26 at 7:14 p.m., R3 stated the food was not hot when it gets to her, she had been told by dietary if she would eat in the dining room it would be warmer, but she did that once and it was only marginally warmer and added she didn't like going down there because it was a hassle for her. R3 added she had talked with management about her food concerns, and she has now joined the Food Committee. R61:R61's quarterly MDS dated [DATE], identified intact cognition and diagnoses of gastroesophageal reflux disorder (GERD), diabetes mellitus (DM), anemia, congestive heart failure (CHF), protein-calorie malnutrition, chronic kidney disease (CKD) stage 3. Section K identified no chewing or swallowing difficulty and unplanned weight loss. R61 was independent with eating.R61's care plan dated 11/26/25, identified a focus statement for potential alteration in nutrition related to altered diet texture or consistency but didn't contain a focus for swallowing difficulty.During an interview on 2/9/26 at 5:24 p.m., R61 was sitting in her recliner with her dinner tray in front of her on a tray table. R61 stated she didn't care for the food here, confirmed she normally ate her meals in her room, and stated the food was often not hot by the time it got to her.During observations and interviews on 2/11/26 at 11:40 a.m., the hot food for lunch was held in a steam table, the cook removed the covers and foil from the food and took temperatures of each item. Each meal was then placed on heated plates, which nested on an insulated base and an insulated cover over it. Each tray was loaded into a speed cart (a non-insulated metal box on wheels) for the residents on that cart's designated hallway. The order the carts went out was second-floor east side, first-floor east side, second-floor west side, second floor east side. At 11:53 a.m., the cart for first-floor east side was starting to be loaded with plated food. At 12:15 p.m., the cart reached the far end of the first-floor east hall, where R3 and R61 resided, the surveyor received a test tray and observed the chicken and green beans to be barely warm. Regional culinary director (RCD)-D tried a bite of the chicken breast and stated if it were any cooler he would not be happy with it. RCD-D stated his minimum temperature expectation would be 135 degrees; however, a thermometer wasn't immediately available, and he would need to go to the basement and get one. RCD-D further stated he wouldn't send it back at a restaurant, but it was at the low end of his expectations.During an interview on 2/11/26 at 12:49 p.m., R61is sitting in a chair in her room with her lunch tray on a tray table in front of her. R61 stated the chicken was barely warm.During an interview on 2/12/26 at 8:53 a.m., nursing assistant (NA)-A stated R61 did complain about the food a lot. NA-A explained she often gets her something else to eat, like the alternate meal or a peanut butter and jelly sandwich. NA-A was making R61 some new toast because what came up from the kitchen wasn't able to be cut by the resident.During an interview on 2/12/26 at 10:57 a.m., the dietary manager (DM)-E stated she thought food temperatures had come up from everybody here, if they could get them to eat in the dining room, the food would be served right off the steam table and would be hot. DM-E added they have tried things to keep the food hot, like not letting the carts sit as long. During an interview on 2/12/26 at 2:35 p.m., the administrator stated residents could always ask to have their food heated up. The residents are welcome to come eat in the dining room where they would be served all at one time, that way they know they would immediately get a hot tray.A document, Menu or Food Committee Minutes dated December 25th, identified sometimes food was cold before it got to the end of the hall.

Based on interview and record review, the facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals.Findings include:A facility-submitted document, dated 11/1/25, identified breakfast was from 7:45 a.m. to 8:15 a.m., lunch was from 11:45 a.m. to 12:15 p.m., and dinner was from 4:45 p.m. to 5:15 p.m.During an interview on 2/12/26 at 10:51 a.m., dietary manager (DM)-E stated she wasn't aware there were more than 14 hours between meals, and they did normally send snacks upstairs to be stocked on each floor around 3 p.m. and starting today they will be sending up diabetic snacks at around 6 p.m. The facility didn't have a process for ensuring residents were offered a substantial evening snack. A policy, Frequency of Meals dated 7/2017, identified the facility would serve at least three meals or their equivalent daily at scheduled times. There will not be more than a 14-hour span between the evening meal and breakfast. Meals would be served four to six hours apart to help assure that residents receive nutritional requirements. The following mealtimes have been established by our facility for residents, however the chart with breakfast, lunch and dinner is blank. A schedule of mealtimes and snacks will be posted in resident areas. Nourishing snacks will be available for residents who need or desire additional food between meals. Evening snacks will be offered routinely to all residents. Timing of the snack will consider relevant factors. Residents will also be offered nourishing snacks if the time span between the evening meal and the next day's breakfast exceed 14 hours. Nourishing snacks are items from the basic food groups, offered either separately or with each other. The facility will choose the snacks that are received at bedtime. However, the dietician and food services manager will solicit input from the residents and/or the resident council. An email from DM-E to the administrator titled Resident Food Council 1/29/26, identified the second floor said they don't have much for snacks at night and DM-E was concerned some individuals were getting multiple items and leaving nothing for the rest. DM-E identified she would encourage nursing to keep dry items behind the desk to distribute and felt it was necessary to begin snack pass delivery in the evening but didn't have the dietary staff to support that and asked if nursing could do a specific evening snack pass. Documents, Menu or Food Committee Minutes, identified the following: 1/9/26, identified more diabetic snacks for the second floor. 12/25/25, identified additional snacks as they get eaten up quickly. September 2025, identified diabetic snacks were being hoarded.

Based on observation, interview and document review, the facility failed to ensure food was properly labeled and stored to prevent food-borne illness. In addition, the facility failed to ensure kitchen cleanliness was maintained in areas where food was prepared. These deficient practices had to potential to affect anyone who ate food prepared by the facility.Findings include:During an observation and interview on 2/9/26 at 11:45 a.m., dietary aide (DA)-A confirmed the commercially-prepared container of coleslaw was dated as opened on 1/21/26; a bag of shredded parmesan cheese was open but not labeled with an opened-on date; a commercially-prepared bag of diced onions was opened, folded, and saran wrapped without an opened-on date. DA-A stated opened food should say the date it was opened and how long it was shelf stable. The dietary manager (DM)-E stated those items should have been labeled when they were opened. DM-E confirmed a bag of cake mix had been opened and not secured or labeled. The DM-E stated that it should be labeled with the date opened and put in a sealable package. In the cook's refrigerator there was another container of prepared coleslaw opened without a date. The DM-E stated these items would be thrown out, and the risk of keeping food too long would be it could make you sick.During observations in the main kitchen on 2/11/26 at 11:15 a.m., in the room where the steam table and tray line were, the floor had areas of visible soil and foot traffic, visible with shoe prints, small brown and black dried spots on the floor. On the steam table, the inside of the glass nearest to the hot food, was covered with different color splatters and drips dried to it from one side to the other and the top to the bottom. On the serving side of the steam table where the cook stood there was a square pillar, with each of the four sides being about one foot wide, right up against the work surface of the steam table. The pillar was missing the corner guards so that dried glue and small pieces of missing sheetrock were exposed, and the side of the pillar adjacent to the cook was stained brownish-black colors from about hip to shoulder height. On top of the upper cabinets directly above the counter behind the steam table had a steel cleaning pad on top of it which was half hung over the edge of the cabinet above a counter used for food preparation. In the steam table room, there was an area where staff staged the beverages to go on the meal trays. Two ceiling tiles above this area had one-to-two-inch strips of peeling plastic along the edge of the tile. Next to the beverage area, there was an approximately four foot by five foot air-handling system about six inches off the floor, there was a four to five inch long one inch wide collection of hair and dust hanging on the bottom blowing in the wind.During an observation and interview on 2/12/26 at 12:37 p.m., the administrator stated maintenance looked at the kitchen at least weekly and as needed if someone noticed something. At the beverage station, the flaking ceiling tile had the loose pieces scraped off. The administrator stated the pillar didn't meet her expectations. MW-A stated he was aware the corner protectors were off the pillar, and he had repaired a leak in the ceiling where the peeling ceiling tiles were. During an interview on 2/12/26 at 10:45 a.m., DM-E stated she had a monthly, weekly and daily cleaning duties list. Mopping should be done every evening, and spot mopped as needed during the day, and she would not expect to have dust bunnies. The DM-E added her expectation was that the glass on the steam table was cleaned after every meal service and confirmed it didn't appear to have been cleaned after the last meal service.A policy, Food Receiving and Storage dated 10/2017, identified all foods stored in the refrigerator or freezer will be covered, labeled and dated by a use-by date. Other opened containers must be dated and sealed or covered during storage.A policy, Cleaning and Disinfection dated 09/2012, identified counter tops, work surfaces, hard surfaces, serving carts, cupboards, tabletops, walls, etc. would be wiped off with a damp cloth to remove food particles, sprayed with a disinfectant solution diluted to manufacturer recommendation until wet. Allow to remain wet 10 minutes to airdry. Tile floors would be swept, wet mopped with disinfectant solution using figure eight strokes and allowed to remain wet 10 minutes to air dry.

Based on observation, interview and document review, the facility failed to ensure residents without an assessment and order to self-administer medications (SAM) were not left with prescription medications to take on their own for 1 of 1 resident (R61) reviewed for self-administration of medication.Findings include:R61's quarterly minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of gastroesophageal reflux disorder (GERD), diabetes mellitus (DM), anemia, congestive heart failure (CHF), protein-calorie malnutrition, chronic kidney disease (CKD) stage 3. R61's care plan dated 11/26/25, didn't contain a focus statement and interventions for SAM.R61'a provider orders effective 2/12/26, didn't contain an order for self-administration of any medication.During an observation on 2/12/26 at 8:51 a.m., R61 was setting up in bed eating with her tray table in front of her with her breakfast tray on it. There was a cup of pills on her tray, and R61 stated those pills were hers, she had to take them with her orange juice. No facility staff were present in the room.On 2/12/26 at 9:19 a.m., nursing assistant (NA)-A stated she knew how to care for the residents by looking at the care guide, which she demonstrated was in her pocket. NA-A looked at the instructions for R61 and stated there were no special instructions for eating. On 2/12/26 at 12:19 p.m., registered nurse (RN)-A stated she didn't know of R61 being someone approved for SAM, which she then verified in the medical record. RN-A stated she would expect there to be an assessment and order for SAM, the risk of having her self-administer would be whether or not she actually took the medication.During an interview on 2/12/26 at 3:24 p.m., the director of nursing (DON) stated she would expect only residents with SAM, assessed and doctor-ordered, to be taking their medications on their own.A policy, Self-Administration of Medications dated 2/2024, identified as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status.

Based on observation, interviews and document review the facility failed to ensure diabetic snacks were provided to 2 of 2 residents (R7, R57) reviewed for food service. Findings include:R7:R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had diagnoses which included diabetes mellitus, depression and anxiety. In addition, R7 was cognitively intact.R7's current order summary report dated 2/12/26, identified the following orders:-provide a snack at bedtime Deli sandwich dated 1/18/22-consistent carbohydrate diet dated 1/3/25-blood sugar checks before meals and at bedtime dated 3/18/25-continuous blood glucose sensor - freestyle libre sensor system dated 12/29/23-monitor for signs and symptoms of hyper/hypoglycemia including but not limited to lethargy, sweating, weakness, confusion, pale, vomiting and excessive thirst dated 9/5/25-one carton boost glucose control or Glucerna as needed twice daily as desired dated 1/14/26-Lantus 100 units per milliliters inject 48 units in the morning dated 12/30/25-metformin 500 milligrams by mouth two times a day dated 9/15/25-Ozempic 2 milligrams every dayshift on Wednesday dated 10/1/25R7's care plan dated 11/30/21, identified he had a potential for alterations in blood sugar related to diagnosis of diabetes. Interventions included to encourage diabetic bedtime snack.R57:R57's quarterly Minimum Data Set (MDS) dated [DATE], identified R57 had diagnoses which included iron deficiency anemia, diabetes mellitus and depression. In addition, R57 was cognitively intact.R57's current order summary report dated 2/12/26, identified the following orders:-consistent carbohydrate diet dated 7/21/25-blood sugars before meals and at bedtime for diabetes mellitus dated 7/21/25-monitor for signs and symptoms of hyper/hypoglycemia including but not limited to lethargy, sweating, weakness, confusion, pale, vomiting and excessive thirst dated 7/21/25-Humalog insulin 6 units subcutaneously with meals for type 1 diabetes mellitus dated 11/19/25-Humalog insulin subcutaneously sliding scale for type 1 diabetes mellitus dated 12/22/25-Lantus 26 units subcutaneously at bedtime for type 1 diabetes mellitus dated 8/13/25R57's care plan dated 8/26/25, identified he had a potential for alterations in blood sugar related to diagnosis of diabetes. Interventions included to encourage diabetic bedtime snack.A review of R57's evening meal ticket dated 2/12/26, did not have any information regarding a bedtime snack.A review of the facility's food council notes revealed the following:1/29/26, Residents stated they did not have much for snacks at night. The notes identified there were not any dietary staff to pass an evening snack.11/25/25 and 9/25/25, residents identified they would like more fresh fruit.On 2/10/26 at 1:39 p.m., with nursing assistant (NA)-D a review of snacks available in the first-floor dining room was conducted. NA-D opened the refrigerator, NA-D verified there were not any sandwiches available for snacks. They did, however, point out the bread on the counter and jelly packets.On 2/10/26 at 1:45 p.m., with licensed practical nurse (LPN)-B a review of snacks available in the second-floor dining room was conducted. LPN-B stated the key to the refrigerator was kept in the nurse's office which was locked, the freezer had ice cream available, the refrigerator had juices but no sandwiches. There was however bread, jelly, and a jar of peanut butter on the counter. LPN-B stated there was not often any meat or cheese in the refrigerator to make sandwiches and stated after 7:00 p.m., there was no one in the kitchen to make a sandwich for residents.On 2/10/26 at 2:02 p.m., a tour of both dining room refrigerator was conducted with dietary manager (DM)-E, there were not any sandwiches in the refrigerators. DM-E stated sometimes there were sandwiches, she also stated sandwiches would need to be requested prior to 7:00 p.m., because that was when the kitchen staff left for the day. DM-E verified there was not any sugar free Jello or puddings for diabetic residents.On 2/10/26 at 2:29 p.m., cook-A arrived at the nursing unit, she stated she was told to come up and check the refrigerators. C-A stated she did not usually do the re-stock which would include juices, med pass (a nutritional drink), fresh fruit. C-A stated meat and cheese was not part of the re-stock for the dining room refrigerators.On 2/11/26 at 12:29 p.m., a tour of the available snacks on the second floor identified the following snacks: applesauce, Jello, pudding, popcorn, [NAME] buddy, peanut butter crackers, and graham crackers.On 2/11/16 at 12:46 p.m., a tour of the available snacks on the first floor identified the following snacks: unsweetened applesauce, peanut butter and crackers, oatmeal creme cookies, graham crackers, [NAME] cookies, [NAME] buddy.During an interview on 2/9/26 at 1:55 p.m., R57 stated he did not think he was getting a diabetic diet, stated too many carbs (carbohydrates).During an interview on 2/9/26 at 4:47 p.m., R7 stated there were not sandwiches in the refrigerator for a bedtime snack, then stated if there were sandwiches, they only had one slice of meat and one slice of cheese, R7 further stated there were no snacks for diabetic residents.On 2/10/26 at 1:55 p.m., DM-E verified the snacks available on the nursing units were chips, granola bars, Jello pudding, cookies, cake. DM-E stated there were also cheese sticks, lunch meat, and cheese. When the refrigerators were checked there were no cheese sticks, lunch meat or cheese.During an interview on 2/10/26 at 2:28 p.m., nursing assistant (NA)-G stated sometimes there was meat and cheese to make a sandwich, rarely fresh fruit, said there used to be carrots and celery but not in the last couple of months.During an interview on 2/10/26 at 2:34 p.m., NA-E stated the refrigerators rarely had fresh fruit, celery, carrots, or meat and cheese available for residents.During an interview on 2/11/26 at 12:01 p.m., NA-C stated sometimes they would see an extra sandwich on the evening meal tray wrapped up. NA-C stated they should put the sandwich in the refrigerator, but they didn't. NA-C stated they didn't have meat and cheese to make an evening snack, just peanut butter and jelly.During an interview on 2/11/26 at 12:02 p.m., NA-F stated they had not seen any extra sandwiches come up from the kitchen on the evening meal pass.During an interview on 2/11/26 at 12:03 p.m., R7 stated there was never an extra sandwich on his meal tray at dinner time for his bedtime snack.During an interview on 2/11/26 at 12:46 p.m., registered nurse (RN)-A stated if the kitchen sent up a diabetic snack on the evening meal tray the residents would eat it right away. RN-A stated the kitchen was supposed to send up meat and cheese so staff could make a sandwich but stated this was not consistently occurring.During an interview on 2/12/26 at 12:58 p.m., RN-A described a diabetic snack as a sandwich, fruits, vegetables, food low in sugar. RN-A verified R57's care plan directed staff to encourage R57 to eat a diabetic snack. RN-A verified there was not a snack cart that was taken room to room at bedtime.During an interview on 2/12/26 at 3:51 p.m., the director of nursing (DON) stated a diabetic snack would be fruit, vegetables, and maybe a meat and cheese sandwich. The DON stated if a diabetic snack was ordered she would expect the resident to receive the diabetic snack as ordered. The DON stated it was important for residents with diabetes to get a bedtime snack to help keep their blood sugars stable.A policy on Physician Orders was requested but not provided.

Based on observation, interview and record review, the facility failed to ensure provider-ordered interventions were in place for safe swallowing for 1 of 3 residents (R61) reviewed for accident hazards.Findings include:R61's quarterly minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of gastroesophageal reflux disorder (GERD), diabetes mellitus (DM), anemia, congestive heart failure (CHF), protein-calorie malnutrition, chronic kidney disease (CKD) stage 3. Section K identified no chewing or swallowing difficulty and unplanned weight loss. R61 was independent with eating.R61's care plan dated 11/26/25, identified a focus statement for potential alteration in nutrition related to altered diet texture or consistency but didn't contain a focus for swallowing difficulty or interventions with instructions for eating and drinking.R61's provider order dated 9/5/25, identified an order for feeding details: regular thin liquids, alternate sips and bites, small single sips and bites, oral care after all oral intake, upright for 30 to 60 minutes following all oral intake, effort swallow and medications as tolerated. On 9/30/25, upright 90 degrees during oral intake, alternate sips and bites, offer small single sips and bites, and an order for a regular diet with regular texture and thin liquids.A hospital Discharge summary dated [DATE], identified an admission diagnosis of aspiration pneumonia (an infection caused from inhaling food, fluid or vomitus) of both lower lobes.During an observation on 2/10/26 at 12:58 p.m., R61 was sitting in her recliner in her room with a tray table and meal tray in front of her. R61 stated she ate the garlic toast, but the crusts were too tough for her to chew. R61 stated staff bring her the tray and then come back to get it when she is done, no one checks back with her. There were no facility staff in the room.During an observation on 2/11/26 at 12:49 p.m., R61 was sitting in her recliner in her room with a tray table and meal tray in front of her today. She was eating a salad with dressing, and a chicken breast with no sauce or gravy. There were no facility staff in the room with her. During an observation on 2/12/26 at 8:51 a.m., R61 was sitting in her bed with the head of the bed up at about 20 degrees, she had her tray table set up over her bed with a breakfast tray on it. R61 had a full glass of orange juice and half-eaten bowl of hot cereal and stated she had the girl make her more toast because hers was so hard she couldn't cut it. During an interview on 2/12/26 at 9:19 a.m., nursing assistant (NA)-A stated she knew how to care for the residents by looking at the care guide, which she demonstrated was in her pocket. NA-A looked at the instructions for R61 and stated there were no special instructions for eating. NA-A was in the first-floor kitchenette making toast for R61 because what she got from the kitchen wasn't cuttable. During an interview on 2/12/26 at 12:19 p.m., registered nurse (RN)-A confirmed feeding instructions in R61'a provider orders, RN-A stated she would expect the orders to be followed; the risk for R61 could be choking and aspiration. During an interview on 2/12/26 at 3:24 p.m., the director of nursing (DON) stated her expectation would be to follow the orders, or if the resident was having a hard time with the instructions to provide education and have a new speech evaluation to see if the interventions were still appropriate for them. The DON stated the risk for R61 could be aspiration.

Based on observation, interview and document review the facility failed to ensure ice packs for personal use were not stored with resident food. This had the potential to affect residents who stored or consumed food from the unit freezers. Findings include: On 3/17/25 at 7:13 p.m., the administrator unlocked the refrigerator and freezer in the first floor dining room. The freezer had food that was labeled for residents, it however also had a large blue ice pack approximately 18 inches by 12 inches labeled to use on the body, with R58's name. There were also two large re-usable ice packs approximately 12 inches by six inches labeled with a resident's name. The administrator stated the resident was no longer in the facility and threw the ice packs away. The administrator verified if ice packs were for use on the body they should not be stored in the freezer with resident food. On 3/19/25 at 1:43 p.m., the culinary director (CD)-C stated the dietary department was responsible for the unit refrigerator/freezers. CD-C stated she would expect staff to notify the nurse and herself if they saw non-food items in the freezers. On 3/19/25 at 2:58 p.m., licensed practical nurse (LPN)-B stated ice packs were not re-usable and should never be in the unit freezers, LPN-B stated she would expect staff to remove non-food items from the freezers. On 3/19/25 at 3:21 p.m., the director of nursing (DON) verified non-food items (ice packs) should not be stored with resident food, stated it was an infection control concern and could contaminate the food. Refrigerators and Freezers policy dated 12/2014, did not address ice pack storage in unit freezers.

Based on interview and record review, the facility failed to review and revise the care plan after discontinuation of self-administered medication for 1 of 1 residents (R50) reviewed for care planning. Findings include: R50's 5 day Minimum Data Set (MDS) dated [DATE], identified intact cognition, and diagnoses that included amputation of lower right leg, congestive heart failure, obesity, gastritis, hypo-osmality (low concentration of solutes in the blood) and hyponatremia (low levels of sodium in the blood), type 2 diabetes, ascites, hyperparathyroidism of renal origin (increase in parathyroid hormone in the blood caused by chronic kidney failure), and end stage renal disease. R50's care plan last reviewed on 1/3/25, identified a focus of 'resident chooses to self administer tenapanor' (medication that lowers phosphorus levels in the blood). Care plan further identified a goal started on 10/17/24 of 'resident will safely self administer tenapanor per physicians orders.' R50's care plan also identified interventions for staff to follow: 'monitor usage of bedside meds, assess that resident is capable of self administering tenapanor correctly on a quarterly basis, assess safe storage, amount left, and expiration date of tenapanor weekly.' R50's order summary report dated 3/19/25, did not identify a current order for tenapanor. Review of R50's discontinued orders identified an order starting 10/15/24 and discontinued on 10/31/24, prescribing tenapanor oral tablet 30 milligrams (mg) to be given twice a day before first and last meals of the day. During joint interview on 3/20/25 at 9:57 a.m., director of nursing (DON) and licensed practical nurse (LPN)-B stated expectation care plans to be updated when needed. DON stated care plan updates would happen for changes in treatments. DON and LPN-B identified nurse managers would be reponsible for updating care plans for residents on their unit. During interview on 3/20/25 at 11:29 a.m., administrator stated expectation care plans were to be updated when treatments for the resident were changed. Facility policy 'Care Planning' last revised 11/2024, identified 'the care plan is to be modified and updated as the condition and care needs of the resident changes.'

Based on interview and document review, the facility failed to provide ongoing, comprehensive discharge (DC) planning to a lower level-of-care for 1 of 2 residents (R49) reviewed for discharge planning. Findings include: R49's admission Minimum Data Set (MDS) dated [DATE], identified R49 was admitted to the nursing home from the acute hospital. The MDS listed a section, Q0400, which was answered an active discharge plan was in place for the resident to return to the community. R49's most recent quarterly Minimum Data Set (MDS), dated [DATE], identified R49 was cognitively intact and needed some assistance with bathing, dressing, and transfers. R49 was wheelchair dependent but was independent in the wheelchair. Diagnoses included cancer and traumatic brain injury. Further, the MDS outlined under section Q0400. Discharge Plan, that an active discharge plan was not in place for R49 to return to the community, and no referrals to the local agencies had been made due to referrals not wanted. R49's care plan, dated 8/11/23, identified R49 wanted to be discharged to Assisted Living Facility (ALF) knowing that there is a chance to possibly go home once resident gets stronger. Resident MNCHOICE assessment (assessment performed to qualify for ALF under county waiver program) was completed on 3/6/24. Interventions included staff would make necessary referrals as needed to carry out resident's DC goals. R49's progress notes from 2/21/24 to 3/19/25 were reviewed and indetified the following: - 2/23/24 4:07 a.m., social services (SS) met with resident today. Resident interested in getting own apartment. Explained due to eviction history on file would not be able to. Social worker did offer an ALF or group home, and resident agreed to that. Would work on this Monday. - Progress notes lacked any other notations related to discharge planning related to this note. - 11/12/24 3:01 p.m., SS met with resident today. Resident interested in discharge to ALF. Writer reached out to the county to see who case worker was to get MNCHOICE assessment. - 11/19/24 at 3:24 p.m., care conference held and provided contact information for assisted living locators. - Progress notes lacked documentation follow up was made to assist with ALF referrals of is resident needed assistance in discharge planning. R49's care conference note dated 11/19/24, indicated resident was interested in moving to a handicapped accessible apartment or ALF. Provided resident with resource for Assisted Living Locators to assist with independent living/ALF connections. R49's care conference note dated 2/18/25, indicated R49 wanted to move to an ALF. During an interview on 3/17/25 at 2:41 p.m., R48 stated he really wanted to move to an ALF. The discharge plan had been brought up with the facility social worker around a year ago, but they never did follow up with me related to anything discharge related. I keep bringing it up at every care conference but nobody ever follow ups on it. I am starting to give up on the idea. During an interview on 3/19/25 at 10:53 a.m., the social services designee (SSD) stated the social services department was responsible to assist residents who wanted to DC from the facility to home or a lower level of care facility. Discussion would occur with the resident related to where they would like to go. If discharge to an ALF or group home was requested, social services would assist by getting insurance information and waivers gathered and completed, and assist the resident by sending referrals to different ALF facilities and setup tours if the resident wished. The social services department would follow through the entire DC process. The SSD was not aware of the resident wishes from 2/23/24 due to a different social worker being present at that time. She did acknowledge the notes existed and stated the process should have started at that time. The SSD reviewed R49's medical record and acknowledged nothing indicated a follow through was completed. The SSD stated during the care conference on 2/18/25, the resident again vocalized wanting to go to an ALF but was ok staying at the care center. SSD stated she had not done any referrals to ALFs or follow up with the resident related to DC planning. SSD stated she was only at the facility twice a week and any staff member could have performed the follow up and the referrals. During an interview on 3/19/25 at 12:11 p.m., the regional licensed social worker (RLSW)-A stated the Assisted Living Locators is a private company that can assist in finding placement. Social services would send referrals to them, they would visit with the resident and then communicate with the facility related to ALF's the resident was interested in. Social services would stay in contact with the ALF locators throughout the DC process. RLSW-A acknowledged a care conference was held on 11/19/24, and information related to the ALF locators had been provided to the resident and a referral was made. RLSW-A stated no follow up was done with the resident or the ALF locators since the information was first provided on 11/19/24 but should have been done by somebody in the facility as part of the discharge planning process. That would ensure referrals are sent out as the resident requests. During an interview on 3/20/25 at 9:52 a.m., the administrator stated social services would follow the resident related to the discharge from the time of admission. If the resident is interested in DC to home or a lower level of care like an ALF conversations should be had in the interdepartmental team (IDT) so everybody is on the same page related to the discharge plans. Assistance would be made to send referrals to the ALF's requested to see if the resident qualified. Assistance with insurance issues and possible waivers would also occur. The provider would be notified towards the end to see if they agreed with the discharge plan and to get discharge orders to transfer or send home. Facility policy, Discharge Planning Policy dated 1/25, indicated discharge planning started at admission. The health care center would make every effort possible to meet the goal of the resident relative to their choices.

Based on observation, interview and document review the facility failed to ensure oral cares were completed for 1 of 3 residents (R18) reviewed for personal cares. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], identified R18 had diagnoses which included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves). R18's MDS identified R18 was cognitively intact. R18 had no rejections of care and required set up for oral hygiene and was dependent of staff for personal hygiene and required substantial to maximum assistance for dressing. R18's nursing assistant care guide dated 3/20/25, identified R18 required an assist of one for bathing, dressing and grooming. R18's care guide also identified R18 had his own teeth. R18's care plan dated 9/21/23, identified R18 had a self care deficit. It further identified staff were to provide assistance with oral cares morning, bedtime, and as needed and to assist with personal hygiene. On 3/18/25 at 10:30 a.m., nursing assistants (NA)-A and NA-B entered R18's room to assist him with morning cares and to get him up, they told R18 what they were planning to do. A brief change was completed with peri-cares and pants were put on R18. A sling for the ceiling lift was placed under R18 and he was lifted out of bed and into his wheelchair. NA-A showed R18 three shirts and let him choose which one he wanted to wear. R18's shirt was changed, no face washing, hand washing or washing under his arms was offered or done. R18's hair was brushed, but he was not offered an opportunity to brush his teeth. R18 was given his soft touch call light and the NA's left the room. During an interview on 3/18/25 at 10:44 a.m., NA-A verified he was not offered an opportunity to brush his teeth and said he should be offered a chance to brush his teeth after he eats. During an interview on 3/19/25 at 10:41 a.m., NA-B stated morning cares included peri-care, dressing, combing hair, and oral cares. During an interview on 3/19/25 at 2:53 p.m., licensed practical nurse (LPN)-B stated morning cares for residents should include face and hands washed, under arms washed, peri-care, and oral cares (teeth or dentures brushed). During an interview on 3/19/25 at 3:18 p.m., the director of nursing (DON) stated oral care should be offered to prevent teeth problems and infections. During an interview on 3/20/25 at 8:04 a.m., R18 stated staff didn't ask him if he wanted to brush his teeth. Said, there's a tooth brush around here some place. R18 stated he had been offered an opportunity to brush his teeth maybe twice this week. R18 stated he would be happy to be able to brush his teeth once a day. The policy Activities of Daily Living dated 3/31/23, identified the facility would ensure a resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility would provide care and services to include hygiene, bathing, dressing, grooming, and oral care.

Based on document review and interview, the facility failed to identify diagnoses or indications for use of medications for 1 of 5 residents (R1) reviewed for unnecessary medications. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition, and diagnoses that included schizoaffective disorder, type 2 diabetes with other skin complications, osteoarthritis (degenerative joint disease resulting from cartilage and bone breakdown), chronic bronchitis, rash, polyneuropathy (disease or damage to the peripheral nerves that presents as weakness, numbness, and pain), and chronic pain syndrome. R1's physician's orders dated 3/18/25, included the following medications and supplements but lacked diagnoses or indication for use: -benzonatate oral capsule 100 milligram (mg), give one capsule by mouth three times a day -cadexomer iodine external gel 0.9%, apply to affected area topically every 72 hours -carbidopa-levodopa oral tablet 25-100mg, give one tablet by mouth every morning and bedtime -clobetasol propionate external cream 0.05%, apply to breasts/abdominal area folds topically two times a day -gabapentin 8% gel, apply to bilateral feet topically three times a day -guaifenesin ER oral tablet extended release 600mg, give one tablet by mouth twice a day -interdry 10, apply to affected area topically every day shift -menthol-methyl salicylate external cream, apply to affected area topically as needed -miconazole nitrate powder 2%, apply to affected area topically two times a day -[NAME] external lotion 0.5-0.5%, apply to affected area topically as needed -zinc oral tablet 50mg, give one tablet by mouth in the morning R1's medication administration record (MAR) also lacked indication for use and administration of above medications. During interview on 3/19/25 at 10:38 a.m., registered nurse (RN)-A verified carbidopa-levodopa tablet and gabapentin gel did not have a diagnosis or indication for use. RN-A stated R1 had been on both medications for a while. RN-A stated medications should have a diagnosis or indication for use as part of the order. During interview on 3/19/25 at 3:24 p.m., RN-B stated expectation for each medication to have a diagnosis or indication for use. RN-B explained even without a diagnosis or indication listed she would know what the general reason was for based on the type of medication. During joint interview on 3/20/25 at 9:57 a.m., director of nursing (DON) and licensed practical nurse (LPN)-B stated the expectation was for each medication to have a diagnosis or indication for use. DON stated this was part of the order for the medication. DON explained nursing staff should seek clarification from the provider if a medication order was missing a diagnosis or indication for use. During interview on 3/20/25 at 11:29 a.m., administrator stated the expectation for every medication order to have a diagnosis or indication for use connected to it. Facility policy 'Medication Administration- General Guidelines' dated May 2022, indicated 'if a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification.'

Based on interview and document review, the facility failed to complete orthostatic blood pressure monitoring for an antipsychotic medication for 1 of 5 residents (R49), reviewed for unnecessary medication use. Findings include: R49's quarterly Minimum Data Set (MDS) dated [DATE], indicated R49 had intact cognition. Diagnoses included anxiety disorder, manic depression, schizophrenia, and post traumatic stress disorder. The MDS indicated R49 received antipsychotic medications on a routine (daily) basis only. R49's Order Summary Report (OSR) identified on 8/25/23, an order was started for Quetiapine (antipsychotic mental health medication) 400mg by mouth at bedtime. R49's treatment administration record (TAR) and vital signs records reviewed from 1/1/25 to 3/1/25, lacked documentation of any orthostatic blood pressures taken. During an interview on 3/20/25 at 9:35 a.m., licensed practical nurse (LPN)- A stated blood pressures needed to be taken monthly for anybody on antipsychotic medications. The orthostatic blood pressures would be taken and documented in the TAR as laying, sitting and standing. If the resident was unable to stand the laying and sitting would still be obtained. During an interview on 3/20/25 at 10:09 a.m., LPN-B stated side effect monitoring included orthostatic blood pressures that would be taken once a month. LPN-B reviewed R49's TAR and acknowledged orthostatic vital signs had not been taken but that they should have been. LPN-B stated orthostatic blood pressure monitoring was important because antipsychotic medications can cause sudden drops in blood pressure which could cause harm to the resident. During an interview on 3/6/25 at 10:27 a.m. the director of nursing (DON) stated orthostatic blood pressures needed to be done once a month and then documented in the medical record. Facility policy Psychotropic Medication Use last reviewed 1/25 indicated orthostatic blood pressures would be taken on a monthly basis, unless otherwise indicated by provider.

Based on observation, interview, and document review, the facility failed to ensure kitchen equipment was kept in a clean and sanitary manner. This had the potential to affect all 54 residents, staff, and visitors who consumed food prepared in and/or served from the kitchen. Findings include: On 2/1/2024 at 8:30 a.m., kitchen tour with culinary service director (CSD) was completed. The small mixer in kitchen was under a plastic cover. Plastic cover was stuck to mixer by food residue. Small mixer observed to have light white-brown colored food remnants on sides and under the mixing head. Toaster was found to have a reddish brown grease-like substance on trim. Crumbs were around toaster on the countertop. Large mixer was under a plastic cover. Large mixer had light brown colored food remnants stuck to the body of mixer and under the mixing head. Protective guard around mixing bowl had white powdery spots. Cabinet next to large mixer had food remnants of the same light brown color as large mixer. Cooler had red sticky substance on bottom of door seal and down the front vents. During interview on 2/1/2024 at 9:08 a.m., CSD stated she was not sure of the exact details of how and when the kitchen and equipment was cleaned as the kitchen was on an informal cleaning schedule and cleaning was not assigned to any staff in particular. All kitchen staff were expected to help clean the kitchen and were expected to clean kitchen equipment after use. CSD also stated a cleaning log for staff to sign after cleaning was started on 1/29/2024, during the recertification survey. CSD confirmed clean kitchen equipment was important to prevent food-borne illness and to prevent any contamination of food. During interview on 2/1/2024 at 12:29 p.m., administrator stated staff were expected to clean kitchen equipment after use. Administrator also stated expectation clean and ready to use kitchen equipment to be under a protective plastic cover. Administrator confirmed clean kitchen equipment was important to prevent food-borne illness and prevent any contamination of food.

Based on observation, interview, and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 related to the proper utilization of personal protective equipment (PPE) for 4 of 4 residents (R1, R2, R3, and R4) reviewed for infection control practices. This resulted in an immediate jeopardy (IJ) due to the increased risk for transmission of COVID-19. The IJ began on 5/25/21, when the facility failed to implement transmission-based precautions (TBP) utilizing all necessary personal protective equipment (PPE) including N95 respirators, for R1 who was newly diagnosed with COVID-19. The facility administrator and director of nursing (DON) were notified of the IJ on 6/3/21, at 5:05 p.m. The IJ was removed on 6/4/21, at 2:30 p.m. but noncompliance remained at the lower scope and severity level of E, pattern, no actual harm with potential for more than minimal harm that is not IJ. Current CDC guidance dated 2/10/21, directed health care workers who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. CMS memo COVID-19 Long Term Care Facility Guidance, dated 4/2/20, directed nursing homes to immediately ensure they were complying with all CMS and CDC guidance related to infection control which included the use of standard, contact and droplet precautions. Findings include: R1 was diagnosed with COVID-19 on 5/25/21. R1's isolation period had been identified as ending 6/4/21. Signage on R1's door indicated R1 was on TBP. A white plastic PPE bin was set up outside of R1's room. R2 was placed under quarantine because she left the faciity on [DATE], for the day. R2's quarantine period had been identified as ending 6/14/21. Signage on R1's door indicated R2 was on TBP. A white plastic PPE bin was set up outside of R2's room. R3 was readmitted to the facility after hospitalization on [DATE], with quarantine identified as ending 6/4/21. R3's quarantine period had been identified as ending 6/4/21. Signage on R3's door indicated R3 was on TBP. A white plastic PPE bin was set up outside of R3's. R4 was placed under quarantine when he admitted to the facility on [DATE]. R4's quarantine period had been identified as ending 6/10/21. Signage on R4's door indicated R4 was on TBP. A white plastic PPE bin was set up outside of R4's room. On 6/2/21, at 11:45 a.m. nursing assistant (NA)-A was observed donning a blue plastic isolation gown, clean gloves, and placed eye goggles over her eye protection. NA-A was wearing a surgical mask. Without donning an N95 respirator, NA-A entered R1's room and closed the door behind her. NA-A remained in R1's room for approximately 4 minutes. On 6/2/21, at 11:56 a.m. licensed practical nurse (LPN)-A was observed donning a blue plastic isolation gown, clean gloves, and placed eye goggles over her eye protection. LPN-A was wearing a surgical mask. Without donning an N95 respirator, LPN-A entered R1's room. LPN-A closed the door behind her and remained in R1's room for approximately 2 minutes. On 6/2/21, at 12:06 p.m. LPN-A and NA-A were both observed donning blue plastic isolation gowns, clean gloves, and they placed eye goggles over eye protection. Without donning an N95 respirator, LPN-A and NA-A were both wearing surgical masks. Without donning N95 respirators, LPN-A and NA-A entered R1's room, where they remained for approximately 3 minutes. On 6/2/21, at 12:12 p.m. therapeutic recreation aide ([NAME])-A was observed donning a blue plastic isolation gown, clean gloves, and placed eye goggles over her eye protection. [NAME]-A was wearing a surgical mask. Without donning an N95 respirator, [NAME]-A entered R2's room with a meal tray. [NAME]-A remained in the room for approximately 2 minutes. On 6/2/21, at 12:14 p.m. NA-A was observed donning a blue plastic isolation gown, clean gloves, and placed eye goggles over her eye protection. NA-A was wearing a surgical mask. Without donning an N95 respirator, NA-A entered R1's room. NA-A remained in R1's room for approximately 3 minutes. On 6/2/21, at 1:21 NA-A was interviewed and stated staff do not wear N95 respirators when providing cares for those residents who are on TBP for either having COVID-19 or are on quarantine. NA-A stated she had worn a surgical mask when caring for R1, R2, R3 and R4. NA-A stated she has never seen staff wear an N95 respirator in the facility since the COVID-19 pandemic began. On 6/2/21, at 1:19 p.m. LPN-A was interviewed and stated staff wore surgical masks when caring for residents with COVID-19, or on quarantine. LPN-A stated she has never seen staff wear an N95 respirator. LPN-A stated the facility had sent out a text message a while back asking if staff wanted to be fit tested for the N95 respirator, but she had not been fitted. On 6/2/21, at 1:22 p.m. NA-B stated she had never been fit tested for an N95 respirator, nor had she ever seen staff wearing a N95 respirator when caring for those residents with confirmed COVID-19 or those under quarantine. On 6/2/21, at 1:32 p.m. the DON was interviewed and stated the facility had an adequate supply of N95 respirators for staff to wear when caring for residents with COVID-19 or those under quarantine. The DON stated the facility had offered staff to get fit tested for the N95 respirators through a meeting or a text. The DON stated staff had chosen not to wear the N95 respirators. The DON stated the facility had not enforced staff to wear N95 respirators when caring for residents with COVID-19 or those under quarantine. The DON stated staff had not worn N95 respirators throughout the COVID-19 outbreak. The DON stated the facility had their first positive COVID-19 case back in 9/2020. DON further stated she had believed the CDC guidance related to the use of N95 respirators was only a recommendation. On 6/4/21, at 2:12 p.m. the administrator was interviewed and stated she believed the CDC guidance related to N95 respirators was only a recommendation and not a requirement. The administrator stated the facility had not enforced staff to wear N95 respirators when caring for residents with COVID-19 or those under quarantine. The administrator stated staff had not worn N95 respirators throughout the COVID-19 outbreak. The facility policy Coronavirus (COVID-19) last revised 2/25/21, directed all residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated implement CDC recommendations. The policy further directed the facility would implement CDC and Department of Health recommendations to prevent the spread of Coronavirus Disease-2019 (COVID-19). The IJ was removed on 6/4/21, at 2:30 p.m. when it was verified through observation, staff interviews and document review the facility educated staff on the use of N95 respirators, and began fit-testing direct care staff who would be wearing N95 respirators, and the facility supplied N95 respirators for staff to use.

Based on observation, interview and document review, the facility did not provide adequate monitoring and interventions which resulted in harm for 1 of 1 (R76) residents experiencing complications secondary to a [MEDICAL CONDITIONS] infection requiring hospitalization , and for 1 of 1 (R138) residents reviewed with pain. R76 sustained actual harm with hospitalization for severe dehydration and acute [MEDICAL CONDITION] secondary to recurrent [MEDICAL CONDITION] infection. R76 had ongoing diarrhea following completion of antibiotic therapy for treatment of [REDACTED]. R76 had multiple [DIAGNOSES REDACTED]. The care plan available for review (dated 8/13/12) did not address the risk of dehydration related to loose stools. The care plan identified the problem of [MEDICAL CONDITION] and directed staff to monitor bowel patterns and report concerns to the physician. The care plan did not identify resident symptoms that would indicate ongoing infection and did not address contact precautions related to the [DIAGNOSES REDACTED]. R76 was diagnosed with [REDACTED]. Review of progress notes revealed R76 continued to have loose stools during the course of [MEDICATION NAME]. The bowel flow sheet maintained in the clinical record did not always indicate the consistency of bowel movements and did not correspond with the progress notes. Following conclusion of the antibiotic treatment on 6/4/12, R76 continued to have frequent loose stools. Nursing progress notes on 6/04/12 at 9:36 p.m. indicated R76 consumed approx. 50% of dinner and a candy bar. CNA reports resident has had one loose bowel movement during the evening. Nursing progress notes dated 6/05/12, at 9:54 p.m. indicated R76 had one loose bowel movement during the evening and denied nausea/vomiting (N/V) but ate only a small amount at dinner. Nursing progress notes on 6/6/12, indicated R76 had one small loose bowel movement and one medium loose foul stool. On 6/7/12, R76 had one medium loose stool. On 6/9/12, at 12:39 p.m. R76 had a small emesis after breakfast and loose stools x 2. On 6/10/12, R76 had 2 loose stools (no indication of amount or consistency). Nursing notes on 6/11/12, indicated R76 had two large and one small loose stools during the day shift, ate nothing for the evening meal, and had 2 loose foul smelling stools on the evening shift. Nursing notes on 6/12/12, at 2:12 p.m. indicated R76 had one large loose, foul stool with mucous present and ate only 25% of breakfast and lunch. At 9:16 p.m. R76 had facial expressions and grimacing, expressing signs of discomfort. R76 was unable to express specifics of being uncomfortable and ate and drank 50% of her evening meal. Progress notes dated 6/13/12, at 11:42 a.m. revealed "Resident's son expressing concern over residents decreased verbalizations and "acting spacey." "On assessment, resident in bed, no verbalization, not answering questions; did shake head when asked if she was having pain. Unable to answer questions about nausea, ate 0/0% for breakfast. Guarding/grimacing with palpation to abdomen, hypoactive bowel sounds. Intake has been decreased over past 3 days, son stated he brought pizza yesterday and resident did not eat that which is not her norm. H/o (history of) [MEDICAL CONDITION] with course of [MEDICATION NAME] 5/25-6/4; resident continues on acidophilus through 6/15." The physician was notified of R76's elevated pulse of 125 beats per minute and R76 was sent to the emergency room (ER) for evaluation and was admitted . The ER History and Physical dated 6/13/12 revealed R76 presented with continued "loose, slimy, foul stools, there is some concern that she had some abdominal pain earlier." Further "She has again poor p.o. (by mouth) intake over the last three days." The reports further indicated R76 was admitted with "Recurrent [DIAGNOSES REDACTED]icile, Severe dehydration, and Acute [MEDICAL CONDITION] secondary to dehydration." The interim director of nursing (IDON), interviewed on 9/14/12, at 1:45 p.m. stated she would have given the physician an update at some point that she (R76) was still having loose stools. Especially by 6/7 or 6/8. "Once you've seen it, you know a [MEDICAL CONDITION] stool. There's no mistaking it." Interview with the medical director on 9/13/12 at 11:40 a.m. indicated "I would expect monitoring and physician contact for ongoing concerns about continued [MEDICAL CONDITION]. That notification needs to be done. That allied health professional needs to be aware of what's happening. We could do better, sounds like we could do better." The medical director added that [MEDICATION NAME] was only effective for about 80% of patients treated so "1 in 5 patients won't have it work." R138 was not provided effective pain management. R138 was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. The Pain Care Area Assessment (CAA) dated 8/28/12, indicated R138 had non-verbal appearance of pain but did not describe the identified symptoms. The CAA did not indicate attempts to assist R138 to quantify the level of pain. The CAA indicated that R138's family reported a history of headaches and abdominal pain. The temporary care plan dated 8/21/12, lacked individualized approaches for pain identification or management for R138. The permanent plan of care did not include nursing measures related to pain management. R138's physician orders [REDACTED]. The orders also directed [MEDICATION NAME] 7.5mg/500mg 15 - 30 ml q4h prn (every 4 hours as needed) for pain with identified parameters of 15 ml for pain rated 1-5 and 30 ml for pain rated 6-10. There was no pain scale established to assist staff with determination of the appropriate dose. There was no evidence that pain scales had been attempted or that the physician was contacted to revise the order. Review of the medication administration records (MARs) indicated that R138 was given 15 doses of prn [MEDICATION NAME] from admission on 8/21/12, to 9/14/12; however, the dosage was not documented. Although R138 was completely aphasic, on 8/22/12, staff documented resident having pain 8 out of 10 and on 8/23/12 had "pain all over." Nursing assistant (NA)-J, interviewed regarding communication with R138 on 9/14/12 at 1:10 p.m., stated, "She has a board but she doesn't like to use the board. The nurse will ask her if she has pain and she kind of nods her head." She further indicated R138 did not appear to have pain with movement during cares. On , at 1:15 p.m., NA-K stated, "We guess." regarding R138's pain. "She refuses to use the board. She's kind of difficult. All she does is baa-baa-baa." The registered nurse (RN)-D, was interviewed on 9/14/12, at 1:20 p.m. and stated, (R138) "has a communication board that she tosses away. This morning she was in pain - she was in tears and I asked her if she had pain and she nodded her head. We keep asking different things. The pain thing she will nod, or grab her head - she'll tell you yeah by nodding her head." RN-A was interviewed on 9/14/12 at 1:30 p.m. regarding R138's pain management and stated, "She is able to verbalize yes/no - she gets very frustrated. It's just getting to know her habits. She doesn't use the prn very often but I guess she does have some pain once and awhile. You just kind of know her." The RN case manager (CM)-A, interviewed on 9/14/12 at 1:20 p.m., stated, (R138) doesn't have pain very often. She doesn't say yes or no but you can get something out of her if she has something hurting her. I guess you would have to go more with behavior and facial expressions." When asked about the pain assessment and use of a pain scale, CM-A replied "It was more me looking at her - I didn't really try any scales with her. With her she has the communication board and she just tosses that aside. She won't even look at it. The most I probably did with her was to ask her if she is having pain." Regarding monitoring pain symptoms, CM-A stated she didn't know R138 was having pain and there was no documented monitoring of her pain. Other staff in the room at the time indicated R138 does have pain and experienced tearful pain that morning. "I guess I didn't know she was having that pain. I wasn't aware she was having anything like that. I hadn't heard she was expressing any pain. I can certainly open an event on that. We haven't been monitoring it before then, no - it would be done with an event."