Every finding on record at The Villas at Brookview

Based on observation, interview, and document review the facility failed to offer necessary assistance to a dependent resident with meal assistance for 1 of 3 residents (R4) reviewed for activities of daily living (ADL) assistance.Findings include:During an observation in the 4th floor dining room on 8/27/26, from 8:15 a.m. to 8:40 a.m., R4 sat in his wheelchair with his untouched tray in front of him. The tray consisted of a bowl of oatmeal, two pieces of bacon, a piece of toast, and scrambled eggs. Silverware was present. R4 was observed to drink some of his water but made no attempt to eat. Staff present in the dining room failed to offer assistance, offer encouragement or alternative food to R4.R4's annual Minimum Data Set (MDS), dated [DATE], indicated he had diagnoses of hemiplegia (severe paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side, epilepsy (seizure disorder), aphasia (language disorder involving communication and language processing), depression, muscle weakness, cognitive deficits following cerebral infarction, was dependent on staff assistance for eating and was on hospice.R4's care plan, dated 10/1/24, indicated he was at risk for decreased oral intake, weight loss with health decline, discontinuation of tube feeding and history of skin breakdown. It included the intervention, dated 11/19/24, to assist with tray set up at left side to promote intake independently and assist with meals if resident is unable. The care plan also indicated he had a self-care deficit related to a stroke and directed to assist with eating, dated 12/23/25.The undated aide care sheet, in use on 8/27/26, directed to assist with eating.A signed order, dated 8/1/26, directed he was to receive a regular diet with set up assistance cutting food.During an interview on 8/27/26, at 8:40 a.m., licensed practical nurse (LPN)-A, stated she was new to her role as the charge nurse on the unit and thought R4 was independent with eating. She stated the nursing assistants (NAs) were directed on the care the residents required by the care sheets, which are developed from the care plans. She stated she would expect the staff to have interacted with R4 to determine why he was not eating his breakfast. She stated any of the NAs were expected to offer assistance with feeding in the dining room.During an interview on 8/27/26, at 8:45 a.m., NA-B stated R4 was not a big breakfast person. She stated we just set it up for him. She did not offer to help him eat his breakfast and he would tell the staff if he needed help.During an interview on 8/27/26, at 8:54 a.m., NA-C stated R4 usually ate by himself she did not offer to help him eat his breakfast. She stated care was directed by the aide care sheets, which indicated R4 required assistance to eat. He was included in her group for the day and she stated he probably should have been the person to feed him.The facility Activities of Daily Living (ADLs)/Maintain Abilities policy, dated 3/31/23, It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.The facility will provide care and services for the following activities of daily living: hygiene, mobility, elimination-toileting, dining-eating, and communication.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on record review, observation and interview the facility failed to provide food to a resident that was palatable and ensure it was served at an appetizing temperature for 1 of 3 residents (R3) reviewed for dietary service.Findings include:R3's quarterly Minimum Data Set, dated [DATE], indicated R3 had diagnoses of sickle-cell disease, anemia, anxiety, depression and was cognitively intact.R3's care plan, dated 5/25/26, directed to monitor food and fluid intake and diet per physician order and recommendation. R3's signed by the nurse practitioner order, signed on 8/1/26, directed R3 to have a regular diet.During an observation on 8/26/26 from 12:09 p.m. to 12:59 p.m., a plate with two grilled cheese sandwiches wrapped in plastic wrap was set on the steam table in the second floor dining room. Condensation was present under the plastic wrap as it sat on the steam table. Cook-A did not check the temperature of the sandwiches before providing to the nursing assistant (NA)-A to deliver to R3's room.During an interview on 8/26/26 at 11:52 a.m., NA-A stated the residents, complain about the food everyday. She stated they complained the food was not hot and she has told the culinary director as well as the administrator.During an interview on 8/26/26 at 1:03 p.m., R3 stated, It's always like this. I get grilled cheese all the time from the bistro menu and they're barely warm. This is soggy. R3 stated she has not asked for a replacement because she did not want to make the staff mad.During an interview on 8/26/26 at 1:10 p.m., Cook-A stated he did not check the temperature of the sandwiches prior to sending up the tray for delivery to R3's room. He stated food should be served at 165 to 180 degrees Fahrenheit (F).During an interview on 8/26/26 at 1:15 p.m., the director of culinary services stated hot food should be served hot to respect the residents' dignity and make sure they get their nutrition. She stated she prepared the grilled cheese sandwich in the kitchen and expected it would be served immediately after she placed it on the steam table. She was unaware R3 was unhappy about the food.During an interview on 8/26/26 at 1:30 p.m., the dietician stated it was very important the food was checked and served at the correct temperature due to increasing the likelihood of foodborne illness, hospitalization and it could increase the risk of infection and harm if it was not served at a safe temperature.During an interview on 8/27/26 at 10:57 a.m., the director of nursing (DON) stated food must be served at safe temperatures to reduce the risk of bacteria growing and the residents getting food poisoning. Appetizing food encouraged residents to eat better which affected their overall health. The facility Food preparation and Service policy, dated 4/2019, directed food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices.The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 F or above 135 F.The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff.

Based on interview and document review, the facility failed to ensure a developed skin rash was assessed and treatment initiated timely to promote healing for 1 of 4 residents (R4) reviewed for non-pressure skin conditions. Findings include: A Vulnerable Adult Maltreatment Report, dated 4/2026, identified multiple concerns with the care provided to R4 while at the care center. This included, [R4] has diaper rash that is not being treated and 'it is so bad. R4's admission Minimum Data Set (MDS), dated [DATE], identified R4 had severe cognitive impairment and several medical conditions including diabetes mellitus. Further, the MDS outlined R4 demonstrated no rejection of care behaviors and had no current skin issues (i.e., wounds, incisions). R4's Care Plan Report, dated 4/10/26, identified R4 had diabetes, malnutrition, used a Foley catheter, and was at risk for skin alterations. The care plan listed a goal for his skin to remain free of breakdown along with interventions which included positioning him with pillows to protect his bony prominences, using pressure-reducing mattress and cushions, keeping the skin clean and dry, and inspecting the skin daily with routine cares. R4's MHM (Monarch Healthcare Management) Weekly Skin Inspection V-6, dated 4/10/26, identified R4 had a shower. A section labeled, Skin Summary, identified R4 allowed the skin check to be completed, along with recorded findings that read, . has GT [g-tube] site to LLQ [left lower quadrant], no other skin issues noted. R4's MHM Weekly Skin Inspection V-6, dated 4/17/26, identified R4 again had a shower and allowed a skin check. The summary recorded, . has a rash to left buttock and groin area. provider [sic] updated. There was no additional assessment of this developed skin condition or evidence of what, if any, treatment was done for the site at the time. R4's MHM Weekly Skin Inspection V-6, dated 4/24/26, identified R4 again had a shower and allowed the skin check. The summary recorded, . has mild rash to left buttock area. Provider notified. However, again, the form lacked any additional assessment of this developed skin condition or evidence of what, if any, treatment was done for the site at the time. R4's entire medical record, which included progress notes and Treatment Administration Record (TAR), lacked evidence that the developed skin rash identified on the weekly inspections was assessed to determine potential causative factors, nor evidence any treatment for it was ever implemented. R4 then discharged from the care center on 4/26/26 to the acute care hospital for elevated blood glucose levels. On 5/15/26, a telephone call was attempted with R4's family member (FM) to discuss his care while admitted to the care center. However, they were unable to be reached. When interviewed on 5/15/26 at 9:47 a.m., nursing assistant (NA)-A stated they recalled working with R4 and described him as needing total care for most activities of daily living (ADL) and had episodes of bowel incontinence but was able to use the commode with assistance. NA-A stated the NA staff will usually check skin on all residents when they do morning cares and then report concerns to the nurses. They did not recall R4 ever having a skin issue or rash and thought they had applied some barrier cream (skincare products designed to help support the skin's natural moisture barrier) to his bottom at times because they do that for most residents. NA-A stated these applications of the cream would not be documented as we use it on almost all residents.When interviewed on 5/15/26 at 10:17 a.m., registered nurse (RN)-A explained the nurses' do a weekly skin check on each resident and record it on the Weekly Skin Inspection form in the record. If a new rash is identified, then it should be documented and the nurse manager and medical provider updated. The nurse manager or leadership would then address it further. RN-A stated they recalled working with R4 and described him as being diabetic and using a tube feeding. RN-A did not recall R4 ever having a skin issue or rash though adding aloud, I'm not sure about that. RN-A stated any performed skin treatments, including use of barrier cream, should be recorded on the TAR or in the progress notes. RN-A added, You chart it. On 5/15/26 at 11:18 a.m., the director of nursing (DON) was interviewed and verified they had reviewed R4's medical record. DON explained if a new skin issue, such as a rash, was identified then it should be measured, documented in the record, and the medical provider updated, along with ongoing monitoring placed on the MAR/TAR. DON verified they were unable to locate evidence the provider ever wrote any treatment orders for R4's skin rash, including in the outside Med Line application. DON acknowledged the lack of an assessment related to the developed rash, and subsequent treatment in the medical record. The DON expressed it seemed to be a breakdown in the system. DON stated they would start some education with the nurses about the process for a newly identified skin impairment, as it was important to ensure skin issues were identified and acted upon quickly so we can heal the skin issue, and it doesn't get worse. The facility Skin Assessment & Wound Management policy, dated 2/2025, identified a section labeled, Non-Pressure Wounds and Altered Skin Integrity, along with directions that when a significant alteration in skin integrity was identified to notify the provider, complete education with the resident/family, initiate a skin and wound evaluation, place referrals if needed, and review/update the care plan.

Based on observation, interview, and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwasher observed. This had the potential to affect all current residents, as well as staff or visitors, who ate food served from dishes and tableware that were cleaned in the dishwasher.Additionally, the facility failed to ensure food items were properly labeled, dated, and stored in the walk-in freezer. The facility also failed to assure that proper hair and beard restraints were used by staff members preparing food within the kitchen. These factors had the potential to impact all residents, staff, and visitors who received food from the kitchen.Findings include: During the initial tour on 4/13/26 at 10:30 a.m., a walkthrough of the dishwashing area was completed. April dishwashing log indicated all temperatures logged with the wash temps of 150 and rinse temps of 180. There were no variations in the temperature range identified. The log for a three-compartment sink identified temperatures were logged at 150 degrees Fahrenheit (F) and the chemical strip results documented were within the desired range. Culinary service director (CSD) stated the equipment was rented. The label identified the company on the front of the machine. On 4/15/26 at 1:22 p.m. dietary aide (DA)-A completed the process of washing dishes. The wash temperature gauge was observed to be 140 degrees (F). The rinse temperature was read at 108 degrees (F). DA-A stated monitoring the temperature was important so the dishes get clean. DA-A stated the temperature was supposed to be 180 degrees F. There were stickers on the front of each gauge which identified Rinse water 120 degrees minimum and Wash water 140 minimum. A sign on the dishwasher indicated a low temp dish machine and directions wash temperature above 120 degrees F. The sign also identified that the low-temp machine depended on chemicals to sanitize the dishes and directed staff to measure with the use of chlorine test paper. The document identified the desired range between 50-100 PPM.DISHWASHING LOG: LOW TEMPERATURE, dated April 2026, included columns labeled wash and PPM for each meal. However, it lacked a spot for rinse temperatures. 4/15/26 noted 130 degrees F for breakfast. However, lacked indication of tracking the noon meal. Further, the April log indicated wash temperatures within the range of 119-130 degrees F and PPM reflected readings between 99-101, with an outlier of 120 on 4/15/26 at breakfast.On 4/15/26 at 2:05 p.m., DA-B stated when the machine was turned on, it would be hot. DA-B stated she was unsure what the required temperature was.On 4/15/26, at 2:07 p.m., DA-A stated the required temperature for the wash cycle was 160 degrees F and 180 degrees F for the rinse cycle. DA-A stated staff were to allow the machine to warm up and check the temperature before anything was run through.January, February and March logs provided were titled DISHWASHING RECORD: HIGH TEMPERATURE. Every entry indicated 150 degrees F under wash column and 180 degrees F under was columns, with no variation. CSD denied any concerns and stated that must be what they were as we watch the temperature closely.On 4/15/26 at 2:22 p.m., review of the test strip bottle indicated numerical options available related to the color of the strips were 10/25/50/100/200 PPM. A review of the test strips was completed with the administrator, with the options clearly displayed. Upon review of the dishwasher log for April, the administrator acknowledged there were multiple entries for 99 and 101. The administrator stated 99 or 101 were not an option to be used. The administrator verified they had not received a new dishwasher between March and April of the present year.On 4/15/26 at 2:36 p.m., a review of test strips was completed with the assistant administrator and CSD. CSD stated the selection of 99 and 101 were the numbers used if it was just a shade of color less than, or greater than, the color designated for the 100. The assistant administrator stated she would have recorded at 100 PPM. The assistant administrator directed attention that the range of the dishwasher temperatures met the specified range outlined on the document on the front of the machine of 120 degrees F as well as the chemical indicator within the desired range of 50-100. However, the labeled temperature gauges indicated Rinse water 120 degrees minimum and Wash water 140 minimum. The assistant administrator stated she was unsure why the gauges were labeled at 140 and 120 but would inquire of this from the service technician. On 4/15/26 at 4:17 p.m., the assistant administrator, CSD, and Regional Consultant-Dietary (RC-D) provided a policy, titled Dishwashing Machine Use, dated 3/10. This was a facility policy, not the manufacturers manual. The policy identified the temperatures required for dishwashers which used hot water for sanitizing and information regarding dishwashing machine chemical sanitizer concentrations and contact time. This graph included the desired range of 50-100 ppm. This policy contained perimeters based on multiple factors which included stationary rack, dual temperature machines or multi-tank, conveyor, multi temperature machines, single tank, conveyor dual temp machines, and for stationary rack, single temperature machines, however, did not specify the specific model of machine currently used. The one-page document on the front of the dishwasher was reviewed with all members, and it was noted although the document identified the temperatures for both the wash and rinse cycles were to be 120 degrees F per this document, the labels on the gauges identified Rinse water 120 degrees minimum and Wash water 140 minimum. RC-D stated she was unaware why gauges on the dishwasher would be labeled this way. On 4/16/26 at 12:42 p.m., the assistant administrator and service technician reviewed the dishwasher. The service technician's manual identified the temperature gauge labels were to be applied on the appropriate gauge to identify: Rinse water 120 degrees minimum and Wash water 140 minimum. Additionally, the product manual identified that the required low temp dishwasher was to have a wash temperature of 140 degrees and a rinse temperature of 120 degrees. The assistant administrator acknowledged the temperature log of April 2026 lacked appropriate wash temperatures of greater than 140 degrees F. Additionally, the log lacked indication of the temperature of the rinse cycle. A review was completed of the current log, to include the lunch reading of 4/15/26 through the current time. It was noted the remaining temps of 4/15/26 failed to meet the required temp of 140 degrees. The morning temperature of 4/16/26 did meet the requirement at 160 degrees.On 4/16/26 at 12:35 p.m., a call was placed to the number provided by the facility for the dishwasher service representative. A message was left with a request for a return phone call, with no call returned. On 4/16/26 at 1:16 p.m., returned to check temperature with CSD. At that time, wash temp was noted to be 140 degrees F., however, the rinse temp was under the 100-degree F. CSD instructed staff to run trays run through, upon running trays through empty for three cycles, the wash temperature was noted to be at 138 degrees F., with the rinse temp at 120 degrees F.On 4/16/26 at 2:58 p.m, DA-A stated sometimes there was a surge from the transformer and that caused the fluctuations of temperatures. Previously DA-A stated the temperatures were to be at 150 and 180 degrees for wash/rinse. Identified with DA-A discrepancy between dishwashing logs. DA-A stated Ok. Now we check it properly. The EcoLab EC-LW Series Conveyors manual, copyrighted 2020, identified the requirements for a low temperature dishwasher were as follows; a wash temperature of 140 degrees F., and a rinse cycle of 120 degrees F. On 4/13/26 at 10:21 a.m., CSD, and assistant Administrator completed a walkthrough in the freezer. A half full 20 pound bag of ice was stored on the floor. This was placed on an empty milk crate so it was off the floor. CSD stated they usually did not use bagged ice and was unsure where this cam from. CSD stated ice, or any items, were not to be stored on the floor of the freezer. The freezer contents were reviewed, and the following was identified in a stainless steel bin near the entry: *A plastic bag, unsealed and twisted shut, with eight pancakes;*A gallon size bag of breadsticks, undated/labeled;*A package of approximately 8 chicken patties, undated/labeled;*A one gallon bag of sugar cookies, with the notation of either yo or 40, which CSD was unable to decipher, undated/labeled;*Two bags, tied off but not zipper sealed, of approximately one gallon of chocolate chip cookies, located in different areas of the freezer, undated/labeled;*A 5lb bag of fruit, 1/2 full, noted to be unzipped and open to air with the fruit noted to be freezer burnt, undated/labeled; and*A bag with approximately 15 patties, per CSD's estimation, in a bag which was tied shut, but not zip sealed.In addition to the bin by the door, a full, sealed bag of freezer burnt berries, with date [DATE] was also noted within the freezer contents. CSD stated she was unaware if that was 2024, however, acknowledged the berries were freezer burnt. CSD stated the dietary staff were to go through the refrigerators and freezers every Tuesday and Friday when food was delivered. CSD stated the freezer should have been checked the previous Friday, however, commented it was not completed thoroughly enough. CSD stated it was important that items were dated so you knew when it was placed in the freezer, how long it was in the freezer, and when it should be used/disposed by. CSD stated using food outside of this range could make people potentially sick. On 4/15/26 at 2:36 p.m., reviewed status of undated/unlabeled food items found in the freezer during the initial kitchen tour. The administrative assistant acknowledged food was to be labeled and dated when stored, and assured food items found unlabeled/undated were disposed of. The facility policy, titled Refrigerators and Freezers, revised 12/14, indicated all food was to be appropriately dated to ensure proper rotation by expiration dates. The policy identified that Use by dates were to be completed with expiration dates on prepared food in the refrigerators, however, lacked this direction for prepared food in freezers. The policy went on to identify the supervisors were responsible to ensure food items in the freezers were not expired or beyond perish dates. The facility policy, Food Receiving and Storage, last reviewed 10/17, identified the for the food items kept in the nursing units all residents' foods must contain the name, the item, and the use by date, however, the policy direction lacked direction as to food stored in the primary freezer in the kitchen.Initial tour on 4/13/26 at 10:21 a.m., was completed culinary service director (CSD) and two dietary assistants (DA)'s A and B. DA-A and DA-B were wearing hair bonnets. However, did not constrain their hair properly.On 4/15/26 at 1:45 p.m., CSD stated all dietary staff should be wearing both hairnets/bonnets and beard masks to prevent food from going into the food being served to others. A review of the facility policy, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 10/17, identified the food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The policy identified hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.

During interview and record review, the facility failed to ensure all residents were offered and up to date on immunizations for 2 of 5 residents (R60, R69) reviewed for immunizations.Findings include:A CDC Pneumococcal Vaccine Timing for Adults feature dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R60's admission minimum data set (MDS) dated [DATE], included an admission date of 1/29/26 and a date of birth of [DATE]. R60's diagnosis included Parkinson's Disease (a progressive disease that could lead to tremors, stiff muscles, slow movement and balance issues), anxiety, and depression. R60's electronic medical record (EMR) included the following pneumonia and influenza vaccines:PCV13 given 11/10/16PPSV23 given 6/20/14Influenza given 10/20/22During interview on 4/16/26 at 10:00 a.m., infection preventionist (IP) stated every resident's immunization status was reviewed upon admission and necessary immunizations were offered. This was a shared task involving the director of nursing (DON), IP, and nurse managers. IP confirmed R60 should have been offered PCV20 and influenza vaccines. IP confirmed there was not a document in R60's electronic medical record (EMR) stating he wished to refuse the PCV20 and influenza vaccines. R69's quarterly MDS dated [DATE], included an admission date of 12/17/25 and a date of birth of [DATE]. R69's diagnoses included debility, heart failure, respiratory failure, and malnutrition.R69's EMR failed to include any documentation of immunizations received or signed declinations for immunizations. During interview on 4/16/26 at 10:00 a.m., infection preventionist (IP) confirmed R69 did not have any record of immunizations received or declinations in his EMR. IP was unsure why R69 had not received any immunizations or education regarding immunizations. Facility policy for influenza dated 11/2025, included vaccination is the primary method for managing influenza and the facility would follow recommendations of the CDC and Minnesota Department of Health for influenza vaccinations. Facility policy for pneumococcal dated 2/2024, included the facility would identify those at risk for pneumococcal disease and offer the pneumococcal vaccination by following the current CDC recommended immunization schedule.

Based on observation, interview, and document review, the facility failed to coordinate services for 1 of 1 resident (R56) evaluated for hospice services. Findings include:R56's admission Record printed 4/17/26, identified admission on [DATE], diagnoses included: pneumonitis (pneumonia-a infection of the lungs which may cause productive cough, fever, chills, and difficulty breathing) due to inhalation of food and vomit, Alzheimer's disease (a progressive neurodegenerative disorder which primarily affected memory, thinking, and behavior), multiple cardiac related diagnoses, chronic kidney disease-stage four (severe, irreversible damage of the kidneys), and oropharyngeal phase dysphagia (a disease which caused problems with swallowing). The admission Record identified R56 was enrolled in hospice.R56's Hospice Certification and Plan of Care identified R56 was enrolled in hospice effective 4/7/26, with the top three diagnoses listed on the plan identified as Alzheimer's disease with late onset, dementia with anxiety, and dysphagia. The plan of care for R56 included skilled nurse visits for symptom management two times a week and additional visits available as needed. R56 was scheduled for home health aide visits three times a week to assist with activities of daily living and personal care needs. Additional services provided by hospice included medical social worker, chaplain, and music therapy.On 4/13/26 at approximately 12:00 p.m., R56 was resting in bed, with head elevated approximately 60-degrees. R56 was being assisted to eat by a female visitor, identified as a visiting agency (VA)-U. Family member (FM)-A was sitting to the bedside. FM-A requested a call was placed to FM-B to obtain information regarding R56, as she was more familiar with cares provided.During phone call on 4/13/26 at 2:02 p.m., FM-B stated family had contracted with a support agency to assure R56 received the necessary care. FM-B stated these services were contracted for 14 hours a day and were in place to provide assist with personal cares.Progress notes dated 4/9/26, identified visiting agency was present, however, the document lacked indication as to what their role was, what their qualifications were, how often they were there and length of visit, if they were contracted services, and if so, by whom.On 4/14/26 at 4:38 p.m., FM-A and FM-C were present with R56 in his room. R56 was observed resting quietly in bed, under covers, with head of bed elevated at approximately 30-degree angle. At this time, a staff member from visiting agency was in the room. FM-C stated he was aware the facility could not have continuous staff in R56's room, however, he was unsure what level of care was expected from facility staff. FM-C stated cares had not occurred from nursing facility staff unless family had requested them. FM-C expressed concerns as to what would happen if R56 was restless and called out and family was not there. FM-A stated often the staff response to R56's calling out was to shut the door. Further, family had experienced long wait times when requesting comfort medications.On 4/15/26 at 8:31 a.m., FM-A arrived and was updated by LPN-A regarding morphine administration to R56 to maintain comfort. After family interaction, LPN-A acknowledged visiting agency was in the room at this time, and family had contracted with this service to sit at bedside to ensure R56 was not alone. LPN-A stated the staff from visiting agency assured R56 was comfortable, provided oral care as needed, and assured that he remained safe in bed. LPN-A stated visiting agency had assisted facility staff with turning and positioning R56. LPN-A stated she was not aware what level of training agency staff had received. LPN-A stated hospice and visiting agency staff provided services above and beyond basic cares provided by facility. They don't take away what we do, they just give them extra care. LPN-A stated this was the first time she was aware of visiting agency presence in the facility. LPN-A stated the visiting agency staff had been present all week.On 4/15/26 at 3:59 p.m., R56 was resting in bed, under covers, on his right side, and the bed slightly elevated to a 30-degree angle. Visiting agency staff (VA-B) was in R56's room. VA-B stated both FM-A and FM-C were in today to spend time. VA-B stated nursing staff have provided her with assist to turn, reposition, and provide incontinent care on three occasions. On 4/16/26 at 12:05 p.m., LSW-A stated R56 was enrolled in hospice and received supportive care from hospice throughout his stay. LSW-A stated family members were here frequently; however, she was unaware of any other services in place. Upon learning of visiting agency prescence, LSW-A looked online and identified this was a home care agency. LSW-A stated residents should not need home care services in a long-term care setting. LSW-A stated she was unaware family members had contracted privately with an outside agency for provision of care for R56.During interview on 4/16/26 at 12:10 p.m., certified nursing assistant (CNA)-B stated CNA-B stated the visiting agency requested help for management of soiled linen and requested fresh linen and briefs. CNA-B stated VA-B provided hands on care for R56 and facility staff helped VA-B to turn, reposition, and provide incontinent care.On 4/16/26, at 12:14 p.m., registered nurse (RN)-B stated R56 received hospice services, as well as services from a visiting agency. RN-B stated the visiting agency provided assist with PCA (personal care attendants) cares (provision of personal cares, including turning, repositioning, etc.) and sought facility staff assistance to help as needed. RN-B stated the services were private services contracted by the family. RN-B stated visiting agency was a home health care agency, however stated she was unaware of the qualifications of the agency staff members providing care, although acknowledged caregivers who provide personal care must be certified. Upon review of R56's care plan, RN-B identified the care plan lacked indication of this service in place.During interview on 4/16/26 at 1:56 p.m., the director of nursing (DON) stated although she was aware the visiting agency was present in the facility, contracted by the family, she was unaware the agency staff were providing personal cares. DON stated it was her understanding the agency was there for companionship. DON stated the visiting agency staff should not have been feeding the resident or providing personal care and was unaware of the level of training by the visiting agency staff and their qualifications to provide care. DON stated the facility was being paid to provide direct care services for R56. DON stated she had reached out to hospice to inquire of this service, however, had not spoken with family about implementation of services. DON stated the facility had not generally allowed personal attendants/outside contracted agencies to provide care within the facility, and to do so would have required a contract in place which would have included their scope of service.A facility policy was requested for coordination of care, however, was unavailable.

Based on documentation and interview, the facility failed to ensure residents were informed of and consented to medications prescribed and given for mental health intervention for 1 of 5 residents (R53) review for unnecessary medication review. Findings include: R53's Face Page indicated the following diagnoses: schizoaffective disorder - unspecified, bipolar disorder - current episode mixed - uncomplicated, anxiety disorder - unspecified and insomnia - unspecified. R53's admission Minimum Data Set (MDS) dated [DATE] indicated R53 was cognitively intact, moderate depression, received partial - minimal assistance with activities of daily living, and substantial - maximal assistance with lower extremity dressing and care. A review of R53's Care Area Assessment (CAA) for Psychotropic Drug Use dated 3/24/26, indicate R53 had taken in the last seven days, medications with the following classifications: antipsychotic, anti-depressant and antianxiety. A review of R53's Hospital Discharge summary dated [DATE], indicated the following medications to be continued at the facility: 1, Clonazepam 0.5 milligrams (mg) 1 tablet by mouth daily at bedtime - benzodiazepine used to treat panic disorder and certain seizure disorders 2. divalproex ER - antiseizure medication - 500 mg capsules, take three capsules by mouth at bedtime3. divalproex ER - antiseizure medication - 250 mg take one capsule by mouth at bedtime4. olanzapine - anti-psychotic - 20 mg, take one tablet orally at bedtime5. trazadone - antidepressant - 150 mg, take one tablet orally at bedtime In review of R53's Physician orders section in Point-Click Care (facility electronic medical record) printed 4/16/26, indicated the physician's diagnoses for the five medications being ordered: clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 0.5 mg by mouth at bedtime for Anxiety Divalproex Sodium ER Oral Tablet Extended Release 24 Hour (Divalproex Sodium) Give 1750 mg by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, UNSPECIFIED OLANZapine Oral Tablet (Olanzapine) Give 20 mg by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, UNSPECIFIED traZODone HCl Oral Tablet (Trazodone HCl) Give 150 mg by mouth at bedtime for chronic insomnia In a review of R53's Informed Consent For Required Medications dated 3/24/26, signed off by care manager (CM)-A and R53, listed only clonazepam and trazadone as medications the facility educated resident on for consent. The diagnoses listed for these two medications were for anxiety and insomnia. Check marks were in place for education and consent for anti-anxiety, antidepressant and antiepileptics (seizure medications). R53's form failed to document:the Divalproex Sodium ER after checking the antiepileptic box, check off the antipsychotic box andlist R53 received Olanzapine (an antipsychotic medication). The assessment / consent form instructed the user to review and list the following medication classifications educated on and consented to: anti-anxiety, antidepressant, Anti-psychotics, sedative/hypnotics, antihistamines, antiepileptics, melatonin/other and simulants. During interview on 4/16/26 at 8:29 a.m., care manager (CM)-A reviewed R53's consent form and current physician orders. CM-A stated she should have listed R53's Depakote ER and Olanzapine as being medications R53 was educated and consented to. CM-A stated she forgot to mark the box that R53 received an anti-psychotic, Olanzapine. CM-A stated the form should include all medications and the categories listed on the form.In an interview on 4/16/266 at 9:53 a.m., the director of nursing (DON) reviewed R53's consent form and physician orders. DON stated the form lacked documentation R53 received Olanzapine and Depakote ER. DON stated was her expectation staff reviewed physician orders, made sure medications matched the classifications the form indicated, be listed on the form, educated the resident, and document consent received. A review of the facility's policy entitled: Psychotropic Medication Use Policy (last dated 5/2025) documented the following:6. Consent: Provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment.a. Obtain informed consent from the resident and/or resident representative and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice.b. The residents and/or responsible party will be notified regarding changes.c. Psychotropic medications will be reviewed quarterly at resident care conferences.

Based on observation, document review, and interview, the facility failed to comprehensively assess residents scoring high on a PHQ-9 (an assessment to determine someone's depression) for 1 of 1 resident (R53) in the samplewho displayed signs and symptoms of moderate depression. Findings include: R53's Face Page indicated the following diagnoses: schizoaffective disorder - unspecified, bipolar disorder - current episode mixed - uncomplicated, anxiety disorder - unspecified and insomnia - unspecified. R53's admission Minimum Data Set (MDS) dated [DATE], indicated cognitively intact, moderate depression, received partial - minimal assistance with activities of daily living, and substantial - maximal assistance with lower extremity dressing and care. A review of R53's Care Area Assessment (CAA) for Psychosocial Well-Being dated 3/27/26, indicated Yes to the statement: Little interest or pleasure in doing things, and indicated the facility would be adding this to R53's care plan, with the overall objective being: improvement, slow and minimize decline, maintain current level of functioning and minimize risks. The form further indicated: Is a referral to another discipline warranted? No. A review of R53's CAA for Mood State dated3/27/26, indicated response of Yes to the statement Thoughts that you would be better off dead, or hurting yourself in some way. No further information was documented on this CAA. During multiple observations during survey 4/13/26 through 4/16/26, R53 was not observed out of his room. Their room door was either opened only a crack or closed. R53 usually sat in his wheelchair, watched TV with the volume down low. In review of R53's Patient Health Questionnaire (PHQ-9, used to determine the level of someone's mood / depression) dated 3/18/26, scored 17, indicated R53 was experiencing Moderately Severe depression. The score was assessed from the following responses: Little interest or pleasure in doing things - 12-14 days YesFeeling down, depressed, or hopeless - 12-14 days YesTrouble falling asleep - YesPoor appetite or overeating - 2-6 days YesFeeling bad about yourself - YesMoving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual - 12-14 days YesThoughts that you would be better off dead, or of hurting yourself in some way - 12-14 days YesSocial Isolation - marked as always A review of R53's comprehensive care plan printed 4/16/26, indicated the following: Alteration in mood and behavior [related to] loss of independence. Resident has a [history] of suicidal thoughts. States talking with staff helps him. Agreed to see [ Associated Clinic of Psychology]. R53's electronic medical record lacked evidence the facility comprehensively assessed resident's history of suicidal thoughts.Interview on 4/16/26 at 9:00 a.m., social worker (LSW)-A reviewed R53's PHQ-9, stated the facility should have conducted a Suicide Prevention Assessment with the PHQ-9 score of 17. R53 was experiencing Moderately Severe depression. In further review of R53's medical record, SW-A stated she was unable to find where resident had been offered ACP (Associated Clinic of Psychology - a mental health counseling service). SW-A stated that they offer it to all residents upon admission and was unable to see where it was documented the services had been offered to R53.On 4/16/26 at 9:53 a.m., the director of nursing (DON) reviewed R53's medical records. Their expectation was to complete a suicide prevention assessment with a score of 17 on the PHQ-9, Facility needed to be able to monitor for concerns related to self-harm. DON stated she was unable to find documentation R53 was offered ACP services. DON stated it was the facility's expectation ACP was offered to ALL residents being admitted to the facility, regardless of mental health status.In review of the facility policy, entitled: Suicide Prevention Policy last revised 11/2023, indicated the following:Policy Interpretation and Implementation1. question 9 on the PHQ-9 or a resident is exhibiting any of the following behaviors, they shall be assessed by an IDT member for suicide risk.Examples include the following observable behaviors:a. Suicidal ideationb. Withdrawal from usual activitiesc. Social isolationd. Detailed plan for suicidee. Signs of depressionf. Farewells to friends and family membersg. Giving away personal belongingsh. Obvious suicidal messagesi. Feelings of hopelessness/helplessnessj. Putting affairs in orderk. Sudden increase of energy after severe depressionl. Increased feeling of euphoria2. The Unit Nurse and/or person in charge must be notified immediately if a resident is expressing these behaviors or states wanting to harm themselves or commit suicide. The unit nurse will assess the situation to gather additional information and determine the course of action.3. If the resident states they have a plan, refuses to share if they do have a plan or have made any physical attempts to harm themselves, resident will be placed on 1:1 supervision and the administrator or director of nursing will be notified.4. The Suicide Prevention interview must be completed.5. If determined to be at risk, a room search will be completed to look for potential dangers that would allow the resident to harm themself. See Room Search Policy/ Alternate care items will be provided as indicated (i.e.: call bell)6. Update the Interdisciplinary team including administrator, director of nursing and social services.7. Contact the physician regarding the outcome of the suicide prevention assessment. Request recommendations for further medical evaluation and/or referral to a counselor or psychiatric practitioner. 8. If necessary, obtain physicians order such as medication or hospitalization to keep the resident safe.9. Determine the need for ongoing interventions per physician orders.10. Update care plan with appropriate interventions and notify the staff.11. Notify family members or responsible party regarding the resident's condition.

Based on interview and document review the facility failed to request a screening in follow up for a new diagnosis of mental illness identified after admission for 1 of 1 resident (R12) reviewed for Preadmission Screening and Resident Review (PASRR).Findings include:R12's admission Record printed 4/17/26, identified admission on [DATE], diagnoses included diabetes mellitus (a disease which impacts the way a body uses sugar (glucose)), anemia (a disorder of the blood), hyperlipidemia (elevated level of cholesterol in the blood) , history of transient ischemic attacks (known as little strokes), cerebral infarction (stroke) without residual deficits (paralysis or weakness), and symptoms and signs involving cognitive functioning (thought processes) and awareness. R12 did not have any diagnosis of mental health conditions upon admission to the facility. The admission Record also indicated R12 was diagnosed with unspecified schizophrenia (a mental health disease) on 2/17/22.A review of the Initial Pre-admission Screening (PAS) results, or PASRR) completed on 12/6/21, identified R12's anticipated nursing home admit date was 12/6/21, and R12 was anticipated to have a stay of less than 30 days. The PASRR identified R12 had no major mental disorder.The Psych Treatment Plan and Updates dated 2/4/22, identified diagnostic impressions of adjustment disorder, unspecified (a strong reaction to stress or trauma which can affect thoughts, behaviors, or emotions). A subsequent note of 2/17/22, indicated effective 2/17/22, R12's diagnostic impressions updated on that date identified other specified schizophrenia spectrum and other psychotic disorder. The treatment plan recommended the treatment team reviewed R12's medical treatment for possible pharmacological treatment for delusions with Paranoia. A review of R12's Progress Notes from 2/1/22, identified tentative discharge plan was to move to an Assisted Living facility (ALF). The narrative notes of 2/11/22, identified a conversation was held with ACP and identified R12 appeared delusional and had scattered thought processes. The note identified ACP was to continue to follow and provide recommendations. On 2/22/22, the narrative noted identified discharge plans changed from desire to discharge to ALF to remain in a long-term care setting. A review of the documents through 4/1/22 lacked indication of outreach for a follow up PASRR due to newly diagnosed mental health illness.A review of resident medical record was completed and was found to have lacked documentation regarding a referral for a subsequent screen following new diagnosis on 2/17/22.During interview on 4/15/26 at 10:16 a.m., Licensed Social Worker (LSW)-A stated when a new diagnosis of mental illness was received, a referral was made to have an updated PASRR completed. LSW-A reviewed the medical record and acknowledged an updated Level II (more detailed screen) had not been completed and should have been. LSW-A stated R12 continued to reside in house and continued to be followed by ACP. LSW-A stated the purpose of an updated screen was for recommendations, and a review of their history.On 4/16/26 at 1:52 p.m., the director of nursing (DON) stated the PASRR was initially obtained prior to resident's admit to the facility. DON stated if there were newly diagnosed mental health illnesses after admission, the expectation was social services followed up to obtain necessary screening.A facility policy for referral process for Level II PASRR assessment for mental health illness diagnosed following admission to the facility was requested but not received.

Based on observation, interview, and record review, the facility failed to implement proper precautions for 2 of 3 residents (R16, R64) reviewed for contact precautions. Findings include: R16's quarterly minimum data set (MDS) dated [DATE], included an admission date of 10/29/25. R16's diagnoses included multidrug-resistant organism [(MDRO) a bacteria that is resistant to at least 3 antibiotics and is contagious]. During observation on 4/16/26 at 8:38 am, R16 had a sign indicating he was on enhanced barrier precautions (EBP). R16's care plan with last review date of 2/17/26, included R16 had a current infection of staphylococcal with interventions to use isolation precautions per protocol. R16's care plan with last review date of 2/17/26, included R16 had a current infection of staphylococcal with interventions to use isolation precautions per protocol. A review of R64's care plan initiated 3/31/26, identified R65 was admitted to the facility on [DATE], with medical diagnoses which included type one diabetes mellitus (a disease where the body was unable to properly manage blood sugar and required insulin), a malignant neoplasm (a cancerous growth) of the tongue, dysphagia (difficulty swallowing), and moderate protein calorie malnutrition, and gastrostomy status (surgically created opening into the stomach, with a feeding tube in place for nutrition, hydration, and medication delivery). The care plan also identified R64 experienced alteration in elimination related to foley catheter (indwelling catheter (tube) which goes directly into the bladder for drainage) and was on enhanced barrier precautions (EBP). The Centers for Disease Control, FAQ's about EBP Precautions in Nursing Homes dated 6/28/24, identified EBP as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). During observation and interview on 4/15/26 at 8:21 a.m., nursing assistant (NA)-A and NA-B provided personal cares for R64. NA-A and NA-B wore gloves, however, no gowns. R64's room had signage to indicate EBP. NA-A and NA-B assisted R64 with dressing. Including handling of urinary bag, threaded it through the pant leg and adjusted the tubing. Further, NA-A and NA-B assisted to place shirt on R64 and adjusted it over the feeding tube site. R64 was turned and repositioned on to side to adjust clothing. Resident was positioned into a back lying position, with pillow adjusted. Once resident was positioned, the catheter bag was placed into the bed bag for privacy. Upon completion of cares, NA-B removed gloves and disposed of them. NA-B stated she should have worn a gown to avoid of the potential spread of infections to both resident and others. NA-A gathered garbage and carried it the soiled utility room. After disposing of garbage, gloves were removed and disposed. Hand hygiene was performed. NA-A stated they were supposed to wear gown as it was important to prevent infection. During interview on 4/16/26 at 10:03 a.m., infection preventionist (IP) confirmed R16 had a diagnosis of MRSA and should have been on contact precautions. IP stated they used infection control signs from the Center for Disease Control and Prevention (CDC). The sign for contact precautions from the CDC included staff must put on gloves and gown before entering the room. During observation and interview on 4/16/26 at 11:06 a.m., IP confirmed the sign outside R16's room was for enhanced barrier precautions (EBP), which was not the same as contact precautions. IP confirmed the EBP sign was the incorrect sign for R16. Facility policy for contact precautions dated 7/31/23, included MDRO infections should be considered for residents who have them and a proper personal protective equipment (PPE) should be used when entering the resident's room.

Based on interview and record review, the facility failed to ensure complete and accurate medical records for 1 of 1 resident (R13) reviewed for mental health practitioner visits.Findings include: R13's quarterly minimum data set (MDS) dated [DATE], indicated R13 was independent in decision making, had the ability to understand others, and make self-understood. Diagnoses included anxiety, depression, schizophrenia, and post-traumatic stress disorder (PTSD). Facility progress note dated 9/24/25, included social work met with R13 to discuss barriers and goals of care. Progress note included R13 had a therapist he worked with. No additional information on therapists included. R13's electronic medical record (EMR) failed to include name of therapist, date of appointments, after visit summaries or additional information regarding mental health care. During interview on 4/14/26 at 5:54 p.m., health unit coordinator (HUC) stated after visit summaries were placed in the resident's hard chart if they have not been scanned into the EMR. HUC confirmed there was no record of visits in the resident's hard chart or EMR. During interview on 4/14/26 at around 6:00 p.m., director of nursing (DON) stated R13's guardian assisted him to appointments and had not always bring back an after-visit summary. DON stated the facility should have followed up with the therapist to collect the information. The DON stated she was unsure if the facility had attempted to follow up for after visit summaries for the mental health visits. During interview on 4/15/26 at 8:35 a.m., HUC stated the facility did not currently have access to the therapist notes but had reached to the providing facility and requested after-visit notes. Facility policy for mental health notes requested and not provided.

Based on observation, interview, and document review, the facility failed to ensure residents were free of medication errors of less than 5% for 1 of 3 residents (R66) observed for medication administration resulting in an 8% error rate.Findings include:R66 was observed on 4/15/26 at 8:20 a.m., during a medication pass. Registered nurse (RN)-A set up oral medications for R66 which included gabapentin (prescription medication used to treat nerve pain) 100 milligrams (mg) tablet. RN-A administered R66's medications. Upon review of R66's electronic medication record (EMR) was unable to locate an order for gabapentin for R66. On 4/15/26 at 11:16 a.m., RN-A stated R66 had previously taken gabapentin 200mg but had been decreased to 100mg. RN-A reviewed EMR, stated they was unable to locate an order for gabapentin for R66, RN-A stated had found an order for pregabalin (a nerve pain medication) 100mg by mouth three times daily. R66 did not receive her ordered pregabalin during medication pass at 8:20 a.m. On 4/15/26 at 11:20 a.m., R66's EMR indicated Gabapentin 200 mg three times daily order had been discontinued 2/3/26. Pregabalin 100mg twice daily was ordered 4/2/26, the pregabalin order was then changed to three times daily on 4/7/26. On 4/15/26 at 2:28 p.m., care manager licensed practical nurse (LPN)-B stated R66's gabapentin was discontinued on 2/3/26. LPN-B was not sure why the medication remained in the medication cart. The expectation was for the medication be removed from the medication cart when it was discontinued to decrease risk of medication error. On 4/15/26 at 3:17 p.m., director of nursing (DON) stated best practice was to remove discontinued medications from the medication cart. The expectation was for overnight nurses to audit the medication carts on a rotating weekly basis and remove discontinued medications. DON reviewed R66's medication cards of gabapentin, and acknowledged the medication was filled on 2/1/26. DON stated upon review of R66's medication cards, orders and pregabalin-controlled medication sign out pages, it had appeared R66 had received several doses of gabapentin instead of the ordered pregabalin between 2/3/26 and 4/15/26. On 4/16/26 at 8:00 a.m., consultant pharmacist (CP)-A stated medications should be removed as soon as possible from the medication cart after the medication was discontinued. CP-A stated to receive gabapentin instead of pregabalin was a medication error. However, this was not considered a significant medication error due to them being similar drugs. Facility Medication and Treatment orders policy dated 2/2024, was provided however the policy lacked direction as to the removal of discontinued medications. Facility policy regarding medication administration was requested, however, none was provided.

Based on interview and record review, the facility failed to initiate an investigation for potential neglect (the failure of the facility, it's employees of service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress) for 1 of 3 residents (R1) reviewed for investigation, prevention and correction of alleged allegation. R1 was given insulin at the incorrect time without a provider's order. R1 was sent to the hospital later that day for hypoglycemia (low blood glucose which includes dizziness, fatigue, sweating, and confusion).Findings include: R1's hospital discharge order dated 2/24/26 indicated R1 was prescribed insulin Aspart pen (a rapid acting insulin) 100 units/ml (milliliter) 1-15 units subcutaneous (below the skin) three times a day with meals. If blood glucose is 150-199 mg/dl (milligrams per deciliter) give 3 units, 200-249 mg/dl give 6 units, 250-299 mg/dl give 9 units, 300-349 mg/dl give 12 units, 350 - 400 mg/dl give 15 units. Normal blood glucose is 70 mg/dl - 110 mg/dl fasting. R1's electronic Medication Administration Record (eMAR) dated 3/13/26 at 12:00 p.m. indicated R1's blood glucose was 355 mg/dl, the eMAR had a check mark indicating the medication was administered, the number 2 indicating she refused the insulin and the number 15 indicating 15 units of Aspart insulin was given. R1's eMAR dated 3/13/26 at 5:00 p.m. indicated R1's blood glucose was 356 mg/dl and 15 units of Aspart insulin was administered. R1's nursing progress notes dated 3/14/26 at 12:12 a.m. indicated around 8:00 p.m. R1 was noted to have had cold clammy hands and weak. Her blood glucose was 52 mg/dl. Her mental status was conscious, but incoherent and confused. Her blood pressure was 139/78 (normal reading 120/80), Pulse was 61 beats per minute (normal range 60-100), O2 saturation rate 22 (normal 92-100). R1 was immediately offered a glass of apple juice and blood glucose went up to 74 mg/dl, another glass of orange juice was offered, and the blood glucose rose to 92 mg/dl. R1 continued to be weak and hospitalized . R1's IDT (intradisciplinary team) note dated 3/16/26 indicated the IDT team met to review R1's rehospitalization for low blood glucoses. R1 was noted to have a blood glucose of 33 mg/dl despite facilities interventions unable to raise blood glucose levels. R1 was transferred to the hospital for further evaluation. R1 was currently unresponsive in the hospital. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score was a 99 indicating R1 did not participate in the assessment.R1's pertinent diagnoses were cancer, cardiorespiratory conditions, diabetes, anxiety, depression, asthma, and respiratory failure. Upon interview on 4/1/26 at 9:40 a.m. R1 stated she did not recall any events that happened on 3/13/26 leading up to her hospitalization. Upon interview on 4/1/26 at 2:09 p.m. registered nurse (RN)-A stated on 3/13/23 at around 2:15 p.m. she heard R1 hysterically crying in her room. RN-A tested R1's blood glucose, and it was above 200 mg/dl. RN-A immediately gave R1 15 units of Aspart insulin. RN-A noticed the day nurse (RN)-B had not recorded R1's noon insulin administration. RN-B was still onsite. RN-A told RN-B that she had taken R1's blood glucose, it was high, and she administered insulin. RN-A told RN-B to chart the insulin as administered at noon because her blood glucose level was high at noon, but not to give the insulin because RN-A gave it around 2:15 p.m. RN-A stated RN-B did chart the insulin as given at noon. RN-A also charted R1's eMAR, the insulin had been given at 5:00 p.m. even though it was given at 2:30 p.m. RN-A stated she called the director of nursing (DON) on 3/13/26 at about 3:00 p.m. and explained the medication error. RN-A was told the DON would take care of the error on the e-MAR and write a progress note. RN-A was not certain if the correction was completed. At approximately 8:00 p.m. on 3/13/26 RN-A found R1 in her room incoherent, cold, and clammy with a blood glucose of 56 mg/dl. RN-A gave R1 juice and got her blood glucose to rise to 92 mg/dl. R1 was still incoherent, cold, and clammy so she was sent to the hospital. RN-A reported the hospitalization to the family and R1's provider, she did not call the DON. RN-A stated the facility had not addressed the medication error or charting with her. Upon interview on 4/1/26 at 2:28 p.m. licensed practical nurse (LPN)-A stated he was aware that R1 had been sent to the hospital for low glucose levels. He denied any knowledge of her rapid acting insulin being given at the incorrect time or both nurses charting the insulin at incorrect times. He was onsite working on 3/13/26 at the time of the incident, however he was not notified. He denied knowledge of a medication error report form filled out or re-education to RN-A. He stated maybe the DON had investigated. Upon interview on 4/1/26 at 2:43 p.m. the DON stated RN-A had called her on 3/13/26 between 2:30 p.m. and 3:00 p.m. stating R1's blood glucose was over 400 mg/dl and RN-A had given the Aspart at 2:15 p.m. The DON stated she instructed RN-A to document the insulin because she had given it. No further instructions were given. The DON viewed the eMAR during the survey and stated it appeared that both RN-A and RN-B had charted the insulin. The DON was not certain what dose of insulin was given. The DON denied filling out a medication error form, investigating the error or re-educating RN-A. Upon interview on 4/1/26 at 3:15 p.m. the Administrator stated she was not aware of the medication error, and the facility did not report the incident. She was not certain if the DON had completed a medication error, investigated, or re-educated RN-A if needed. Attempts were made to reach out to RN-B during the survey; however, no response was received. An investigation policy was requested, however none received.

Based on interview and record review the facility failed to maintain accurate medical records for 1 of 3 residents (R1) reviewed for resident records. R1's medication administration was inaccurately documented when R1's medication Aspart (fast acting insulin) was only administered on 3/13/26 at 2:15 p.m. R1's electronic medical record (eMAR) indicated R1's Aspart insulin was administered on 3/13/26 at 12:00 p.m. and 5:00 p.m. Findings include: R1's hospital discharge order dated 2/24/26 indicated R1 was prescribed insulin Aspart pen (a rapid acting insulin) 100 units/ml (milliliter) 1-15 units subcutaneous (below the skin) three times a day with meals. If blood glucose is 150-199 mg/dl (milligrams/deciliter) give 3 units, 200-249 mg/dl give 6 units, 250-299 mg/dl give 9 units, 300-349 mg/dl give 12 units, 350 - 400 mg/dl give 15 units. R1's electronic Medication Administration Record (eMAR) dated 3/13/26 at 12:00 p.m. indicated R1's blood glucose was 355 mg/dl, the eMAR had a check mark indicating the Aspart insulin was administered, the number 2 indicating R1 refused the insulin and the number 15 indicating 15 units were given. R1's eMAR dated 3/13/26 at 5:00 p.m. indicated R1's blood glucose was 356 mg/dl and 15 units of Aspart insulin was administered. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score was a 99 indicating R1 did not participate in the assessment. R1's pertinent diagnoses were cancer, cardiorespiratory conditions, diabetes, anxiety, depression, asthma, and respiratory failure. Upon interview on 4/1/26 at 2:09 p.m. registered nurse (RN)-A stated on 3/13/23 at around 2:15 p.m. (RN)-A gave R1 15 units of Aspart insulin. (RN)-A was aware that the timing of the Aspart administration was not as ordered. (RN)-A told (RN)-B to document that she had given the Aspart insulin at noon because R1 had refused at that time. (RN)-B documented at 12:00 p.m. that the insulin was refused, however 15 units was administered. (RN)-A documented 15 units of insulin was given at 5:00 p.m. Upon interview on 4/1/26 at 2:28 p.m. licensed practical nurse (LPN)-A denied knowledge that R1's Aspart insulin had been given at 2:15 p.m. and the eMAR documentation indicated the Aspart insulin was administered at 12:00 p.m. and 5:00 p.m. Upon interview on 4/1/26 at 2:43 p.m. the DON stated (RN)-A had called her on 3/13/26 between 2:30 p.m. and 3:00 p.m. stating R1's blood glucose was over 400 mg/dl and RN-A had given the Aspart insulin at that time. The DON stated she instructed (RN)-A to document the insulin because she had given it. No further instructions were given. The DON viewed the eMAR during the survey and stated both (RN)-A and (RN)-B had charted the insulin as administered. The DON was not certain what dose of insulin was given. Upon interview on 4/1/26 at 3:15 p.m. the Administrator stated she was not aware that R1's Aspart insulin was administered at 2:15 p.m., however documented on the eMAR at 12:00 p.m. and 5:00 p.m. as administered. Attempts were made to reach out to RN-B during the survey; however, no response was received. A medical records policy was requested, however none received.

Based on observation, interview, and record review the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication errors. R1's Aspart (a short acting insulin) was given at the incorrect time. The Aspart insulin was ordered as an insulin sliding scale (an order in which the insulin dose is based on a resident's blood glucose level) to be taken with meals and was given at 2:15 p.m. without a meal. In addition, during the survey process R1's 8:00 a.m. medications were administered nearly three hours late. Findings include: Upon observation on 4/1/26 at 10:40 a.m. registered nurse (RN)-C was setting up R1's medications for administration. Upon observation on 4/1/26 at 10:51 a.m. (RN)-C entered R1's room to give R1 her morning mediations. R1 was asleep. (RN)-C aroused R1 and assisted her to a sitting position on the side of her bed. R1 stated that her medications were late again and that she had to be woken up to take them. RN-A acknowledged the medications were late to R1 and continued to administer. R1's medication administration record (MAR) dated 4/1/26 indicated the following medications were scheduled for administration at 8:00 a.m. on 4/1/26:Amiodarone HCl tablet 200 mg (milligrams) give one table by mouth daily for antiarrhythmic (irregular heart rate)Apixaban Calcium 80 mg tablet give one tablet one tablet by mouth twice daily for atrial fibrillation (rapid irregular heart rhythm).Buprenorphine HCL-Naloxone HCl sublingual film 4-1 mg. Give one film sublingually (under the tongue) three times a day for history of substance use.Calcium Carbonate-Vitamin D oral tablet 500-5 mg give one tablet by mouth daily with breakfast for supplemental.Cyclobenzaprine HCl oral tablet give 1 tab by mouth three times a day for muscle spasmsFenofibrate 40 mg tablet give one tablet by mouth daily for cholesterol.Insulin Glargine Solution 100 unit/ml (milliliter) inject 15 units subcutaneously two times a day for diabetes.Lasix 20 mg tablet give three tablets daily for diuretic (water pill).Metoprolol Tartrate give 25 mg by mouth twice daily for hypertension (high blood pressure).MiraLAX oral power 17 gm/scoop (grams) give one scoop by mouth daily for constipation.Mucinex tablet extended release 12-hour 600 mg give one tablet by mouth twice daily for Chronic bronchitis.Potassium 20 meq (milliequivalents) give one tablet by mouth daily for hypokalemia (low potassium).Pregabalin 50 mg capsule give one capsule by mouth three times a day for pain.Prozac 20 mg capsule give one capsule by mouth daily for antidepressantSenna oral tablet 8.6 mg tablet give one tablet by mouth daily for constipation.Spiriva Respimat inhalation aerosol solution 2.5 mcg (microgram) inhale two puffs orally daily for COPD (chronic obstructive pulmonary disease).Thiamine HCl 100 mg tablet give one tablet by mouth daily for supplemental.Nystop External Powder 100000 unit/gram apply to peri-area twice daily for skin protection R1's hospital discharge order dated 2/24/26 indicated R1 was prescribed insulin aspart pen (a rapid acting insulin) 100 units/ml (milliliter) 1-15 units subcutaneous (below the skin) three times a day with meals. If blood glucose is 150-199 mg/dl (milligrams/deciliter) give 3 units, 200-249 mg/dl give 6 units, 250-299 mg/dl give 9 units, 300-349 mg/dl give 12 units, 350 - 400 mg/dl give 15 units. R1's electronic Medication Administration Record (eMAR) dated 3/13/26 at 12:00 p.m. indicated R1's blood glucose was 355 mg/dl, the eMAR had a check mark indicating the Aspart insulin was administered, the number 2 indicating R1 refused the insulin and the number 15 indicating 15 units were given. R1's eMAR dated 3/13/26 at 5:00 p.m. indicated R1's blood glucose was 356 mg/dl and 15 units of Aspart insulin was administered. R1's nursing progress notes dated 3/14/26 at 12:12 a.m. indicated around 8:00 p.m. R1 had cold clammy hands and weakness. Her blood glucose was 52 mg/dl. Her mental status was conscious, but incoherent and confused. Her blood pressure was 139/78 (normal reading 120/80), her pulse was 61 beats per minute (normal range 60-100), her oxygen saturation rate was 92 (normal 92-100). R1 was immediately offered a glass of apple juice and her blood glucose rose to 74 mg/dl, another glass of orange juice was offered, and the blood glucose was 92 mg/dl. R1 continued to be weak and thus the hospitalization.R1's IDT (intradisciplinary team) note dated 3/16/26 indicated the IDT team met to review R1's rehospitalization for low blood glucoses. R1 was noted to have a blood glucose of 33 mg/dl despite the facilities interventions unable to raise blood glucose levels. R1 was transferred to the hospital for further evaluation. R1 was currently unresponsive in the hospital. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicted R1's Brief Inventory of Mental Status (BIMS) score was a 99 indicating R1 did not participate in the assessment.R1's pertinent diagnoses were cancer, cardiorespiratory conditions, diabetes, anxiety, depression, asthma and respiratory failure. R1's hospital discharge order summary dated 3/27/26 indicated R1's morning medications were:Amiodarone HCl tablet 200 mg (milligrams) give one table by mouth daily for antiarrhythmic (irregular heart rate)Apixaban Calcium 80 mg tablet give one tablet one tablet by mouth twice daily for atrial fibrillation (rapid irregular heart rhythm).Buprenorphine HCL-Naloxone HCl sublingual film 4-1 mg. Give one film sublingually (under the tongue) three times a day for history of substance use.Calcium Carbonate-Vitamin D oral tablet 500-5 mg give one tablet by mouth daily with breakfast for supplemental.Cyclobenzaprine HCl oral tablet give 1 tab by mouth three times a day for muscle spasmsFenofibrate 40 mg tablet give one tablet by mouth daily for cholesterol.Insulin Glargine Solution 100 unit/ml (milliliter) inject 15 units subcutaneously two times a day for diabetes.Lasix 20 mg tablet give three tablets daily for diuretic (water pill).Metoprolol Tartrate give 25 mg by mouth twice daily for hypertension (high blood pressure).MiraLAX oral power 17 gm/scoop (grams) give one scoop by mouth daily for constipation.Mucinex tablet extended release 12-hour 600 mg give one tablet by mouth twice daily for Chronic bronchitis.Potassium 20 meq (milliequivalents) give one tablet by mouth daily for hypokalemia (low potassium).Pregabalin 50 mg capsule give one capsule by mouth three times a day for pain.Prozac 20 mg capsule give one capsule by mouth daily for antidepressantSenna oral tablet 8.6 mg tablet give one tablet by mouth daily for constipation.Spiriva Respimat inhalation aerosol solution 2.5 mcg (microgram) inhale two puffs orally daily for COPD (chronic obstructive pulmonary disease).Thiamine HCl 100 mg tablet give one tablet by mouth daily for supplemental. Upon interview on 4/1/26 at 9:40 a.m. R1 was in her room seated on bed. R1 had completed breakfast, her breakfast tray on her wheelchair chair ready to be removed from her room. R1 stated she was waiting for medications which should have been given on or around 8:00 a.m. with her breakfast. R1 did not recall the incidents that happened on 3/13/26 which led to her hospitalization; however, she was told her blood glucose was very low. R1 she was glad the hospital discontinued her Aspart rapid acting insulin and kept her on a scheduled dosage of insulin only. Upon interview on 4/1/26 at 11:00 a.m. R1 stated her medications were given late a few times a week. R1 stated when her medications are over an hour late, it messed with pain control and her breathing because of having to wait for the medications. R1 asked if it was safe for her insulin to be administered almost three hours late because then the second dose would be given early, and she has had hyper and hypoglycemia (high and low blood glucose levels) episodes at the facility which led her to the hospital. R1 stated when her pain medication is given late her pain sets in and then it takes longer for it to go away, and her breathing becomes more obstructed when she has had to wait on her Mucinex. Upon interview on 4/1/26 at 11:11 a.m. R1's Nurse Practitioner (NP) stated the Aspart insulin should not have been given between meals because rapid acting insulin without food can drop the blood glucose levels significantly. The facility nurse should have called the provider if they felt the need or the resident was requesting the insulin be administered at an off-scheduled time. The NP's expectation was that the facility administered the medications an hour before or an after the scheduled time, if they cannot meet those time frames they should change the times. Upon interview on 4/1/26 at 11:55 a.m. the Pharmacist stated R1's Glargine insulin and her Mucinex should be given as close to 12-hours as they can be for the best results for diabetic and COPD control. It is important to keep pain medications on a schedule as well because it prevents pain from becoming severe and harder to manage. As far as the nurse who gave the Aspart insulin incorrectly, may or may not be the reason her blood glucose dropped to abnormal levels requiring her to be sent to the hospital. There are too many factors unknown. Upon interview on 4/1/26 at 2:09 p.m. registered nurse (RN)-A stated on 3/13/23 at around 2:15 p.m. she heard R1 hysterically crying in her room. (RN)-A tested R1's blood glucose and found it was above 200 mg/dl. (RN)-A immediately gave R1 15 units of Aspart insulin. RN-A then noticed the day nurse (RN)-B had not recorded R1's noon Aspart insulin administration. (RN)-B was still onsite. (RN)-A told (RN)-B that she had given R115 units of Aspart insulin because her blood glucose was 356 mg/dl. (RN)-A then told (RN-B) to chart the Aspart insulin as administered at noon because her blood glucose level was also high at noon, but not to give any insulin. (RN)-A stated (RN)-B charted the insulin as administered at noon, even though it was not. (RN)-A also charted insulin administration under the 5:00 p.m. slot on the eMAR, even though it was given at 2:15 p.m. and not charted. (RN)-A stated she called the director of nursing (DON) on 3/13/26 at about 3:00 p.m. and explained the medication error. (RN)-A was told the DON would take care of the error on the e-MAR and write a progress note for (RN)-A. (RN)-A was not certain if the correction was completed by the DON. At approximately 8:00 p.m. on 3/13/26 RN-A found R1 in her room incoherent, cold, and clammy with a blood glucose of 56 mg/dl. RN-A gave R1 juice and her blood glucose rose to 92 mg/dl. R1 was still incoherent, cold, and clammy was sent to the hospital. Upon interview on 4/1/26 at 2:28 p.m. licensed practical nurse (LPN)-A the nurse manager denied knowledge that R1's Aspart insulin had been given at 2:15 p.m. and the eMAR documentation indicated the Aspart insulin was administered at 12:00 p.m. and 5:00 p.m. (LPN)-A stated he was working onsite and the (RN)-A should have reached out to him and he would have directed (RN)-A to call the provider because giving the insulin between the meal times was a medication error. Upon interview on 4/1/26 at 2:43 p.m. the DON stated (RN)-A had called her on 3/13/26 between 2:30 p.m. and 3:00 p.m. stating R1's blood glucose was over 400 mg/dl and (RN)-A had given the Aspart insulin at 2:15 p.m. The DON stated she instructed (RN)-A to document the insulin because she had given it. No further instructions were given. The DON viewed the eMAR during the survey and stated it appeared that both (RN)-A and (RN)-B had charted the insulin as administered. The DON was not certain what dose of insulin was actually given. The DON stated (RN)-A's giving insulin at the incorrect time was a medication error and (RN)-C giving medications almost three hours late was a medication error. Upon interview on 4/1/26 at 3:15 p.m. the Administrator stated she was not aware that R1's Aspart insulin was administered at 2:15 p.m., however documented on the eMAR at 12:00 p.m. and 5:00 p.m. as administered. The Administrator stated all medications should be given within an hour before or after the ordered time of the medication. If they cannot be for any reason the nurse needed to notify the provider for any further details. Attempts were made to reach out to RN-B during the survey; however, no response was received. An insulin medication policy was requested. A facility standing order sheet was provided titled Standing Orders for nursing Facilities and Skilled Nursing facilities dated 2026. The order sheet did not indicate an intervention for hyperglycemia treatment in regard to a sliding scale.

Based on interview and record review, the facility failed to report potential neglect (the failure of the facility, it's employees of service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress) to the State Agency (SA), no later than 24 hours for 1 of 3 (R1) residents reviewed for reporting. R1 was given insulin at the incorrect time without a provider's order. R1 was sent to the hospital later that day for hypoglycemia (low blood glucose which includes dizziness, fatigue, sweating, and confusion).Findings include: R1's hospital discharge order dated 2/24/26 indicated R1 was prescribed insulin Aspart pen (a rapid acting insulin) 100 units/ml (milliliter) 1-15 units subcutaneous (below the skin) three times a day with meals. If blood glucose is 150-199 mg/dl (milligrams per deciliter) give 3 units, 200-249 mg/dl give 6 units, 250-299 mg/dl give 9 units, 300-349 mg/dl give 12 units, 350 - 400 mg/dl give 15 units. Normal blood glucose is 70 mg/dl - 110 mg/dl fasting. R1's electronic Medication Administration Record (eMAR) dated 3/13/26 at 12:00 p.m. indicated R1's blood glucose was 355 mg/dl, the eMAR had a check mark indicating the medication was administered, the number 2 indicating she refused the insulin and the number 15 indicating 15 units of Aspart insulin was given. R1's eMAR dated 3/13/26 at 5:00 p.m. indicated R1's blood glucose was 356 mg/dl and 15 units of Aspart insulin was administered. R1's nursing progress notes dated 3/14/26 at 12:12 a.m. indicated around 8:00 p.m. R1 was noted to have had cold clammy hands and weak. Her blood glucose was 52 mg/dl. Her mental status was conscious, but incoherent and confused. Her blood pressure was 139/78 (normal reading 120/80), Pulse was 61 beats per minute (normal range 60-100), O2 saturation rate 22 (normal 92-100). R1 was immediately offered a glass of apple juice and blood glucose went up to 74 mg/dl, another glass of orange juice was offered, and the blood glucose rose to 92 mg/dl. R1 continued to be weak and hospitalized . R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score was a 99 indicating R1 did not participate in the assessment.R1's pertinent diagnoses were cancer, cardiorespiratory conditions, diabetes, anxiety, depression, asthma, and respiratory failure. R1's IDT (intradisciplinary team) note dated 3/16/26 indicated the IDT team met to review R1's rehospitalization for low blood glucoses. R1 was noted to have blood glucose of 33 mg/dl despite facilities interventions unable to raise blood glucose levels. R1 was transferred to the hospital for further evaluation. R1 was currently unresponsive in the hospital. Upon interview on 4/1/26 at 9:40 a.m. R1 stated she did not recall any events that happened on 3/13/26 leading up to her hospitalization. Upon interview on 4/1/26 at 2:09 p.m. registered nurse (RN)-A stated on 3/13/23 at around 2:15 p.m. she heard R1 hysterically crying in her room. RN-A tested R1's blood glucose, and it was above 200 mg/dl. RN-A immediately gave R1 15 units of Aspart insulin. RN-A noticed the day nurse (RN)-B had not recorded R1's noon insulin administration. RN-B was still onsite. RN-A told RN-B that she had taken R1's blood glucose, it was high, and she administered insulin. RN-A told RN-B to chart the insulin as administered at noon because her blood glucose level was high at noon, but not to give the insulin because RN-A gave it around 2:15 p.m. RN-A stated RN-B did chart the insulin as given at noon. RN-A also charted R1's eMAR, the insulin had been given at 5:00 p.m. even though it was given at 2:30 p.m. RN-A stated she called the director of nursing (DON) on 3/13/26 at about 3:00 p.m. and explained the medication error. RN-A was told the DON would take care of the error on the e-MAR and write a progress note. RN-A was not certain if the correction was completed. At approximately 8:00 p.m. on 3/13/26 RN-A found R1 in her room incoherent, cold, and clammy with a blood glucose of 56 mg/dl. RN-A gave R1 juice and got her blood glucose to rise to 92 mg/dl. R1 was still incoherent, cold, and clammy so she was sent to the hospital. RN-A reported the hospitalization to the family and R1's provider, she did not call the DON. RN-A stated the facility had not addressed the medication error or charting with her. Upon interview on 4/1/26 at 2:28 p.m. licensed practical nurse (LPN)-A stated he was aware that R1 had been sent to the hospital for low glucose levels. He denied any knowledge of her rapid acting insulin being given at the incorrect time or both nurses charting the insulin at incorrect times. He was onsite working on 3/13/26 at the time of the incident, however he was not notified. He denied knowledge of a medication error report form filled out or re-education to RN-A. He stated maybe the DON had investigated. Upon interview on 4/1/26 at 2:43 p.m. the DON stated RN-A had called her on 3/13/26 between 2:30 p.m. and 3:00 p.m. stating R1's blood glucose was over 400 mg/dl and RN-A had given the Aspart at 2:15 p.m. The DON stated she instructed RN-A to document the insulin because she had given it. No further instructions were given. The DON viewed the eMAR during the survey and stated it appeared that both RN-A and RN-B had charted the insulin. The DON was not certain what dose of insulin was given. The DON denied filling out a medication error form, investigating the error or re-educating RN-A. Upon interview on 4/1/26 at 3:15 p.m. the Administrator stated she was not aware of the medication error, and the facility did not report the incident. She was not certain if the DON had completed a medication error, investigated, or re-educated RN-A if needed. Attempts were made to reach out to RN-B during the survey; however, no response was received. An investigation policy was requested, however none received.

Based on observations, interviews, and document review, the facility failed to ensure medications were stored securely in areas where residents, staff and guests could not access medications in 1 of 1 medication carts observed, potentially affecting one unit, Unit 400, of the facility. Findings include: During observation and interviews on 3/13/26 at 12:27 p.m., Employee (E)-I walked away from the medication cart, leaving it unlocked in the hallway of the 400 unit, stationed between resident rooms. At 12:31 p.m., the Director of Social Services (DSS)-A walked by the cart and pulled on the locked narcotics drawer. The DSS-A stated she was making sure the drawer was locked and then walked away. The cart remained unlocked and unattended until 12:37 p.m., when E-I returned to the cart. From 12:27 p.m. to 12:37 p.m. one resident wheeled by the cart, and two nursing assistants (NA) walked by the unlocked cart. E-I acknowledged the medication cart was unlocked when she left but should have been locked when she stepped away. Further, E-I stated the cart was supposed to be locked to ensure other staff and residents could not take medications from the cart, which could make them sick. During an interview on 3/17/26 at 3:43 p.m., E-E stated if she walked away from a medication cart, it had to be locked. During an observation and interview on 3/13/26 at 2:27 p.m., the medication cart in the hallway of the 400 unit, stationed between resident rooms was found unlocked and unattended. From 2:27 p.m., to 2:47 p.m., NAs walked by the unlocked cart five times. At 2:47 p.m., the director of nursing (DON) walked by the cart and pushed the lock to lock the medication cart and stated it was not good that the cart was unlocked, medications could go missing, and the cart was supposed to be locked when staff walked away from the cart. The Storage of Medications policy dated May 2022 indicated the medication supply was accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. Medication carts were locked when not attended by people with authorized access.

Based on observation, interview, and record review the facility failed to ensure pressure ulcer prevention interventions were utilized as ordered for residents at risk of developing pressure ulcers for 2 of 3 residents (R1, R4) reviewed who were at risk for pressure ulcers.Findings include: R1 R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired, at risk for pressure ulcers and used pressure reducing devices for her chair and bed. R1's diagnoses included a brain tumor, difficulty speaking, diabetes, and paralysis on the right, dominant side. R1's care plan dated 11/6/25, directed to float heels with pillow and turn and reposition every two-to-three hours and as needed (PRN). R1's care plan lacked an update or mention of precautions to prevent friction and sheer, although the progress notes indicated that risk. R1's provider orders dated 11/10/25 indicated weekly skin inspection by licensed nurse. R1's progress notes indicated the following:11/20/25 at 2:47 p.m., makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Friction and Shear is a potential problem.12/2/25 at 2:15 p.m., order placed for air mattress to prevent skin breakdown. R1's hospice progress notes indicated the following:11/28/26 at 4:16 p.m., poor skin turgor (reduced elasticity in skin making it more vulnerable to damage) and anasarca (severe, total-body swelling that severely compromises skin integrity and potential breakdown)12/1/25 at 11:11 a.m., patient's son had nurse speak to facility about making sure they reposition and place patient on their side, checked coccyx to ensure there is no skin breakdown; there is none During an interview on 3/18/26 at 8:30 a.m., family member (FM)-A, who returned a call that was placed on 313/26 at 10:08 a.m., stated staff's version of turning R1 was putting a towel under the shoulder, and when hospice staff came, they [hospice] turned R1 correctly. During an interview on 3/17/26 at 3:43 p.m., Employee (E)-E stated a resident could not be positioned properly with a towel, but instead staff used pillows. A resident would not stay in position with only the support of a towel. R4 R4's admission MDS dated [DATE], indicated intact cognition, risk for pressure ulcers and used pressure reducing devices for her chair and bed. R4's diagnoses included malnutrition, pneumonia, and respiratory failure. R4's provider orders dated 2/24/26, indicated apply TED hose (Thrombo-Embolism-Deterrent compression stockings used to reduce swelling in the legs in the presence of edema), every day shift for edema. Provider orders dated 3/6/26, indicated apply ACE wraps on in the morning and off at bedtime to help manage swelling. R4's provider note dated 3/17/26, indicated 3+ (three-plus- a clinical grading of pitting edema) (moderate-to-severe pitting edema, where significant fluid retention leaves a deep, prolonged indentation after pressure is applied) edema in lower extremities. R4's progress notes indicated the following:3/10/26 at 1:57 p.m., indicated a 10 pound weight gain over a month, with legs that looked quite edematous, and wearing compression stockings.3/17/26 at 10:46 a.m., discussion with daughter related to weight gain, and new order for compression to bilateral lower extremities to assist with edema.3/17/26 at 4:42 p.m., weight remains elevated due to edema and fluid retention R4's care plan dated 2/2/26, indicated turn and reposition and offload (reduction or redistribution of pressure on a specific area) every 2-3 (two-to-three) hours and as needed. During continuous observation and interview on 3/13/26 from 11:52 a.m., to 2:20 p.m., R4 was lying in bed on her back, with the head of bed raised, feet resting on a pillow, and a pillow resting on top of her feet at the base of the bed. At 2:20 p.m., staff entered the room to assist R4 to reposition. R4 was not wearing TED hose or ACE wraps as ordered. During an interview on 3/13/26 at 2:14 p.m., E-K stated R4 required assistance to reposition and to move up in bed, and staff was supposed to do that every two hours as R4 could turn a little bit on her own, but needed help. At 1:55 p.m., R4 stated her feet were still on the pillow and she didn't know why there was a pillow laying on her legs, but it felt heavy on them. During an observation and interview on 3/13/26 at 2:20 p.m., E-H, a licensed nurse, acknowledged R4's feet and legs had a lot of swelling, and the top R4's socks were making indentations in R4's feet. E-H stated R4 was at risk to get sores from the socks being too tight. R4's heels were directly on a pillow instead of floated off the bed, and the E-H acknowledged R4's heels were on the pillow instead of floated, and was not wearing TED hose but should have been. The Employee E stated she put the pillow on R4's feet when she repositioned R4 in the morning and forgot to remove it. E-H did not reposition R4's lower extremities to float the heels, did not remove the socks or apply the TED stockings before leaving the room. During an interview on 3/17/26 at 5:25 p.m., the director of nursing (DON) stated pressure ulcer prevention included a turning and repositioning program, incontinence care, floating heels, padding bony prominences and using an air mattress. The DON stated offloading pressure from heels meant putting a pillow under the legs, with the heels off the pillow so the heels were floating. The Skin Assessment and Wound policy dated 2/2025, indicated the facility would implement appropriate preventative skin measures including a mobility and repositioning plan and pressure redistribution plan. The facility would update the care plan to identify risks for skin breakdown.

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan to properly care for 1 of 3 residents (R2) reviewed for baseline care plan. Additionally, the facility failed to provide a summary of the baseline care plan to 1 of 3 residents (R2). Findings include: R2's admission Data Collection (nursing assessment) dated 2/16/26 at 12:50 p.m., indicated R2 had pain frequently over the past five days that made it hard to sleep at night and limited day-to-day activities. Pain was rated as moderate pain as a five (5) on a scale of 0-10. Nursing assessment indicated R2 had a wound on the coccyx described as, right butt has opening. R2's progress notes indicated on 2/16/26 at 3:18 p.m., R2 was admitted with a chronic stage IV (4) (full-thickness tissue loss with exposure of muscle, tendon, ligament, or bone) sacral ulcer. R2's Physical Therapy (PT) Evaluation and Plan of Treatment dated 2/17/26 (no time), indicated R2 had pain which interfered with functional activity and sleep. Nursing would address the pain. R2's provider progress note dated 2/17/26 (no time), indicated R2 rated pain at 5/10 on 2/16/26 at 1:31 p.m. R2's pain ratings included the following:2/16/26 at 1:31 p.m., pain rated as 5/102/18/26 at 7:17 a.m., pain rated as 6/102/18/26 at 3:29 p.m., pain rated as 8/102/18/26 at 3:31 p.m., pain rated as 8/10 R2's 48-Hour Care Plan (baseline care plan) dated 2/18/26, indicated R2 admitted [DATE]. R2's care plan indicated R2 experienced pain but failed to include interventions to relieve pain. The 48-Hour care plan indicated R2 was on Enhance Barrier Precautions (EBP) related to wounds but failed to include R2 had skin issues or interventions to treat the wounds. The 48-hour care plan failed to indicate if R2, or R2's family/representative was offered a copy of the 48-hour care plan or the opportunity to sign the 48-hour care plan. R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 admitted with pain that interfered occasionally with sleep, therapy, and day-to-day activities, with pain rated as 5/10 and a Stage III (full-thickness skin injury that extends into the subcutaneous fat but does not expose muscle, tendon or bone) pressure ulcer (PU). During an interview on 3/17/26 at 3:43 p.m., employee (E)- A stated if a resident had pain or pneumonia on admission, they should be addressed on the baseline care plan and there should be a plan for staff to follow to provide care. The resident should be offered a copy and an opportunity to sign the care plan. During an interview on 3/17/26 at 4:30 p.m., E-B stated a care plan was developed right away after admission, and should include pain, pressure ulcers, and skin checks with interventions that match the orders sent by the hospital. The residents should sign the care plan and is offered a copy. During an interview on 3/17/26 at 5:25 p.m., the director of nursing stated if a resident was admitted with pain and/or a pressure ulcer, inventions should be on the resident's 48-Hour care plan and the resident should be provided with a copy. Facility provided document, The Care Plans - Baseline policy dated 7/21/23, indicated the baseline care plan is used until staff can conduct a comprehensive assessment and develop an interdisciplinary person-centered care plan and should include any services and treatments to be administered by the facility.

Based on interviews, observation, and document review the facility failed to comprehensively develop and implement care plan interventions for 1 of 3 residents (R4) when R4 had poor nutritional intake with a diagnosis of malnutrition. Findings include:R4's admission Minimum Data Sheet (MDS) dated [DATE], indicated R4 admitted to the facility on [DATE], with intact cognition, required set-up assistance for meals, and diagnoses included pneumonia and malnutrition. R4's care plan dated 2/2/26, indicated a potential nutritional problem related to moderate malnutrition with interventions to assist with meal set-up, record nutritional intakes, take orders at meals and offer alternatives. The care plan failed to include interventions for when R4 did not eat meals as well as direction when to offer nutritional supplement that was ordered. During an observation and interview on 3/13/26 at 12:56 p.m., R4 independently drank fluids from her glass, drank her fruit cup instead of using utensils, and ate a few bites of the fish from her plate with her fingers. R4 did not eat the rest of her meal that included pasta and a vegetable. R4 stated she did not like her meal, it was fish but didn't taste like fish. During an observation and interview on 3/13/26 at 1:21 p.m., E-G entered R4's room, asked if R4 was done eating. R4 replied she was done. Employee G removed R4's tray. E-G stated R4 ate about 10% of her noon meal. E-G was aware R4 disliked the facility food. E-G stated when residents didn't eat, staff should offer an alternative food choice or ask if the resident required assistance to eat. E-G acknowledged she did not do either. E-G stated she should look at the care plan for how a resident eats, or for their food preferences, but had not done this for R4 and stated the nurse managers were responsible to update the care plans. During an interview on 3/13/26 at 2:20 p.m., E-H stated R4 ate about 50% of her noon meal and she charted it in R4's medical record. E-H acknowledged she had not removed the tray from R4's room and had not seen R4 eat, but 50-75% was what R4 typically ate. E-H further acknowledged charting R4 ate 50% of the noon meal was not accurate, the amount R4 actually ate was about 25%. E-H stated typically staff would offer to help a resident eat or offered an alternative food choice if the resident did not eat well. E-H acknowledged she had not done this. On 3/17/26 at 9:00 a.m., upon review of R4's care plan, the care plan was not updated with interventions for what to do if R4 did not want to eat, nor with food preferences. During interview on 3/17/26 at 3:01 p.m., R4 stated she didn't think staff had ever asked her about her food preferences. During an interview on 3/17/26 at 5:25 p.m., the director of nursing (DON) stated R4's noon meal charted on 3/13/26, indicated R4 ate 50-75% of her meal. The DON stated if a resident does not eat well, staff should ask the resident if they didn't like the meal, offer something else and if the appetite has declined, notify the nurse, dietician, and provider. In addition, DON expected more monitoring was put place for the resident. DON acknowledged this was not done for R4. DON expected interventions were in the care plan. The Care Planning Policy dated 11/2024 indicated the comprehensive care plan was used to develop the resident's daily care routines and was utilized by staff for the purposes of providing care to the resident. 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 ensure 1 of 3 residents (R3) was free from a significant medication error. This resulted in an Immediate Jeopardy (IJ) for R3 who was given the wrong dose of medication that resulted in hospitalization in the intensive care unit. The IJ began on 11/4/25 at 7:07 a.m. when R3 was administered the incorrect amount of 40 milligrams (mg) of methadone (a long-acting opioid pain medication) which was 16 times the prescribed amount of 2.5 mg. The administrator and director of nursing (DON) were notified of the IJ on 11/7/2025 at 1:50 p.m. The IJ was removed on 11/5/25 prior to the start of the survey and was therefore past noncompliance Findings include:The package insert for Methadone Hydrochloride informed while serious, life-threatening, or fatal respiratory depression can occur at any time during the use of Methadone Hydrochloride Tablets, the risk is greatest during the initiation of therapy or following a dosage increase. The peak respiratory depressant effect of methadone occurs later and persists longer than the peak analgesic (pain relieving) effect, especially during the initial dosing period. To reduce the risk of respiratory depression, proper dosing and titration (process of gradually adjusting the dose of a medication to find the optimal amount that provides the maximum benefit with the fewest side effects for an individual patient) of Methadone Hydrochloride Tablets are essential. Respiratory depression from opioid use, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid overdose reversal agents. R3's admission Minimum Data Set (MDS) dated [DATE] indicated R3 did not have cognitive impairment. R3 was dependent on staff for activities of daily living (ADLs) and diagnoses including fracture of neck of right femur and Chronic obstructive pulmonary disease (COPD). R3's handwritten order dated 11/3/25 instructed: methadone 10mg/mL give 2.5mg (.4ml) via g-tube once daily Dx. [diagnosis] Pain. This order was written by registered nurse (RN)-F who was a hospice nurse. RN-F did not identify the correct number of mL for administration; the conversation 0.4 mL is equal to 4.0 mg of medication; 0.25 mL is the correct measurement to administer 2.5 mg of Methadone. In addition, the order was not written according to requirements by the Board of Pharmacy. The Minnesota board of Pharmacy undated document Requirements for a Valid Prescription instructed to use leading zeros for doses less than 1 measurement unit (example 0.3 mg never .3mg).During a phone interview on 11/7/25 at 8:48 a.m., RN-F stated on 11/3/25, when she arrived at facility, she was instructed to change all of R3's medication orders from tablets to liquid dosages. RN-F hand wrote all R3's medication orders on a facility order sheet and gave the orders to LPN-D. LPN-D handed the orders to RN-A around 2:00 p.m. on 11/3/25. RN-F stated the nurses' station at the facility was busy at the time and staff were doing change of shift report. Typically, RN-F would hand write all orders for the facility, transcribe all orders in an online system for her facility medical provider, and send the orders to the pharmacy. Since the transcription error on 11/3/25, RN-F's company changed the order writing process to include taking a screenshot of all handwritten orders and sending them to the medical provider, and education on transcribing orders.R3's transcribed order that was entered into the electronic health record on 11/3/25 at 3:11 pm by (RN)-A instructed: methadone oral concentrate 10mg/mL Give 4. ml via g-tube one time a day for pain. This was a difference of 3.6 ml of medication and equivalent to 40 mg of Methadone. R3's medication bottle sent from pharmacy instructed: Methadone bottle 10mg/mL Give one half (0.5) ml (5mg) per g-tube once daily. During an interview on 11/5/2025 at 1:57 p.m., pharmacist (Pharm)-A confirmed the order received from the provider that was escribed-that order was placed on the medication bottle: Methadone concentrate 10mg/mL Give one half (0.5) ml (5mg) per g-tube once daily. Pharm-A stated side effects from methadone could include sedation, drowsiness, respiratory depression, hypotension, and syncope. The half-life (the time it takes for the amount of the medication to decrease by half in the body) was 96 hours. R3's medication administration record (MAR) indicated LPN-A administered 4.0 ml of methadone 10mg/ml (40 mg) on 11/4/25 at 7:07 a.m.During an interview on 11/5/2025 at 12:45 p.m., LPN-A stated when she was getting ready to administer R3's medications on 11/4/25 around 7:00 a.m. she noticed the order in the MAR did not match the medication bottle. She administered the dose that was in the MAR (4 mL) because normally the orders in the MAR are the most current. LPN-A stated she should not have administered the medication and should have contacted the provider for clarification.During an interview on 11/5/2025 at 12:26 p.m., Hospice registered nurse supervisor (HRNS) stated a hospice nurse was at the facility on 11/4/25 around noon to see R3. She noticed he was sleepy and lethargic, which was not his normal. On assessment, R3's respiratory rate was 7 (normal range [NR] is 12-18), blood pressure 115/66 (NR 90/60-120/80), oxygen was 86 (NR above 90%) on 2 liters (L) of supplemental oxygen, pulse was 104 (NR 60-100), pupils were pinpoint, and he was not really responding. Intramuscular Narcan (medication used to reverse the effects of an opioid pain medication overdose) was administered. R3 was alert after the Narcan was administered then was sent to the hospital where he was admitted .R3's hospital transfer note dated 11/04/25 at 1:27 p.m., indicated R3 was sent to the hospital because he received an extra amount of Methadone and a onetime dose of Narcan (before he left the facility). R3's record did not identify any other information. During an interview on 11/5/2025 at 2:59 p.m., Hospital RN stated R3 had been admitted to the intensive care unit (ICU) and was on a Narcan drip (continuous liquid medication administration via a small tube directly into a vein) due to Methadone overdose. In the emergency department, R3 was given a bolus of Narcan, but as soon as it started to wear off R3's blood pressure would drop. R3 needed a constant infusion of Narcan to keep him awake and breathing. R3's Narcan drip was stopped the morning of 11/5/25. R3's blood pressure dropped to 76/43 and he became very somnolent so the Narcan drip needed to be restarted.During an interview on 11/6/25 at 12:21 p.m., RN-A stated when a new order is received the nurse who received the order should enter it into the computer. Then, that nurse should hand the order sheet to another nurse to double check the order. A double check was important to be sure the order was entered accurately into the computer. On 11/3/25, LPN-D handed RN-A, R3's handwritten order sheet to transcribe the orders into the computer. The dose amount for R3's Methadone had been scribbled darker like it had been written over, but RN-A entered the order into the computer as she interpreted the handwriting. RN-A did not notice the dot in front of the '4' and there was no '0' before the '4', so she entered 4 ml. When RN-A had completed entering all the orders into the computer, she gave the order sheet to LPN-D to be double checked. On 11/4/25 after R3 had received the incorrect dose, RN-A found the order sheet next to the computer with no double check completed. RN-A stated LPN-D should have double checked the orders or passed the order sheet to the night nurse to double check the orders. RN-A stated she should have clarified the Methadone order before she entered it into the computer. Double checking orders was important to confirm the order had been entered correctly into the computer.During an interview on 11/7/25 at 9:38 a.m., LPN-D stated he did not recall why R3's orders did not get double checked, but did recall the shift was very busy.During an interview on 11/5/2025 at 11:56 a.m., RN-B stated if a written order was unclear or the orders in the MAR did not match the order on the medication card or bottle, the medication should not be administered, and the provider should be contacted.During an interview on 11/5/2025 at 2:26 p.m., Nurse practitioner (NP)-A stated when administering medications, a nurse should make sure the medication order in the MAR is the same as the order on the medication card or bottle. If the orders do not match, the nurse should not administer the medication and should clarify the order. Potential side effects from a large increase of methadone include being lethargic, unresponsive, decreased heart rate and decreased blood pressure, low respirations, they could stop breathing.During an interview on 11/6/2025 at 1:14 p.m., director of nursing (DON) stated when administering medication, a nurse should compare the order in the MAR with the order on the medication bottle or card. If the orders did not match, the medication should not be administered, and the order should be clarified. The nurse who administered the correct dose should have not administered the medication when she noticed the orders did not match.The Medication and Treatment Orders policy dated 2/2024 instructed: orders for medications and treatments will be transcribed accurately and in a timely manner. Orders must include:a. Name and strength of the drug;b. Number of doses, start and stop date, and/or specific duration of therapy;c. Dosage and frequency of administration;d. Route of administration;e. Clinical condition or symptoms for which the medication is prescribed; andf. Any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). The facility implemented the following actions prior to the start of survey so the IJ is being issued at PNC: - 11/4/25 The facility immediately suspended the nurse who administered the incorrect dose and began educating all nurse who were currently working.- 11/4/25 Provided education to the nurse manager who incorrectly transcribed the order regarding clarification of any orders that are scribbled, dose increase that is too high or the handwriting is not legible.- 11/4/25 Provided education to the nurse who administered the incorrect dose regarding whenever a discrepancy on the MAR and the medication bottle or bubble pack, the order must be clarified, and the medication should not be administered.- 11/4/25 Hospice agency educated their nurse related to transcription error and conflicting orders from the hospice doctor and the nurse. Hospice agency revised procedure for ordering medications.- 11/4/25 Audit was completed on all hospice residents' provider orders and any errors were corrected. Audits on all new orders will be completed daily.- 11/4/25 All licensed nursing staff/contracted agency nurses were educated on the rights of medication administration, transcription of medications, processing of medications, narcotic administration and side effects, what to do when a med error occurs. Those who have not received education yet will receive the education prior to their next shift.- 11/4/25 Developed a system to ensure appropriate transcription and order double check. Nurses confirmed knowledge of the new transcription procedure into the electronic health record system. The triple check of all new orders was added to the night shift nurse duty list.- 11/5/25 reviewed policies and procedures related to medication administration, transcription, and transcription errors-11/5/25 Reviewed hospice contracts for medication management

Based on interview and document review, the facility failed to implement appropriate interventions in response to refusal of personal care, medical treatments and medications for 1 of 4 residents (R281) reviewed for hospitalization . This resulted in actual harm when R281 required hospitalization for uncontrolled type 2 diabetes and [CONDITION] diaper rash (a rash caused by a yeast infection). Findings include: R281's discharge assessment Minimum Data Set (MDS) of [DATE], lacked answers under the section cognitive assessment and mood state. The MDS identified R281 exhibited physical, behavioral symptoms direct toward others (i.e. hitting, kicking, pushing, scratching, grabbing, abusing others, etc. ) however, did not identify behaviors of rejection of care (blood work, taking medication, activities of daily living (ADL's)-(activities of dressing, grooming, bathing, incontinence cares, etc.). The MDS indicated R281 required extensive assistance with mobility, dressing, incontinence care, and personal hygiene. R281's [DIAGNOSES REDACTED]. R25's quarterly MDS of 8/25/19, indicated R281 had moderate cognitive impairment, with no changes identified for behaviors and ADL's. R281's Emergency Department (ED) notes of [DATE] at 1:19 p.m. indicated R281 presented to the ED with potential diabetic ketoacidosis (DKA)- (a life-threatening problem that affects people with diabetes) and failure to thrive (identified as weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity). The note identified R281 was deaf and required [REDACTED] interpreter. Although an interpreter for ASL was used, the note identified R281 responded to only approximately 20 percent of questions and responses were often I don't know. The note identified R281 had diffuse diaper [CONDITION] (yeast infection) related to infrequent diaper changes versus refusal of care, and had [CONDITION] (the inability to retract the skin (foreskin) covering the head of the penis). R281's Hgb A1C was 14 (Glycosylated hemoglobin-a test to reflect overall diabetic management of the past two to three months. Normal value was less than 5.7). R281's A1C was high, almost three times the normal value. R281 received [MED] (a medication which may be used for nausea/vomiting) for R281. The report indicated the clinical impression of R281's status was uncontrolled type 2 diabetes, and [CONDITION] (yeast infection) diaper rash. On 2/27/20, at 9:26 a.m. family member (FM)-A identified R281 was seen in the ED on 9/8/19, for problems related to treatment of [REDACTED]. R281 was brought back to the ED on [DATE], related to elevated blood sugars, after he had been taken to the clinic for evaluation of his skin. FM-A said the ED doctor informed her R281 had not received his [MED] as ordered, with many doses missed. FM-A stated she had not assisted R281 with personal cares over the past two months or so, however, had done so prior to that time. FM-A expressed she felt R281 was neglected, but was aware R281 had refused his [MED]. FM-A stated staff should have left the area when R281 refused care and attempted cares/[MED] administration at a later time. FM-A further stated R281 didn't trust staff, so she had instructed staff to contact her if R281 was refusing medications and cares and she would coordinate a family member to come and assist the facility with R281. She was not consistently contacted with refusal of cares/medications. FM-A identified R281 was deaf, and staff were to face him and gain his attention because of his hearing loss. FM-A said R281 was able to read lips, however, when staff approached R281 from the side and asked him questions or proceeded to move him away, R281 would not understand what the staff wanted which may cause R281 to be startled, react, and pull away. FM-A stated the facility lacked interventions to accommodate R281's hearing when going out for appointments, such as coordinating an interpreter, as R281 is able to use [REDACTED]. FM-A additionally added, communication wasn't consistently relayed when R281 went on appointments regarding his hearing loss, family availability, or staff accompanying him on visits. FM-A expressed in firm tones, at an increased volume, that R281's skin observed on [DATE], had not occurred from refusing a change or two and commented it was from lack of bathing and personal cares. FM-A described R281's skin as all raw and pink, no black skin, and, these people don't give two[***]!. FM-A stated R281 was transferred to an alternate facility following discharge from the hospital and would not be returning to this facility. On 2/27/20, at 12:10 p.m. nursing assistant (NA)-C stated R281 was deaf, and because of this, his response was often very loud. NA-C stated they were able to communicate with R281 using written notes, gestures, and by assuring eye contact was made. NA-C stated there was also a card thing to help R281 communicate his needs which was provided through therapy. NA-C stated R281 was known to strike out at times when cares were provided, and would refuse [MED]. NA-C stated when this occurred, FM-A was called and either FM-A, their spouse, or children would come in to assist NA-C said when FM-A came in, they were usually able convince him to cooperate with cares. NA-C stated R281 was not always receptive to toileting, however, at times R281 consented to lay down for cares if informed he could get back up in his chairs after cares were completed. NA-C stated R281 had skin issues with scratches on the tip of penis and chafing in his groin area. NA-C identified R281 had become tearful at times, however, stated staff were unsure if this was related to depression or behavior. On 2/27/20, at 12:42 p.m. nurse practitioner (NP)-A stated although NP-(B) no longer covered facility residents, NP-A was able to review R281's records and that R281 was last seen by NP-B on 7/2/19, at which time the note reflected No concerns per staff. NP-A stated when cares were refused, staff were expected to determine the root cause of the behavior, which included a review of the physical, and psychological aspects of the refusal, as well as a review of medications and treatments. NP-A stated assessment of the problem and development of appropriate plan of care was to be completed with the resident, family, facility staff and the provider. NP-A stated when [MED] was refused by residents, it was important to have weekly updates. NP-A stated they were readily available as they round twice weekly, and were available seven days a week, via phone, text, email, etc. NP-A stated with refusal of [MED] frequently, and continued high sugars, the immunity would be lowered with the risk increased for skin breakdown, open sores, and decreased healing would occur. NP-A stated if staff were to to update the provider as they depended on the facility for updates on changes, adding two months between visits may be too late, as a delay in notification may have impacted a change which could have been prevented. Additionally, NP-A stated the code status was to be reviewed, as a decline in health was anticipated. On 2/27/20, at 1:16 p.m. NA-D stated R281 required encouragement to allow staff to assist him with incontinence care, and identified R281 was more receptive to female staff assitance and listened to women better. R281's care plan, reviewed on 8/23/19, lacked recommendation to provide assist by female caregivers. A request was made for the nursing assistant care sheet, however, this was no longer available per medical records (MR)-A. On 2/27/20, at 1:28 p.m. an interview was completed with registered nurse (RN)-A and RN-B. RN-B stated R281 was very resistant with blood sugar checks, administration of [MED], combative with cares, adding R281 disliked laying down to receive incontinence cares. RN-B stated R281 was resistive to anything which gave him a prick, including blood sugar checks and administration of [MED]. RN-B stated R281 was approached multiple times if he refused cares/blood sugar monitoring/[MED]. RN-B stated R281's acceptance of medications and treatments varied related to R281's mood for the day and there was no pattern for acceptance or refusal of cares. Refusals were documented in resident's record, and reported off to the next nurse. RN-B stated the physician/provider was contacted when R281's blood sugar exceeded established range (The September Medication Administration Record [REDACTED]. RN-B was unaware FM-A wanted to be contacted if R281 had refused medications/cares. RN-B stated he could not recall a time where R281 refused his [MED]/blood sugar check for him. Although RN-B stated he was aware of R281 being resistive to anything causing a prick, a review of narrative notes lacked identification of this, or consultation with the provider for alternate plan of treatment. R281's September MAR indicated [REDACTED]. RN-A stated staff were to contact FM-A when he refused cares/medication/monitoring, however, was unaware of how often FM-A was contacted and was uncertain how staff were made aware to contact FM-A with refusals. RN-A identified this was not indicated on the med sheet. RN-A stated she talked with FM-A regularly, but did not have an established routine for follow up. RN-A stated there were perimeters to contact the physician if blood sugars were greater than 350 mg/dl (milligrams per deciliter-a unit of measurement, normal reading less than 100 mg/dl). RN-A stated with R281's refusal of cares there were concerns which included skin condition and diabetic management. RN-A indicated FM-A had assisted with cares for R281. RN-A stated R281's skin breakdown was related to moisture associated skin disorder (MASD)-(general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine and stool/feces) and described R281's skin as chafed. RN-A stated a barrier cream was used, as well as [MEDICATION NAME] cream (an antifungal ointment). RN-A said if R281 had refused [MED] administration, the provider would be notified either via a phone call or with routine visits. RN-A stated she expected the information to be documented in the nurses notes. She was unaware how often this was done. Due to the frequency of R281's refusal blood sugars checks and [MED] administration, she would have contacted the provider weekly. RN-A stated with R281's history of elevated blood sugars, refusal of monitoring, and frequent refusal of [MED], R281's status could go all the way to a coma. R281's Psychiatric Process Note, dated 6/22/18, indicated R281 was seen in evaluation with the [DIAGNOSES REDACTED]. The note indicated R281 was to be seen in follow up in one month. A subsequent note of 7/20/18 identified R281 was seen in follow up, however, was experiencing problem with hearing and left visit. Staff identified his hearing aides were missing and this caused R281 to be increasingly irritated with care. The note identified R281's behavior as baseline. The note identified R281 continued to have refusal of cares/[MED], however, described him as accepting of cares with staff members he knew. The progress note did not identify a frequency for follow up, however, identified staff should continue to update psychiatrist about changes in mood which could indicate internal distress. The Psychiatric Progress Note of 11/15/18, identified medication changes were made and recommended R281 was to be followed with psychotherapy as appropriate. Recommendations were made for follow up in two months, however, no further notes were provided. The consulting clinic was contacted and verified no additional appointments were made with R281. A request was made for additional documentation regarding any subsequent visits. The information provided from the facility included summary notes from interdisciplinary team meetings held with the facility staff and consulting psychology members from 1/4/19 through 7/19/19. The notes lacked recommended interventions or plans to decrease R281's refusal of cares and administration of medication. A review of R281's June 2019, MAR indicated [REDACTED]. R281's blood sugars were checked three times a day with the following average results as follows: 8:00 a.m.: 221 mg/dl (milligrams per deciliter-a unit of measurement), 12:00 p.m.: 242 mg/dl, and 5:00 p.m.: 219 mg/dl. R281 refused to have his blood sugar checked on eight opportunities in June, 2019. A normal blood sugar reading per the American Diabetes Association is less than 100 mg/dl. A review of the progress notes for June lacked any indication staff contacted FM-A in coordination with refusal of cares. R281's July 2019 MAR indicated [REDACTED]. R281's blood sugars continued to be checked three times daily and averaged as follows: 8:00 a.m.: 334 mg/dl, 12:00 p.m.: 318 mg/dl, and 5:00 p.m.: 266 mg/dl. R281 refused to have his blood sugar checked on 33 opportunities in July. Although R281 refused [MED] dosing's on 44 occasions, and monitoring of his blood sugar on 33 occasions, a review of the narrative notes indicated FM-A was only contacted in follow up on 7/19/19. In August of 2019, R81 was noted to have refused 36 doses of [MED] out of 155 opportunities. R281's blood sugars were monitored with average as follows: 8:00 a.m.: 281 mg/dl, 12:00 p.m.: 329 mg/dl, and 5:00 p.m.: 258 mg/dl. R281 refused his blood sugar to be checked on 19 occasions out of [AGE] opportunities. The progress notes lacked indication FM-A had been contacted in follow up regarding R281's refusal of [MED] dosing and blood sugar monitoring, with the exception of 8/24/19. A review of R281's September 2019 MAR indicated [REDACTED]. R281's blood sugars averaged as follows: 8:00 a.m.: 2[AGE] mg/dl, 12:00 p.m.: 2[AGE] mg/dl, and 5:00 p.m. at 234 mg/dl. R281 was out of the building on three of days in September, and refused blood sugar monitoring on one occasion. A review of the progress notes lacked indication of outreach to FM-A, even though R281 refused monitoring and [MED] on 10 occasions. R281's provider progress notes of 2/10/19 identified in January of 2018, R281 was hospitalized and was found to have a glucose level of greater than 500 mg/dl, with a Hgb A1C of 12.8. At that time, R281 was started on [MED]. The record reflected R281 had refused subsequent lab work for Hgb A1C on 6/2018, 10/22/2018, 1[DATE]18, and labs were ordered again on 2/20/19. The provider progress note of 5/13/19, indicated R281 continued to refuse blood work. The physician progress notes [REDACTED]. The progress notes lacked indication a discussion had been held as to alternative frequency of blood sugar monitoring or review of frequency of [MED] administration. R281's Nursing Evaluation, dated 5/25/19, indicated skin color and temperature were normal, however, the assessment identified R281 had skin integrity concerns. The body diagram lacked any indication of affected areas or narrative notes to describe integrity concerns. A review of R281's progress notes identified no skin concerns in June. On 7/7/19, the progress note indicated staff implemented treatment for [REDACTED]. The progress notes lacked further interventions or identification of other skin care problems. A subsequent Nursing Evaluation, dated 8/23/19, again indicated normal skin color and warm temperature. The evaluation indicated there were no skin integrity concerns. On 8/24/19, the progress note reflected FM-A had questioned staff as to why R281 had not received personal cares. The staff updated FM-A of refusals of medications and cares, and FM-A was able to get resident to accept personal cares. R281 was identified as having no redness in groin, however, documented observation of MASD, which was described as possibly yeasty. The note identified the crown of the penis and foreskin was clean, although macerated (softened tissue with some breakdown related to moisture) related to refusal to be changed. A narrative note of 8/29/19 indicated there was an IDT related to excoriation of buttocks. Patient has a history of not complying with check and changing program The note indicated R281 complained of itching and barrier cream was identified as being applied with each incontinent episode. Additionally, is was noted nail care had been completed. The note lacked and indicated staff had contacted FM-A in follow up. A second entry had been made on 8/29/19 where small amount of blood was noted on sheets, which R281 stated he had scratched, and went on to state the area was itchy. The document reflected, after gentle cleansing, [MED] was applied. The document reflected the provider and family member were contacted. A review of R281's MAR's from June, July, and August of 2019 indicated he received routine treatment with [MEDICATION NAME] Cream (an antifungal cream) was applied twice a day with the exception of occasional refusals (x 1 in June, x 4 in July, x 5 in August, and x 1 in September). On 2/27/20, at 2:56 p.m. the director of nursing (DON) stated R281 had a history of [REDACTED]. DON identified staff used cue cards to communicate with R281, and would negotiate completion of cares with food offerings R281 enjoyed. DON stated R281 would strike out and be aggressive with cares. DON stated MD-A had followed R281, and she had assumed this had been documented in the progress notes. DON stated the provider and family were updated regarding resident refusal of [MED] and cares, however, was unable to identify frequency. Additionally, DON stated the provider should have been updated weekly if a resident were refusing medications and this would be documented in the narrative notes. DON stated staff did interact frequently with FM-A and the provider, however, identified it may not be indicated in the documentation. During interview on 2/27/20, at 5:00 p.m. medical doctor (MD)-A stated upon review of the notes for R281, it was identified R281 was last seen on 5/13/19. MD-A stated although they were made aware of R281's refusal of lab draws and occasion cares as indicated in the progress notes, they were unaware as to the frequency [MED] dosing was refused (greater than 40 doses in May 2019). MD-A stated it was her expectation of the facility to inform them of R281's refusal of medications on a routine basis, whether via text, phone call, or during routine nurse practitioner (NP) visits, however, this was very rarely done. MD-A stated diabetic management was important for R281, especially in light of his skin condition, and potential for skin breakdown. Review of elevated Hgb A1C of 14, MD-A stated the elevated glucose indicated the diabetes was not currently controlled and this affected R281's level of response to infections with the potential for increased infections everywhere, and indicated this was reflected with the oral infection and presence of [CONDITION] rash. Although it was identified R281 responded best to female caregivers and R281 was more receptive to laying down for incontinence care when staff provide assurance they would assist him back into his chair, the care plan lacked direction to staff to implement these interventions to improve cooperation with cares/monitoring/and medication administration. R281 was also identified as cooperating with cares with presence of FM-A/other family members, and FM-A had requested to be contacted if behaviors of refusal were noted, however, FM-A was contacted infrequently. Additionally, although it was noted R281 hated anything to do with pricks, R281 was receiving five separate injections with [MED] dosing and three blood sugar checks to monitor blood sugar level, to total eight pricks a day. The record lacked any indication of consultation with the provider regarding current medications and monitoring orders, or actual frequency of refusal, and consultation as to the most appropriate plan of care in light of frequent refusals. As a result of lack of follow through R281 was seen in the ED on [DATE] with the [DIAGNOSES REDACTED].

Based on observation, interview and document review the facility failed to provide care in accordance with professional standards of practice when the facility failed to have an emergency medical services (EMS) response (911) system that functioned and that staff could use. This failure resulted in a delay of emergency care for 1 of 4 residents reviewed, Resident #1 (R1), when she experienced a change in condition and was sent to the hospital by ambulance The finding constituted an Immediate Jeopardy (IJ) situation for all 72 residents in the facility with the potential for serious harm, impairment or death. The Immediate Jeopardy began on [DATE] at 2:37 p.m. when facility staff were unable to use the facility phones to dial 911 to access EMS assistance. The Administrator, Director of Nursing, Assistant Administrator, Director of Clinical Services and Regional Director of Clinical Services were informed of the IJ finding on [DATE] at 5:30 p.m. The IJ was removed on [DATE] at 3:45 p.m. but noncompliance remained at the lower scope and severity F. Medical record review revealed R1 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. R1's care plan, dated [DATE] revealed R1 was her own health care decision maker and sometimes refused cares or assistance. R1 had a history of [REDACTED]. Nursing notes dated [DATE] revealed R1 was up to eat lunch and go outside during the day shift. RN-I observed a change in condition for R1 including confusion, unintelligible speech, inability to take medications, fluctuating pulse, and foaming at the mouth at 5:21 p.m. RN-I contacted the resident's on-call doctor, who ordered every 15 minute monitoring of the resident. At 7:30 p.m., RN-I called the doctor back related to R1's condition, and the on-call physician ordered RN-I to send R1 to the hospital for evaluation. The Ambulance call documentation, dated [DATE] revealed the 911 call came in at 8:48 p.m., one hour and eighteen minutes later. When paramedics arrived they found R1 sitting on the edge of her bed with Law Enforcement officers with R1. Law Enforcement officers relayed that R1 had declining condition since 4:00 p.m. today and R1 was unable to respond to questions or walk with her walker, and her normal baseline was alert and oriented in all spheres and able to walk with her walker. R1 was unable to provide paramedics with her chief complaint, but kept repeating Help me God. R1 became combative on the way to the hospital and paramedic staff started R1 on oxygen. The hospital record dated admitted [DATE] at 9:27 p.m. indicated R1 was admitted with altered mental status. R1's temperature was 102.4 F, her pulse was 133, her respirations were 24 and her blood pressure was ,[DATE]. R1 was diagnosed with [REDACTED]. The death certificate revealed R1 died on [DATE]. The cause of death was listed as [DIAGNOSES REDACTED] due to pneumonia with Septic shock and Acute [MEDICAL CONDITION] listed as another significant condition contributing to death but not resulting in the underlying cause. The manner of death was listed as natural. During an interview on [DATE] at 4:15 p.m., RN-I stated when R1 experienced a change in condition on [DATE], the doctor ordered her to be sent to the hospital. When asked why it took from 7:30 p.m., when the physician's orders [REDACTED]. RN-I stated he went down to the desk phone on second floor and tried to call 911 again, and the call did not go through, but it sounded like it was ringing at the lobby desk. RN-I stated he went out to the lobby desk to try to call, and that call did not go through to 911 dispatch either. RN-I stated at this point he started to panic, and went to find his own personal cell phone, that he does not keep with him during working hours. When he found his cell phone, initially the call did not go through, then the call went to another city and there was confusion related to where he was calling from and what he was calling about. RN-I stated he did not know how long this process took.During observations on [DATE] at 2:25 p.m., all desk phones at each nursing desk on 4th floor, 3rd floor and 2nd floor were observed and no phones had any directions related to what to dial in order to call 911 from the desk phones to activate the Emergency Medical System (EMS) through 911. During an interview on [DATE] at 2:30 p.m. LPN-J stated if he were to call 911 to activate EMS, he would pick up the desk phone and dial 911 for emergency assistance. During an interview on [DATE] at 2:30 p.m. RN-K stated if she were to call 911 to activate EMS, she would pick up the desk phone and dial 911 for emergency assistance. At 2:37 p.m. on [DATE] the Director of Nursing (DON)-C attempted to call 911 from the desk phone on second floor, after this surveyor asked her to call 911 as she would if there was an emergency and she needed an ambulance/fire or police to activate EMS. DON-C picked up the phone on the desk on 2nd floor and dialed 911, the call did not go to 911 emergency dispatch. DON-C hung up and attempted the call several other times and the call never went through to 911 dispatch. DON-C stated she kept getting a busy signal. During this time Administrator-A attempted to call 911 with the same result. Eventually DON-C stated she dialed using 9 then 1 then 911 and the call went to 911 dispatch. DON-C and Administrator-A stated they were not aware that a person would have to dial 9 then 1 then 911 to call 911 dispatch to activate EMS. During an interview on [DATE] at 12:15 p.m., MD-L stated that [MEDICAL CONDITION] every minute is important and that it possible the delay in calling 911 impacted R1's eventual outcome and her ability to recover from this event. Policies related to how to call 911 from the facility were requested, and none were provided. The Immediate Jeopardy began on [DATE] at 2:37 p.m. was removed on [DATE] at 3:45 p.m. when the facility implemented a removal plan which included the phone company changing the set-up for 911 calls, staff education related to calling 911, policy changes and signage placed on all desk phones with direction related to how to call EMS via 911.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 residents (R19) identified with swallowing difficulties received safe and appropriate assistance from nursing staff when there was an identified concern while feeding a resident. The findings constituted an immediate jeopardy (IJ) situation for R19, with the potential for serious harm, injury or death. The immediate jeopardy began on 10/04/17, at 8:12 a.m. when the resident was observed to have on-going issues with coughing while eating. Staff were not following the feeding program established by the speech language pathologist due to dysphagia (difficulty swallowing). The executive director (ED), interim director of nursing (DON), director of clinical services (D(NAME)S), assistant ED-A and ED-B were informed of the immediate jeopardy on 10/04/17, at 4:15 p.m The IJ was removed 10/05/2017, at 2:54 p.m., but non-compliance remained at the lower scope and severity of (D) isolated, with potential for more than minimal harm that is not Immediate Jeopardy. In addition, the facilty failed to ensure a behavior plan was in place for 1 of 1 residents (R108) with bullying behaviors which contributed to verbal altercations. Also, the facility failed to comprehensively assess for pain, and provide pain medications timely for 1 of 3 residents (R48) who had complaints of pain. The facility also failed to coordinate hospice services for 2 of 2 residents (R138, R48) reviewed for hospice. Finding include: EATING: R19's Admission Record undated indicated that he had dementia and dysphagia (difficulty swallowing). R19's annual Minimum Data Set ((MDS) dated [DATE], indicated he needed extensive assistance of one with eating and had no swallowing disorders. R19's Nutritional Status Care Area Assessment (CAA) dated 09/13/17, indicated he required assistance with feeding at meals and had a need for special diet or altered consistency which might not appeal to resident. The CAA further indicated he received sufficient eating assistance. A Discharge Summary Note dated 12/02/16, from North Memorial Medical Center, indicated he was hospitalized from [DATE] to 12/02/16. The Discharge Summary note identified he had aspiration pneumonia, and x-ray with bilateral infiltrates of the lungs (something that has gotten in to the lungs from the outside. Any abnormal density will show up in the otherwise air filled lungs. Usually the infiltrate will mean pneumonia, or some sort of infection with [MEDICAL CONDITION]/swelling that is in the lung). R19's Speech Therapist note dated 08/02/17, indicated PT (patient) seen for skilled ST services to address dysphagia and complete final session to receive discharge documentation. Therapist followed up with nursing staff regarding use of printed compensatory swallowing strategies to reduce aspiration risk. A 24-hour log updated for discontinuation of services due to inability to progress due to dementia and inability to follow cues. Nursing staff to implement use of compensatory swallowing strategies and monitor for ongoing signs and symptoms of aspiration. A 24 Hour Status Report (communication report for nursing staff) dated 08/02/17, indicated: D/C (discontinue) from ST today continue puree/honey thick liquid diet. Printed strategies at patients table to follow during meals. The speech therapy instruction sheet directed staff to do the following swallowing strategies: * Bite sizes should be 1/2 spoonful of puree * Use spoon to give honey thickened fluids (1/2 spoon size) *Allow patient to clear mouth completely before giving another bite * Do not put more food in patient's mouth if he is still chewing * If he begins coughing, do not give more food until coughing discontinues. During observation on 10/01/17, at 12:12 p.m. nursing assistant (NA)-B was observed to give R19 a drink of his juice bringing his cup of honey thickened liquids to his mouth and having him drink it instead of using a spoon as required. She proceeded to have him take three drinks and R19 started to cough while drinking from the cup. NA-B stopped when he coughed waited from him to stop and then continued to give him a teaspoon full of his potatoes, and then a teaspoon of his pureed roast beef and he coughed again. At 12:19 p.m. NA-B fed him a level teaspoon full of his mashed potatoes and he coughed again. NA-B stated to R19 'It's ok and gave him a drink of his juice from his cup. At 12:20 p.m. the surveyor intervened and asked NA-B if she was aware of R19's specific feeding recommendations from the speech language pathologist (SLP)-A and showed her the instructions that were on the window sill of the dining room. NA-B stated she was not aware and NA-M instructed her that he should only receive 1/2 teaspoons of food and liquids at a time. NA-B then took the teaspoon at the table and placed in his honey thickened juice and proceeded to feed him 1/2 teaspoons of his food and beverages and his coughing had decreased. During observation 10/04/17, at 8:12 a.m. HR-A was observed in the first floor dining room assisting R19 with eating. R19 had scrambled eggs, pureed sausage, oatmeal and honey thickened cranberry juice. At the same table directly across from HR-A, sat assistant director of nursing (ADON)-B whom was assisting R134 with eating. HR-A gave R19 a level teaspoon full of pureed sausage and then immediately gave a heaping teaspoonful of his oatmeal, without first waiting for R19 to swallow the spoonful of pureed sausage before immediately giving a heaping spoonful of oatmeal to R19. R19 immediately started to cough, loudly turning his head away from HR-A to the right. HR-A stopped feeding him and rubbed his back and waited for him to stop coughing. HR-A then brought R19's glass of honey thickened cranberry juice just below his chin and began spoon feeding R19 three spoonfuls of thickened juice, one after another without first waiting for R19 to swallow each bite. HR-A fed R19 a full teaspoon of thickened juice, not a half teaspoon as identified by the ST swallowing strategies. HR-A proceeded to give R19 a heaping spoonful of his pureed sausage and R19 immediately began to cough. HR-A stopped again and let him cough without waiting and HR-A then brought R19's glass of honey thickened cranberry juice to his chin and quickly began feeding R19 three level teaspoonfuls of juice, and a level teaspoon full of oatmeal. HR-A did not wait for R19 to swallow each bite, before she gave him another bite to eat. R19 began to cough loudly and his face turned red while HR-A covered his mouth with his clothing protector while he coughed. ADON-B whom was directly across from HR-A while she fed R19, made no attempts to stop HR-A from feeding R19 even though HR-A was not following the ST swallowing strategies and R19 continued to cough while being fed. R19 had eaten 100% of his scrambled eggs, pureed sausage, and half of his oatmeal and 3/4 of his honey thickened cranberry juice. ADON-B left the same table HR-A was assisting R19 and NA-M then sat down to assist R134 across the same table R19 was sitting at. At approximately 8:25 a.m. SLP-A entered the dining room, and surveyor informed her of the above observation. HR-A was removing R19's clothing protector and SLP-A immediately walked up to the table and instructed HR-A she should have been following her recommendations of bite sizes which is 1/2 spoonful of liquids and food. HR-A then stated that NA-M had just informed her of the SLP instructions and she had stopped feeding R19. R19's Nutrition Risk Care Plan dated 09/08/17, indicated he received a pureed diet with honey thickened liquids and needed total assistance to the dining room and reminded of meal times. The care plan did not list specific speech therapy recommendations. Review of R19's diet card, undated, indicated he needed total assistance to be fed and received honey thickened liquids and a pureed diet. In addition, R19's nursing assistant care sheet, undated, indicated his liquids were honey consistency and he needed total assistance with eating with a note, see ST (speech therapy) instruction. During interview on 10/04/17, at 12:25 p.m. licensed practical nurse (LPN)-D stated she was not aware of any feeding recommendations for R19 and stated, What I don't know I can't tell you! During interview on 10/04/17, at 12:42 p.m. SLP-A stated she had written up the instructions with R19's plan of care, and had made these recommendations for R19 on 7/24/17, and trained staff that assisted with feeding him. The SLP indicated she left the feeding instructions at the table where he ate and the instructions would disappear and she would have to make new cards and leave them again at his table. SLP-A stated she also told the interim nurse manager during this time, but she no longer works at the facility. In addition, the SLP-A stated she wrote these recommendations on the 24 hour communication board for all staff to see. The SLP-A further stated R19 will cough while eating and she recommended a swallow evaluation awhile ago, but did not think the facility followed through on her recommendation. She relied heavily on the staff to follow through with her recommendations since he was at such high risk for aspiration and it was vital to follow through with SLP's recommendations. The SLP-A stated when she feed R19 1/2 teaspoons of his food and liquids he coughs much less and it reduced his risk of aspiration. During interview 10/04/17, at 1:01 p.m. ADON-B stated, I don't know anything about a swallow evaluation and that she had been working on the floor at the facility for six weeks. This happened before me and I wasn't aware of the recommendation and reported she could call his guardian. In addition, ADON-B stated she found out about R19's recommendations last Friday when she overheard a NA instruct another NA how to feed him. ADON-B further stated R19 gets pureed food and you have to give it to him slowly and she was not aware of any portion size but to just feed him slowly. During interview on 10/4/17, at 3:32 p.m. NA-O stated R19 had coughed a lot while eating, was slow to eat, received thickened liquids and pureed liquids. NA-O stated they use a four ounce glass to assist R19 to drink. If R19 had coughing while using the glass, he would use a spoon for the thickened liquids and give a full teaspoon of fluid. Previously (approximately 3 months ago) there were written directions on the table that directed staff to use a spoon for fluids but these directions were removed from the table. NA-O added staff resumed to feed R19 as did previously, either with a glass or spoon, and monitor his response. NA-O was unaware he needed to give R19 half teaspoon of fluids and not use a glass. During interview on 10/04/17, at 3:42 p.m. NA-L stated an educator from the facility instructed her on R19's SLP-A recommendations but she stated, I told her as soon as you walk away I won't remember what you told me. She didn't say anything and had me sign a paper saying I was educated. NA-L then stated, I had not fed him since he was on his new diet. During interview on 10/5/17, at 2:15 p.m. NA-Q stated she received new education and the staff needed to check the meal ticket for any special feeding instruction and directions that referred to the black book would be located on the beverage cart. A nurse needed to be in the dining room prior to staff serving resident and if anyone started coughing or choking they were to alert the nurse. Specific instructions were added to R19's meal ticket. During interview on 10/5/17, at 2:17 p.m. LPN-F stated she had been educated on the new process regarding residents who have special diet. The ticket on table would have the instructions and if needed would indicate to check the black book which would be located on the beverage cart Nurse needed to be in the dining room prior to serving and supervise staff and assist if there were any issues with coughing or choking. Only trained staff can assist with feeding residents. Although R19 had a history of [REDACTED]. ADON-B and NA-M were directly across the table while HR-A was feeding R19 incorrectly, and made no attempts to stop or intervene while this occurred. A policy was requested for following SLP recommendations but none was provided. The immediate jeopardy that began on 10/4/17, at 8:12 a.m. and removed on 10/5/17, at 2:54 p.m. when it was verified by observation, document review, and staff interview of whom could and could not feed residents, that a nurse needed to be in the dining room when residents were eating, where individual resident swallowing guidelines were located in the dining room, and what guidelines to follow to assist R19 to eat. The facility checked other resident with swallowing guidelines to ensure their programs were being followed and updated R19 careplan's along with other residents who were at risk. R108's facility face sheet, undated, identified R108 had [DIAGNOSES REDACTED]. R108's quarterly MDS dated [DATE] identified he had intact cognition, disorganized thinking, verbal altercations and physical staff assistance for activities of daily living. The behavior CAA worksheet dated 2/24/17, identified resident displayed delusions and hallucinations which could cause behaviors problems. During observation on 10/3/17 at 10:12 a.m. R108 was yelling in the entry way of the nursing home at (R71 and R201) stating, Look at yourself in the mirror and you will see the definition of ugly, R71 yells back. Social Service (SS)-B whom was in the area talks to R71 who is very upset yelling (R108) calls us names all the time and nothing happens, R71 leaves the area. R201 who was in the same area, stated, yeah in agreement to what R71 was saying. R108 remained in area after the confrontation, looking around, no one talked with R108 about his yelling at R71. At 10:16 a.m., four minutes later, R71 was outside of the administration office yelling at executive director (ED), and assistant executive director (AED)-A, AED-B and director of quality. R71 very upset yelling, he was tired of him (R108) yelling' and calling him an Indian, and (R201) a Nigger. You have not done anything about this, and I am tired of it. All you tell (R108) to do is calm down, nothing gets done and I am sick of it. You have no idea what I or (R201) have gone through when we get called those's names. I am sick of it! The ED, and AED-A tried to calm R71 down. R71 kept telling administration (R108) bums cigarettes from (R192) all the time. I have heard him get mad at her, she doesn't like it when (R108) goes off on people, so she gives into him and he gets 3-4 cigarettes a day from her. While R71 was yelling at administration. R108 was sitting in his wheelchair approximately 15 feet away, smiling and grinning with enjoyment while watching R71 yelling at the facility administraiton staff. R71's admission MDS identified he was cognitively intact, and needed minimal staff assistance with activities of daily living. R201 was just admitted to the facility on [DATE]. There was no MDS data available as a result of R201 being in her assessment period. During interview on 10/4/17 6:53 a.m. health unit coordinator (HUC)-B stated R108 was none compliant, and he instigates riots here, he does this to staff and other residents. He is very demanding to other residents and staff, and wants cigarette. He tells resident's and staff that he will pay you tomorrow. HUC-B indicated if they say no to him, he swears at them using profanity which occurs several times a day. He yells, curses at everyone and bully's them when they do not do what he wants. During observation on 10/4/17 at 7:03 a.m. R108 was sitting in the dining room with a coffee pot in front of him. He started yelling at licensed practical nurse (LPN)-H who is in the hallway approximately 50 feet away. R108 was yelling at LPN-H, Why did you not tell him I needed my [MEDICATION NAME] (narcotic pain medication), now someone else has to do your work. He continues to yell at LPN-H about his [MEDICATION NAME]. During interview on 10/4/17 at 7:10 a.m. LPN-H stated R108 was yelling for his [MEDICATION NAME]. If he doesn't get his coffee, pain medicaiton or cigarettes right away he has behaviors. He gets [MEDICAL CONDITION] demanding, calling other residents names like, fat flop, and Niger. LPN-H indicated no behavior plan in place, he is very demeaning to others. During interview on 10/4/17 at 7:18 a.m. NA-A and NA-C both stated (R108) yells, swears, uses the F word, and racial profanities telling us to go back to the country that we came from. He is very mean, and has a lot of behaviors. He especially yells when we want to do cares for him, reposition or toilet him. He tells us no, and when we try to calm him down he says. I don't have to be nice, I can yell when I want. The only time that we can get him to do anything is in the early morning when he wants to get up and have a cigarette. We tell him, after we change you then you can get up and he agrees to this. When he gets what he wants, then he starts yelling again. If he knows a resident smokes he will bug that resident until he gets a cigarette. NA-A and NA-C both were unaware of any behavior plan to help deal with R108's behaviors. During interviews on 10/4/17 at 7:30 a.m LPN-A stated R108 frequently refuses treatments, turning and repositioning along with yelling, screaming, and cursing. He calls other residents and staff, Niger, Indian and calls the ladies [***] es. He is very demeaning and tells staff I pay for you to work, so you have to listen to me. If he wants something he expects you to drop everything and do what he wants. LPN-A indicated she attempted to talk with him softly and make a plan with him, sometimes it works, other times not. He always wants his pain medicaiton sooner than scheduled. His pain medications are due at 3:00 p.m., and at 2:00 p.m. he tries to get them, but you have to stay firm with him and tell him not until 3:00 p.m. Once 3:00 p.m. comes, you need to make sure that you are there with his pain medications, then he seems to build trust with you, as long as you follow through with what you told him. This seems to work, but not all the time. If you break his trust, this will not work. There is no behavior plan the NA or nurses are following for R108, we just do our best. During interview on 10/4/17 at 7:47 a.m. R201 stated R108 calls me a, Niger, [***] es, hoes, fat ass, and good for nothing person. He calls me everything but a child of god. I hate being cursed at and making me something that I am not. He hurts my feeling when R108 talks bad to me. He tries to bum a cigarette, and I tell him no, then he goes off, yelling at me. R201 stated this was not right that they have to put up with this and he makes me feel that I am not worth anything. When he wants something he can be all sweet until he gets what he wants, and then back to himself. Staff talk with him, but nothing changes. During interview on 10/4/17 at 7:57 a.m. R71 stated he was coming out of the dining room the other day trying to get coffee, and R108 just yelled at him, Hey, you [***] ing Indian, why are you not on the reservation. He tells me all the time that I am a, [***] ing dirty Indian. I try to ignore him, and tell him come on dude let it go, but nothing works. I just lost a (significant family member FM-A) on 9/11/17, unexpectedly. He found out about this, and at first he said he was sorry and was good. Then on Tuesday (10/3/17), I was in the dining room watching the television about the shooting in Las Vegas. R108 come up to me and asked for a cigarette, I told him No. He tells me, I just saw you smoking one, and I know you have one, so I just ignored him. R108 then tells me, I wonder how you dead (FM-A) is. I turned around and told him why is he like that and left the dining room, then when he was in the hallway entrance yelling, I went off on administration. Nothing changes here, staff do nothing about this, and they tell me they try, but I see nothing, and no changes to this at all. During interview on 10/4/17, 8:42 a.m. maintenance director (M)-A stated R108's behavior varies, he asks for coffee so I get him a pot of coffee. He calls the kitchen staff the C word, and has burned his bridges with them. I treat him with respect, talk with him and we get along. If you do little things for him and get his respect he is better, but sometimes not. I can tell by his facial expression his mood. When he has a frown, has a glassy eyed look and staring out into space this is not a good day. SS-A used to roll him cigarettes, not sure what happened to that. R108 smokes a lot, and by the third week of the month, his behaviors get really bad because he had ran out of money. When he gets his check, his mood is better, until he spends his money. During interview on 10/4/17, at 9:12 a.m. HUC-A stated R108's behaviors are bad, he yells at everyone and is demeaning and not nice. He used to have a behavior plan and SS-A rolled cigarettes for him. R108 would come back and get more cigarettes rolled, then sell them to other residents. The more SS-A rolled, the more cigarettes he demanded so that program did not last. As long as they (residents) give him cigarettes, he gets along with them. He tell residents he will pay them back, but he never does, resident avoid him. There is no behavior plan at all. R108's Mood and Behavior Assessment Care Plan review on 8/8/17, identified [MEDICAL CONDITION] affective disorder, and used [MEDICATION NAME] and [MEDICATION NAME]. The interventions included, monitor for side effects, periods of altered perception or awareness, disorganized speech, lethargy, changed in cognitive level, hallucinations and constipation. There are no staff interventions idenfied to assist staff of how to deal with R108's behavior of being demanding, using profanity and name calling of other residents in the facility to help decrease these behaviors. Review of the Associated Clinic of Psychology (ACP) notes from 3/31/17 to 9/29/17 identify R108 had areas of concern that increased his risk which included: compliance with medical advice, wound care, fluid restrictions, participation in therapies, medication compliance, impulse control, activity level and social isolation. The note identified R108 main focus was cigarettes. The ACP recommendations were as identified: staff need to check to make sure he is consistently taking his medicaiton, needs to follow physician recommendations, and compliant with all his cares so R108 can be successful in his recovery; R108 has agreed not to empty his [MEDICAL CONDITION] bag outside; FM-B is helping R108 with the cost of his cigarettes so he has more money to purchase the cigarettes, to help reduce his behaviors. He wants his motorized wheelchair back even though R108 was unsafe using the power chair. R108's power chair has broken parts, and the facility was working on getting parts for this chair, but this is difficult since the chair model has been discontinued. A 3/31/2017 ACP note indicated that using the word boundaries is something that R108 knows and responds to, redirecting him by reminding him of the boundaries of his peers and staff may be helpful at times. There is no further mention of using boundaries. A 7/21/17, and 7/28/17, note identified the writer provided R108 with validation of his feelings and emotional support as effective interventions. The 9/15/17 and 9/29/17 ACP note identified the writer used problem solving, insight oriented therapy, emotional support and reinforcement for positive behaviors as effective interventions. During interview on 10/4/17 at 9:23 a.m. with ADON-A and SS-A both stated, R108 has lots of behaviors of yelling at staff and resident with very colorful words and has called 911 when he wanted to get out of bed and was very sick. He refuses all cares also and is a difficult person. He sees ACP on a regular basis but also refused to see them as well, he does this about once every four visits. He has only verbal behaviors and not physical, cigarettes are his main focus with his behaviors. ACP told us to develop a cigarette plan, and roll his cigarettes so his money lasted longer and this would stop him from bothering other residents. This program initially worked, but then he wanted more and more cigarettes. He started to sell them to other residents, then he complained they were not packed right and did not like the taste, so he (R108) stopped this program. This program stopped at the end of June 2017, and we have not implemented any other behavior plan since, we do our best. He uses profanity to get your attention, and if you ask him why, he says that he does this to get their attention. He is a work in progress, we try to figure out what we need to do but we do not have a plan in place for his behaviors and his behaviors have gotten worse since he was placed on 2nd floor. They try to keep him occupied but with the big staff turn over it has been tough to be consistent. Although ACP has made some recommendations, there was no indication the facility has consistently used these recommendations or had a plan to place to handle or divert R108 behaviors of using profanity, yelling at residents, staff and refusing his cares. Pain R48's quarterly MDS dated [DATE], indicated R48 was cognitively intact. The MDS identified [DIAGNOSES REDACTED]. The MDS identified R48 was receiving scheduled and as needed pain medication, however, did not receive any non- pharmalogical interventions related to pain. The MDS pain interview indicated R48 had pain occasionally, which made it difficult to sleep at night and limited R48's daily activities. R48 rated her pain a 7 out of 10 at the time of the MDS. R48 did not have a Pain Care Area Assessment. During interview on 10/1/17, at 3:53 p.m. R48 stated she had pain from her belly button all the way around to her back, including her shoulders. She rated her pain 9 out of 10, with 10 being the worse pain. R48 stated she hurt like that all the time, and it went away only when she slept, if she could fall asleep. R48 did not display any signs or symptoms of pain during the interview. R48's physician's orders [REDACTED]. The orders included the following medications used to control pain: - [MEDICATION NAME] (narcotic for moderate to severe pain) soluble tab 5 milligrams (mg) every 4 hours PRN (as needed), started on 7/11/17. - [MEDICATION NAME] soluble tab 5 mg every hour PRN, started on 8/4/17. - [MEDICATION NAME] 0.4 mg dissolve 1 tab under the tongue every 5 minutes up to 3 doses PRN, started 3/6/17. - [MEDICATION NAME] (nerve pain) 400 mg 2 caps twice daily, started 3/6/17. - [MEDICATION NAME] sulfate ER 15 mg 1 tablet every a.m. and 2 tablets in the evening every 12 hours, started 7/29/17. - MPAP ([MEDICATION NAME]) 500 mg 2 tabs three times daily, the order did not indicate a start date. R48's Medication Administration Record [REDACTED] - [MEDICATION NAME] 400 mg 2 caps twice daily scheduled for 8:00 a.m. and 8:00 p.m. - [MEDICATION NAME] sulfate ER 15 mg 1 tablet every a.m. and 2 tablets in the evening every 12 hours, scheduled for 9:00 a.m. and 9:00 p.m. - MPAP ([MEDICATION NAME]) 500 mg 2 tabs three times daily, scheduled for 8:00 a.m., 12:00 p.m. and 8:00 p.m. R48's facility medical record lacked a comprehensive pain assessment and a care plan directed towards pain. On 10/3/17, at 9:37 a.m. R48 was observed seated in her wheelchair in her bedroom. R48 did not display and signs or symptoms of pain, but had a flat affect. R48 stated she had scheduled pain medication for 8:00 a.m. and had not received her medications yet. R48 stated hospice has communicated to the facility it was important to receive the pain medication timely. She stated the floor nurse told her she was running behind on her medication pass this morning. R48 stated she rarely asked for her PRN pain medication as it took staff so long to bring it, she just tries to sleep away the pain. R48 again rated her pain a 9 out of 10. On 10/3/17, at 10:19 a.m. RN-E administered R48's morning medications by bringing them to her room. During interview on 10/3/17, at 10:20 a.m. RN-E stated she had a hectic morning pre- packaging residents' medications to take on leave from the facility and was just administering R48's morning medication. RN-E stated the medications were scheduled for 9:00 a.m. RN-E stated the staff have an hour before and an hour after the scheduled medication times to administer medication. At 10:22 a.m. RN-A approached RN-E's medication cart. RN-E stated she was just administering R48's morning medications, that included pain medications. RN-A then stated, that's not good. At 10:48 a.m. RN-E stated she administered R48 the following medications after the scheduled time: [MEDICATION NAME] (treatment of [REDACTED]. During interview on 10/3/17, at 11:46 a.m. NA-C stated R48 had never complained of pain to her, but if she did NA-C would notify the nurse. NA-C further stated the nursing assistants did not interact much with R48 as she was independent with most cares. During follow up interview on 10/3/17, at 2:06 p.m. R48 stated her pain was pretty bad right now, and after receiving her pain medications late, it didn't help her pain much. R48 stated she was going to lie down and try to sleep to relieve her pain. On 10/3/17, at 2:35 p.m. RN-E stated R48 was asked her pain level at least every shift, occasionally she requested PRN pain medication, and usually rated her pain a 7 out of 10 or better. RN-E stated she thought the medications helped her and stated going to chapel was a non- pharmalogical intervention. RN-E stated a comprehensive pain assessment was done on admission, but was not sure if the pain assessments were completed any other time. During interview on 10/5/17, at 9:12 a.m. ADON-C stated it was important to receive pain medications timely, because it is hard to get pain under control, and when it gets out of control R48 becomes more anxious increasing the pain. When interviewed on 10/5/17, at 10:14 a.m. ADON-A stated she was not aware R48 was having pain, or had changes to her pain medications within the last few months. ADON-A reviewed R48's chart and stated there should be a comprehensive pain assessment and care plan to help manage R48's pain. During telephone interview on 10/5/17, at 11:25 a.m. hospice RN-F stated he had communicated to the floor nurse on how giving pain medications timely was very important for R48. RN-F stated it was important not only to control her pain, but for her psychosocial well being as she gets very anxious which increased her pain levels. HOSPICE R134's significant change MDS dated [DATE], indicated he was severely cognitively impaired, needed extensive assist of two with toileting and was always continent of urine. R134's MDS failed to indicate he had an indwelling urinary catheter. R134's care plan dated 10/17, indicated he had a history of [REDACTED]. R134's Urinary Incontinence Care Area Assessment (CAA) dated 7/27/17, indicated he needed total dependence with toileting and was incontinent of bowel and bladder and staff managed all incontinence car

Based on observation, interview and document review, the facility failed to ensure 1 of 1 residents (R19) identified with swallowing difficulties received safe and appropriate assistance with eating. A non-trained paid feeding assistant/staff member, Human Resources (HR)-A, assisted with feeding a resident who had a history of [REDACTED]. R19 was observed coughing while being fed by HR-A. Even though nursing staff were directly across the table while this occurred, they did not intervene placing R19 at risk. The findings constituted an immediate jeopardy (IJ) situation for R19, with the potential for serious harm, injury or death. The facility also failed to ensure residents who were fed by a paid feeding assistants (PFA) were appropriately assessed to be fed by a PFA, and receive training through a state approved program for 2 of 2 (R19, R97) residents who were observed to be fed by a PFA. R97 did not have swallowing problems but needed staff assistance with eating. The immediate jeopardy began on [DATE], at 8:12 a.m. when HR-A was observed to assist R19 with eating, who had a complicated feeding problem and was having difficulty swallowing. The executive director (ED), interim director of nursing (DON), director of clinical services (D(NAME)S), assistant ED-A and ED-B were informed of the immediate jeopardy on [DATE], at 4:15 p.m The IJ was removed on [DATE], at 2:54 p.m., but non-compliance remained at the lower scope and severity of (D) isolated, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: During entrance interview on [DATE], at 12:16 p.m. with the adminstrator and the interim director of nursing (DON) both stated they did not have a paid feeding assistance program (PFA) to assist residents with eating. R19's Admission Record undated indicated that he had dementia and dysphagia (difficulty swallowing). R19's Minimum Data Set ((MDS) dated [DATE], indicated he needed extensive assistance of one with eating and had no swallowing disorders. R19's Nutritional Status Care Area Assessment (CAA) dated [DATE], indicated he required assistance with feeding at meals and had a need for special diet or altered consistency which might not appeal to resident. The CAA further indicated he received sufficient eating assistance. A Discharge Summary Note dated [DATE], from North Memorial Medical Center, indicated he was hospitalized from [DATE] to [DATE]. The Discharge Summary note identified he had aspiration pneumonia, and x-ray with bilateral infiltrates (something that has gotten in to the lungs from the outside. Any abnormal density will show up in the otherwise air filled lungs. Usually the infiltrate will mean pneumonia, or some sort of infection with [MEDICAL CONDITION]/swelling that is in the lung). R19's Nutrition Risk Care Plan dated [DATE], indicated he received a pureed diet with honey thickened liquids and needed total assistance to the dining room and reminded of meal times. The care plan did not list specific speech therapy recommendations. Review of R19's diet card, undated, indicated he needed total assistance to be fed and received honey thickened liquids and a pureed diet. In addition, R19's nursing assistant care sheet, undated, indicated his liquids were honey consistency and he needed total assistance with eating with a note, see ST (speech therapy) instruction. R19's speech therapist note dated [DATE], indicated PT (patient) seen for skilled ST services to address dysphagia and complete final session to receive discharge documentation. Therapist followed up with nursing staff regarding use of printed compensatory swallowing strategies to reduce aspiration risk. A 24-hour log updated for discontinuation of services due to inability to progress due to dementia and inability to follow cues. Nursing staff to implement use of compensatory swallowing strategies and monitor for ongoing signs and symptoms of aspiration. A 24 Hour Status Report dated [DATE], indicated: D/C (discontinue) from ST today continue puree/honey thick liquid diet. Printed strategies at patient's table to follow during meals. The speech therapy instruction sheet indicated the following: * Bite sizes should be ,[DATE] spoonful of puree * Use spoon to give honey thickened fluids (,[DATE] spoon size) *Allow patient to clear mouth completely before giving another bite * Do not put more food in patient's mouth if he is still chewing * If he begins coughing, do not give more food until coughing discontinues. During observation on [DATE], at 12:12 p.m. nursing assistant (NA)-B was observed to give R19 a drink of his juice brining his cup of honey thickened liquids to his mouth and having him drink it instead of using a spoon as required. She proceeded to have him take three drinks and R19 started to cough while drinking from the cup. NA-B stopped when he coughed waited for him to stop and then continued to give him a teaspoon full of his potatoes, and then a teaspoon of his pureed roast beef and he coughed again. At 12:19 p.m. she fed him a level teaspoon full of his mashed potatoes and he coughed again, then NA-B stated to R19 'It's ok and gave him a drink of his juice from his cup. At 12:20 p.m. surveyor intervened and asked NA-B if she was aware of R19's specific feeding recommendations from the speech language pathologist (SLP)-A and showed her the instructions that were on the window sill of the dining room. NA-B stated she was not aware and NA-M instructed her that he should only receive ,[DATE] teaspoons of food and liquids at a time. NA-B then took the teaspoon at the table and placed in his honey thickened juice and proceeded to feed him ,[DATE] teaspoons of his food and beverages and his coughing had decreased. During observation [DATE], at 8:12 a.m. HR-A was observed in the first floor dining room assisting R19 with eating. R19 had scrambled eggs, pureed sausage, oatmeal and honey thickened cranberry juice. At the same table directly across from HR-A, sat assistant director of nursing (ADON)-B whom was assisting R134 with eating. HR-A gave R19 a level teaspoon full of pureed sausage and then immediately gave a heaping teaspoonful of his oatmeal, without first waiting for R19 to swallow the spoonful of pureed sausage before immediately giving a heaping spoonful of oatmeal to R19. R19 immediately started to cough, loudly turning his head away from HR-A to the right. HR-A stopped feeding him and rubbed his back and waited for him to stop coughing. HR-A then brought R19's glass of honey thickened cranberry juice just below his chin and began spoon feeding R19 three spoonfuls of thickened juice, one after another without first waiting for R19 to swallow each bite. HR-A fed R19 a full teaspoon of thickened juice, not a half teaspoon as identified by the ST swallowing strategies. HR-A proceeded to give R19 a heaping spoonful of his pureed sausage and R19 immediately began to cough. HR-A stopped again and let him cough without waiting and HR-A then brought R19's glass of honey thickened cranberry juice to his chin and quickly began feeding R19 three level teaspoonfuls of juice, and a level teaspoon full of oatmeal. HR-A did not wait for R19 to swallow each bite, before she gave him another bite to eat. R19 began to cough loudly and his face turned red while HR-A covered his mouth with his clothing protector while he coughed. ADON-B whom was directly across from HR-A while she fed R19, made no attempts to stop HR-A from feeding R19 even though HR-A was not following the ST swallowing strategies and R19 continued to cough while being fed. R19 had eaten 100% of his scrambled eggs, pureed sausage, and half of his oatmeal and ,[DATE] of his honey thickened cranberry juice. ADON-B left the same table HR-A was assisting R19 and NA-M then sat down to assist R134 across the same table R19 was sitting at. At approximately 8:25 a.m. SLP-A entered the dining room, and surveyor informed her of the above observation. HR-A was removing R19's clothing protector and SLP-A immediately walked up to the table and instructed HR-A she should have been following her recommendations of bite sizes which is ,[DATE] spoonful of liquids and food. HR-A then stated that NA-M had just informed her of the SLP instructions and she had stopped feeding R19. During interview [DATE], at 9:22 a.m. HR-A stated she had been working at the facility since [DATE], and became a NA in 2005, her NA certificate had expired in 2008, and she had not renewed her certificate. HR-A stated she assists with feeding when they are short staffed and had also assisted another resident (R97) on the fourth floor. HR-A stated she does not need to feed the resident on fourth floor but just makes sure she does not spill her food while she is feeding herself. During interview on [DATE], at 12:20 p.m. NA-K stated she knows that when feeding R19 they are to give small amounts of food and then give liquids to make the food go down. NA-K stated she does not know if there was any size amounts of the food or liquids and he had a tendency to cough while being fed. She indicated his ticket says instructions on how he should be fed and it should also be on his care plan. During interview on [DATE], at 12:25 p.m. licensed practical nurse (LPN)-D stated she was not aware of any feeding recommendations for R19 and added, What I don't know I can't tell you! During interview on [DATE], at 12:42 p.m. SLP-A stated she had written up the instructions with his plan of care, and had made these recommendations for R19 on [DATE], and trained staff that assisted with feeding him. The SLP indicated she left the feeding instructions at the table where R19 ate and the instructions would disappear, so she would make new cards and leave them again at his table. SLP-A stated she also told the interim nurse manager during this time, but she no longer works at the facility. In addition, the SLP-A stated she wrote these recommendations on the 24 hour communication board for all staff to see. The SLP-A further stated R19 will cough while eating and she recommended a swallow evaluation awhile ago, but did not think the facility followed through on her recommendation. She relied heavily on the staff to follow through with her recommendations since he was at such high risk for aspiration and it was vital to follow through with SLP's recommendations. The SLP-A stated when she feed R19 ,[DATE] teaspoons of his food and liquids he coughs much less and it reduced his risk of aspiration. During interview on [DATE], at 1:01 p.m. assistant director of nursing (ADON)-B stated, I don't know anything about a swallow evaluation. ADON-B added she had been working on the floor at the facility for six weeks which was prior to the SLP recommendation and indicated she could call his guardian. In addition, ADON-B stated she found out about R19's recommendations last Friday when she overheard a NA instruct another NA about how to feed him. ADON-B further indicated he gets pureed food and that you have to give it to him slowly and was not aware of any portion size but to just feed him slowly. During interview on [DATE], at 3:06 p.m. ADON-B stated that administration told her that HR-A was a certified nursing assistant so she did not say anything to her about not assisting R19. ADON-B added she not realize she (HR-A) was not following his feeding instructions but once she found out she was not following his instructions she contacted respiratory therapy to do an evaluation and took his vital signs which were with in normal limits. In addition, ADON-B stated she placed a call out to R19's primary physician informing him of the facility not following the SLP-A feeding instructions and had not heard back from him. Further, ADON-B stated R19's instructions for feeding were not at the table during lunch today and a downfall they have at the facility is they keep rotating staff from different floors so they do not know the residents. During interview on [DATE], at 3:32 p.m. NA-O stated R19 had coughed a lot while eating, was slow to eat, received thickened liquids and pureed food. NA-O stated they use a four ounce glass to assist R19 to drink. If R19 had coughing while using the glass with increased coughing, he would use a spoon for the thickened liquids and give a full teaspoon of fluid. Previously (approximately 3 months ago) there were written directions on the table that directed staff to use a spoon for fluids but these directions were removed from the table. They resumed to feed R19 as they did previously either with a glass or spoon, and monitor his response. NA-O was unaware he needed to give R19 half teaspoon of fluids and not use a glass. During interview [DATE], at 3:42 p.m. NA-L stated an educator from the facility instructed her on R19's SLP-A recommendations but she stated, I told her as soon as you walk away I won't remember what you told me. She didn't say anything and had me sign a paper saying I was educated. NA-L then stated, I had not fed him since he was on his new diet. On [DATE], at 8:07 a.m. the director of regional operations (DORO) stated HR-A was not directed by any management team member to assist with feeding and she had never done any type of feeding before; however, DORO then stated HR-A had been misleading the facility by telling facility staff members she was a nursing assistant. Although DORO identified this, there was no indication any management staff had checked with HR-A if her nursing assistant certification was current, even though they identified HR-A communicated to them she was a nursing assistant. During interview [DATE], at 2:15 p.m. NA-Q stated she received new education and the staff needed to check the meal ticket for any special feeding instruction and directions that referred to the black book would be located on the beverage cart. A nurse needed to be in the dining room prior to staff serving resident and if anyone started coughing or choking they were to alert the nurse. Interview on [DATE], at 2:17 p.m. licensed practical nurse (LPN)-F stated she had been educated on the new process regarding residents who have special diet. The ticket on the table would have the instructions and if needed would indicate to check the black book which would be located on the beverage cart. Nurse needed to be in the dining room prior to serving and supervise staff and assist if there were any issues with coughing or choking. Only trained staff can assist with feeding residents. The immediate jeopardy that began on [DATE], at 8:12 a.m. was removed on [DATE], at 2:54 p.m. when it could be verified by observation, document review, and staff interview, the facility had educated dietary, ST and nursing staff of who could and could not feed residents, that a nurse needed to be in the dining room when residents were eating, where individual resident swallowing guidelines were located in the dining room, and what guidelines to follow to assist R19 and R97 to eat. The facility checked other resident with swallowing guidelines to ensure their programs were being followed and updated R19 care plans along with other residents who were at risk. Although R19 had a history of [REDACTED]. In addition, ADON-B and NA-M were directly across the table while HR-A was feeding R19 incorrectly, and made no attempts to stop or intervene while this occurred. A policy was requested for following SLP recommendations but was not provided. R97's undated admission record, identified [DIAGNOSES REDACTED]. R97's annual MDS dated [DATE], identified she was severely cognitively impaired, and needed extensive assistance with eating. The Nutrition Risk Data Collection and assessment dated [DATE], identified R97 had a regular diet, with nutritional supplements. She had no problems with chewing or swallowing and only needed staff assistance as needed. An updated nutrition progress note dated [DATE], identified speech language pathology recommended to cut resident's food into bite size pieces and place food to the left side of resident and assist to feed as needed. R97's care plan updated [DATE], identified a problem with nutrition, which directed staff to assist with meals as needed after total set-up and cut food into bite size pieces and place food on left side. During interview [DATE], at 9:22 a.m. HR-A stated she had been working at the facility since [DATE], and became a NA in 2005 but her NA certificate had expired in 2008, and had not renewed her certificate. HR-A stated she assisted with feeding when facility was short staffed and had assisted R97 on the fourth floor. HR-A stated she did not need to feed this resident but just made sure she did not spill her food while R97 was feeding herself. During interview on [DATE], at 12:20 p.m. NA-G who worked on the forth floor stated (HR-A) came up to the 4th floor to help with dining frequently assisting R97 to eat, however, she was unable to be more specific regarding the time frame of frequently. This interview conflicted with HR-A's interview that she only makes sure R97 did not spell her food, and did not feed her.

Based on interview and document review, the facility failed to ensure staff followed the physician order [REDACTED]. R1's PICC was not removed and staff did not assess or change the PICC site dressing. R1 had an increase in temperature, was sent to the hospital, and was diagnosed with [REDACTED]. Findings include: R1's medical record was reviewed. R1 had [DIAGNOSES REDACTED], osteo[DIAGNOSES REDACTED], chronic pressure ulcers, [MEDICAL CONDITIONS] bladder and bowel, a [MEDICAL CONDITION], a [MEDICATION NAME] and a peripherally inserted central catheter (PICC) line placed in a forearm to administer medications for extended periods. R1's Brief Interview of Mental Status dated 1/27/17, with a score of 13-15, indicated no or mild cognitive impairment. R1's care plan dated 1/27/17 indicated R1 was non-ambulatory and required the assistance of two staff for transfers and the assistance of one staff for activities of daily living (ADLs). R1's care plan dated 5/16/17 indicated R1 had a rash to arms and legs due to a secondary intravenous (IV) antibiotic allergy. R1 had a history of [REDACTED]. R1's nursing note dated 6/22/17 indicated R1 was readmitted to the facility from the hospital with an order to receive IV antibiotic vancomyocin beginning 6/23/17 at 8:00 a.m. R1's skin assessment form dated 6/22/17 indicated a left side two lumen PICC line in R1's forearm. A physician's orders [REDACTED]. R1's nursing note dated 6/22/17 indicated R1 was readmitted to the facility with an order to receive IV [MEDICATION NAME], an antibiotic, beginning 6/23/17 at 8:00 a.m. and a skin assessment was done. R1's nursing note dated 6/26/17 indicated the PICC line was patent with no signs or symptoms of infection and IV [MEDICATION NAME] was administered. R1's care plan dated 6/27/17 indicated R1 had [MEDICAL CONDITION]-resistant staphyloccus aureus (MRSA) wounds and a yeast rash to buttocks. R1's care plan interventions for R1's wounds included monitoring for signs and symptoms of infection: increased redness, drainage, odor, pain and temperature. R1's care plan dated 6/27/17 indicated to follow the IV site and tubing care per protocol. R1's nursing note on 6/29/17 indicated IV [MEDICATION NAME] was administered. R1 had no treatment administration record (TAR) for June 2017. R1's treatments were written on the June 2017 Medication Administration Record [REDACTED]. R1's June 2017 MAR indicated [REDACTED]. Copies of R1's June 2017 TAR were requested from the facility but were not received. Copies of R1's June 2017 MAR indicated [REDACTED] A physician's orders [REDACTED]. R1's primary physician progress notes [REDACTED]. The progress note indicated R1 was susceptible [MEDICAL CONDITION]. R1's nursing note and situation, background, assessment and recommendation (SBAR) communication form, both dated 7/4/2017 indicated R1 had a temperature of 102 degrees. The nurse notified the on-call physician and received an order to send R1 to the hospital for evaluation. R1's emergency room (ER) progress note dated 7/4/17 indicated R1's condition on arrival at the ER was a concern to hospital staff. R1 was alert and oriented but disheveled. The PICC line was still in R1's left arm and the insertion site was uncovered. The clear [MEDICATION NAME] dressing was no longer sticking to R1's skin because it was so heavily soiled with crusted flaking skin. R1's PICC line dressing was dated 6/22/17, 12 days earlier. A hospital infectious disease physician consultation note dated 7/6/17 indicated R1's PICC line was removed in theER on [DATE] and cultured and had gram negative bacilli present. When interviewed on 08/07/2017 at 2:01 p.m., registered nurse (RN)-A said it was important to check the PICC line site regularly for swelling, redness, and drainage. RN-A said she never had PICC line training at the facility. When interviewed on 8/7/2017 at 3:41 p.m., the director of nursing (DON)-F said the unit managers do rounding with the wound doctor and if there is a concern she would look at it. When interviewed on 9/12/17 at 1:37 p.m., family member (FM)-H said she was upset about R1's condition because she looked pale, her skin was scaly, they had already cleaned her up for an hour, and she still looked bad when she got to the hospital. FM-H said R1 lives at a new facility; her infection has improved and her skin is healing. When interviewed on 9/25/17 at 10:00 a.m., medical doctor (MD)-J said there should be a daily assessment and documentation of R1's PICC line whether used or not. MD-J said it was the responsibility of nursing staff to contact a physician if staff are not sure about R1's PICC line dressing changes or PICC line removal. MD-J said the expectation was R1's PICC line be removed by facility nursing staff within 24 hours of the order. When interviewed on 10/02/17 at 9:00 a.m., emergency room RN-H said R1's left upper arm was swollen, red and tender on arrival at the emergency room . Yellow, foul-smelling pus flowed from R1's uncovered PICC line site when touched. RN-H said R1 told hospital staff the facility never changed her PICC line dressing. RN-H said common practice is to change a PICC line dressing every 72 hours or when the dressing is soiled or loose. The facility policy titled Central Vascular Access Device ([MEDICAL CONDITION]) Dressing Change dated May 2016 addressed the following PICC line issues and cares: insertion site is a potential entry site for bacteria that can cause catheter-related infections; a transparent dressing over the PICC is preferred but sterile gauze and tape may also be used; transparent dressings need to be changed at least weekly or when the dressing is wet, soiled or loose; sterile gauze dressings must be changed every two days or when the dressing is wet, soiled or loose; the access site should be assessed at least every two hours during continuous therapy, before and after intermittent infusions and at least once every shift when not in use. A assessment for signs and symptoms of infusion-related complications; assessment of the entire arm with the indwelling vascular device include [DIAGNOSES REDACTED], drainage, swelling or induration, change of skin temperature at site or along vein tract and integrity of the dressing; measuring the length of the external catheter is indicated during dressing changes or if signs/symptoms of complications are present.

Based on observation, interview, and document review, the facility failed to ensure 3 of 4 residents (R89, R115, R60) received care and services to promote healing and prevent the development of pressure ulcers. This resulted in actual harm for R89 whose stage II pressure ulcer became worse when interventions were not implemented. This resulted in actual harm for R89. Findings include: R89 was readmitted to the hospital on [DATE], for fever, shortness of breathe, and was discharged back to the facility on [DATE], per the Hospital Discharge Summary dated 1/25/16. The discharge summary also noted R89 had a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising) pressure ulcer on the coccyx and had another open wound on the LE (lower extremity). The Admission Skin assessment dated [DATE], indicated R89 had a stage I ulcer (nonblanchable [DIAGNOSES REDACTED] of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, [MEDICAL CONDITION], induration, or hardness may also be indicators) on the coccyx and the heels were void of any ulcers. R89's progress note dated 1/26/16, indicated no signs and symptoms of the coccyx being open and there was no mention of the LE wound. The note commented the staff would use the barrier cream to the resident's bottom. However, the medical lacked any evidence of skin monitoring of the heel. R89's quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident had severe cognitive impairment, required extensive assistance with all activities of daily living (ADL) except for eating, was at risk for pressure ulcer development, but had no current pressure ulcers. R89's quarterly MDS dated [DATE], indicated the resident remained at risk for pressure ulcers, but had no current pressure ulcers. The quarterly MDS did not identify the stage I ulcer noted upon re-admission on 1/26/16. R89's Skin Integrity Assessment: Prevention and Treatment Plan of Care dated 2/25/16, was revised and indicated the resident had a stage II pressure ulcer on the right heel, and directed staff to float (relieve pressure) the heels, and apply a bootie onto the right foot. The plan of care did not indicate how often R89 was to be turned and repositioned. The plan of care indicated the wound was to be monitored weekly and staff were directed to document on the Skin Grid. R89's Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form dated 2/25/16, noted R89 had a stage II ulcer on the bottom of the right heel. R89's progress notes dated 2/25/16, at 6:00 p.m. indicated, New blister found to R (right) heel. Serous filled 5 cm x 5 cm (centimeter). The note further indicated staff would float heels and add the bootie. The Progress Notes lacked evidence of daily wound monitoring. R89's progress note dated 2/25/16, at 8:30 p.m. indicated the primary physician was notified of R89's pressure ulcer on the right heel, and orders were given to elevate legs, apply a soft boot, and continue to monitor. R89's progress note dated 3/1/16, indicated a dressing change was done to the resident's right heel pressure ulcer, and there was a scant amount of bleeding, and, only complains of pain when heel touched. The undated and untitled NA assignment sheet did not specify R89 was to have the heels floated, nor were staff directed that R89 was to wear a foam boot on the right foot. The section under skin noted staff were to complete, Q (every) shift skin checks. Assist resident with back scratcher PRN (as needed). R89 was continuously observed on 3/2/16, from 6:20 a.m. to 7:29 a.m. in bed. R89 was sleeping on his back, and both heels were lying directly on the mattress. The right heel had a blue foam boot on that was to float R89's heel. At 7:29 a.m. nursing assistant (NA)-A was interviewed and stated R89 did not have the heels floated, and NA-A stated she did not believe staff were supposed to be floating the resident's heels. On 3/2/16, at 11:30 a.m. registered nurse (RN)-B was interviewed and was asked if R89 was going to see the wound MD today. The wound list was reviewed and noted R89's name was not on the list and was added by RN-B. On 3/2/16, at 1:13 p.m. physician (MD)-A was observed to assess R89 during wound rounds. MD-A assessed the pressure ulcer on the right heel and stated, That's going to mature to a big time ulcer. That is 4 cm by 6 cm deep tissue injury (an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area) of right heel. Anticipate that will turn to eschar (a slough or piece of dead tissue that is cast off from the surface of the skin) in the next week or two. MD-A also stated the orders were for pressure relief to the heels with a boot and to float the heels. During interview on 3/3/16, at 8:00 a.m. corporate registered nurse (RNC)-A stated R89 was observed not to have the heels floated. RNC-A remarked R89 had a newly formed blister on the right foot and it was intact. There was no treatment to the right heel as the blister was intact. RNC-A verified the NA sheet lacked direction of the blue foam boot and the floating the heels. RNC-A indicated the skin assessment was the plan of care. The health unit coordinator (HUC)-A was observed on 3/2/16, at 8:10 a.m. to look at the computerized NA sheet. HUC-A acknowledged the information of the blue boot and floating the heels was not on the computerized NA sheet. During observations on 3/3/16, at 8:17 a.m. and 8:27 a.m. R84 was sitting in his wheelchair in the dining room, with the right foot pedal pushed off to the side, and R84's foot was in a blue boot placed directly on the floor. R89 was observed leaning forward in the wheelchair and was putting pressure onto his right foot. At 8:57 a.m. NA-B moved the right foot pedal in front of R89, and placed R89's right foot on the pedal, and brought R89 to his room. There was no pressure relieving device placed on the foot pedals. During interview on 3/3/16, at 9:08 a.m. NA-A stated both of the foot pedals for R89's wheelchair were missing until yesterday, however, staff provided foot pedals when R89 left the faciity on [DATE], for an outing. NA-A stated R89's feet would be resting on the floor when in the wheelchair if no foot pedals were used. During interview on 3/3/16, at 9:10 a.m. NA-B stated R89's feet were to be elevated, and he should be wearing the protective boot on the right foot. During interview on 3/3/16, at 11:13 a.m. RN-B stated the first time she had seen the pressure ulcer was 3/2/16, during wound rounds with MD-A. RN-B stated R89 returned to the facility on [DATE], from the hospital with a pressure ulcer, but was not sure if R89 was added to the wound round list at that time. RN-B stated R89's heels were to be floated, and foot rests were to be used when he was in the wheelchair. RN-B stated she was aware R89 did not have foot pedals on his wheelchair from 2/25/16 to 3/2/16. R89's Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form dated 2/25/16, was reviewed with RN-B. The Skin Grid Sheets had been changed from a stage II to a stage III pressure ulcer (Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). RN-B indicated she did alter the documentation because MD-A stated the pressure ulcer was a stage III pressure ulcer during his rounds on 3/2/16, however, MD-A indicated R89 had a deep tissue injury. During interview on 3/3/16, at 1:02 p.m. RNC-A stated education would be provided to the nurses on staging a pressure ulcer. RNC-A stated she had done the wound rounds on 2/25/16, with RN-B and informed her how to fill out the assessment form, and the pressure ulcer was a stage II pressure ulcer at that time (that statement contraindicated what RN-B stated on 3/3/16, at 11:13 a.m.). RNC-A stated she was not aware the documentation was changed by RN-B to a stage III, and stated, She (RN-B) can't do that; This is very serious. On 3/3/16, at 1:13 p.m. R89 was observed lying in bed with his heels directly touching a pillow which was placed underneath, and the heels were not floated. R89 was wearing the blue boot on the right foot. At 1:16 p.m. licensed practical nurse (LPN)-D observed R89 in bed and stated R89's heel was directly on the pillow and not floating to relieve pressure as ordered. LPN-D assessed R89's heel in the boot, and stated the pressure ulcer on the right heel was directly on the foam inside the Rooke Breeze Boot, touching the sheep wool lining, which was not relieving the pressure to the pressure ulcer on the right heel. The Wound Prevention and Treatment policy effective July 2015, directed staff to review assessments and identify interventions using the Skin Integrity Assessment: Prevention and Treatment Care Plan. Staff were to manage the pressure of a resident by utilizing support surfaces on bed or wheelchair, use turning and repositioning and off load heel pressure. R89 did not receive the care and services to promote the healing of the right heel blister. The heel blister went from a stage II to a deep tissue injury and that caused R89 harm. R115's admission MDS dated [DATE], indicated R115 had moderate cognitive impairment, needed extensive assistance with bed mobility, was totally dependent on staff for transfers, was at risk for pressure ulcers, and had an unhealed stage II pressure ulcer on admission. The MDS identified R115 had a pressure reduction device for the bed and chair, was on a turning/repositioning program with nutrition interventions to promote pressure ulcer healing, and hydration management interventions in place to manage skin problems. The MDS indicated the resident had [DIAGNOSES REDACTED]. R115's Skin Integrity Assessment: Prevention and Treatment Care Plan dated 1/16, indicated R115 had a pressure ulcer to midline sacrum, and a pressure ulcer to the coccyx, and directed staff to provide treatment per MD order. Physician's wound care orders dated 2/3/16, directed staff to apply Santyl, apply skin prep, and cover with foam dressing once daily to the Stage III pressure wound to midline sacrum, and right medial buttock following a surgical debridement of the pressure ulcer(s). On 3/2/16, at 8:41 a.m. with nurse practitioner (NP)-A R115 pressure ulcers were observed. R115's had two ulcers one to the coccyx and one above it at the midline sacrum. Both wound beds were beefy red, without drainage, odor, with edges intact and showed no signs of infection. NP-A stated the pressure ulcers appeared as they were healing. R115's February 2016, treatment record directed staff to do a daily treatment to the pressure ulcers including cleanse the wound, apply Santyl, apply skin prep, and cover with adhesive foam. 7 days in February the treatment was left blank, and 4 days were marked as refused. When interviewed on 3/3/16, at 3:43 p.m. RN-G stated R115 was to have a daily dressing change to the sacrum pressure ulcers using Santyl and Allyven, and the wound physician sees R115 every Wednesday. RN-G stated R115's pressure ulcer treatment is not always completed because R115 refused treatments at times. RN-G stated the treatment sheets indicated resident refusals, and if the treatment sheets were blank and not marked as refused, it indicated the pressure ulcer treatments were not completed. R60's admission MDS dated [DATE], indicated R60 was cognitively intact and required extensive assistance with bed mobility, transfers, was at risk for developing pressure ulcers, did not have current pressure ulcers, and had a pressure reduction device for the bed and chair. The MDS identified R60 had [DIAGNOSES REDACTED]. R60's Skin Integrity Assessment: Prevention and Treatment Care Plan dated 1/16, indicated the resident had a pressure ulcer to the right ischium, and directed staff to provide treatment per MD order. R60's physician's orders [REDACTED]. On 3/3/16, at 9:27 a.m. R60 refused surveyor observation of pressure ulcer. The January 2016, treatment record directed staff to cleanse the pressure ulcer, apply Santyl, and cover it with non adhesive foam. Three out of five days the treatment was not documented as completed with no indication as to why the treatment was not completed, and one out of five days was marked as refused. The February 2016, treatment record directed staff to cleanse the pressure ulcer, apply Santyl, and cover it with non adhesive foam. Nine out of 28 days the treatment was not documented as completed and was blank with no indication as to why the treatment was not completed, and seven out of 28 days there were staff initials which were circled (which indicate treatment was not completed), and one out of 28 days were documented as refused. When interviewed on 3/3/16, at 3:12 p.m. R60 stated the nurses put cream on her bottom every day, however, staff did not change the dressing on a daily basis. R60 stated she was not aware why staff did not change the pressure ulcer dressing every day, and stated she had not ever refused to allow nursing to complete the treatment for [REDACTED]. During interview on 3/3/16, at 3:38 p.m. RN-I stated R60 had pressure ulcer treatment ordered to be completed daily to her coccyx,however, staff is not able to complete this everyday because of lack of staffing. RN-I stated if she is not able to complete the pressure ulcer treatment, it is reported off to the next shift so they can complete it. When interviewed on 3/3/16, at 3:50 p.m. RN-H stated pressure ulcer treatments should be completed as ordered by the physician, and she had been told by nurses at times that the pressure ulcer treatment(s) could not be completed due to lack of staffing. RN-H stated nurses are directed to pass it on to the next shift to ensure the treatment is done as ordered. When interviewed on 3/3/16, at 5:43 p.m. RNC-A stated she expects all treatments to be done according to physician orders. The facility policy/procedure Wound Prevention and Treatment dated 7/15, recognizes even the most vigilant nursing care may not prevent the development and or worsening of pressure ulcers in some residents. In most cases, intensive efforts will be directed at the following: managing risk factors, providing preventative interventions and providing treatment. The facility procedure Pressure Ulcer Prevention/ Treatment dated 7/15, directs staff to Assess all residents upon admission, review assessments and identify individualized interventions . by managing pressure, moisture, nutrition, friction and friction and sheer. The procedure also indicated that interventions will be communicated to staff and training would be provided as needed.

Based on observation, interview and document review, the facility failed to implement interventions to reduce skin irritation and breakdown for 2 of 2 residents (R5, R23) reviewed for non-pressure related skin conditions. This resulted in actual harm for R5 whose moisture associated skin damage became worse when interventions were not implemented. In addition, the facility failed to collaborate care with an outside [MEDICAL TREATMENT] agency for 1 of 1 residents (R86) reviewed for [MEDICAL TREATMENT]. Findings include: NON PRESSURE SKIN R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident had severe cognitive impairment, had an indwelling urinary catheter, was always incontinent of bowel, and dependent on staff for all activities of daily living (ADL's). The MDS also identified [DIAGNOSES REDACTED]. During interview on 3/1/16, at 12:08 p.m. registered nurse (RN)-B stated R5 had two areas of moisture associated skin breakdown, one on the left buttocks measuring 7 cm (centimenters) x 4.5 cm, and one on the right buttock measuring 7 cm x 5 centimeters (cm) on the right buttocks. On 3/2/16, R5 was observed continuously from at 6:21 a.m. to 8:28 a.m At 6:21 a.m. R5 was lying on his back in bed with a pillow on the right side. At 7:06 a.m., respiratory therapist (RT)-A entered room to perform respiratory cares. At 7:35 a.m., R5 continued to remain in the same position on his back, RT-A completed the respiratory cares and exited the room. R5 remained on his back, and was not repositioned nor was peri care performed during this time. At 8:18 a.m. R5 remained in the same backlying position. At 8:28 a.m. nursing assistant (NA)- B entered the room, and informed the surveyor that routine personal morning cares were provided by the night shift staff before 6:00 a.m., more than 2 hours and 28 minutes earlier. The day shift staff were responsible to provide R5 assistance with incontinence care prior to getting him up for breakfast. NA-B provided pericare and R5 was incontinent of a soft stool during this time. R5's skin had two large areas on his right and left buttocks, near rectum, that was macerated (an area of soft, white, deteriorating skin), which was covered with white barrier cream and areas of pink underlying tissue exposed. There was also an area of maceration under the right gluteal fold that measured approximately 2 cm in length and 1 cm in width which had a build up of slough (a mass of dead tissue) to the side of the maceration, with bright pink underlying tissue present (skin was intact). NA-B stated this area (right gluteal fold) was new and she would let the nurses know. On 3/2/16, at 12:58 p.m. R5 was seen by the wound care medical doctor (MD)-A and RN-B to evaluate the macerated areas on his buttocks with the surveyor present. MD-A assessed the area on R5's buttocks and stated the macerated areas were incontinence associated [MEDICAL CONDITION] with excoriations. The area on the right gluteal fold was an old healed ulcer over the ischial tuberosity that was becoming macerated. RN-B stated that she was not aware of the new area of maceration on the gluteal fold until now. MD-A recommended to RN-B to provide careful and meticulous hygiene combined with barrier protection to these areas. During a subsequent interview at 1:34 p.m., MD-A stated R5's skin has an acid mantle of about 4.5 to 6 and that incontinence, especially stool, is alkaline and can easily excoriate the skin. MD-A stated that treatment recommendations for incontinence associated [MEDICAL CONDITION] included provision of pericare, application of a barrier cream, and monitoring of the area. On 3/3/16, at 9:44 a.m. R5 was observed in his room seated in his wheelchair (w/c). At 10:11 a.m. he continued to be in the same position. At 10:16 a.m. NA-B and NA-A were assisting R5 into bed with the mechanical lift. NA-B stated that (R5) was last provided with pericare this morning at about 7:45 a.m. (2 hours and 31 minutes earlier). NA-A and NA-B provided pericare to R5, who was incontinent of soft stool. RN-B, who was in the room at the time, obtained measurements of the three macerated areas. The right buttock measured 8 cm x 6 cm, left buttocks 9 cm x 6 cm and right gluteal fold 2.5 cm x 2 cm RN-B stated all three areas of macerations had increased in size from previous measurements taken on 2/21/16. Review of progress notes 2/21/16 identified that R5 had an open area on bilateral buttocks with the right buttocks measuring 7 x 5 cm and left buttocks 7 x 4.5 cm The note indicated that open does not look new, but there is no order for dressing changes. Review of subsequent progress notes did not identify any monitoring, measurements, or a comprehsive assessment of R5's macerated skin areas. Review of the physician progress notes [REDACTED]. A review of MD-A's (wound care physician) progress notes of 3/2/16, identified the the [DIAGNOSES REDACTED]. Review of R5's care plan updated on 1/15/16, identified a risk of skin breakdown with impaired mobility and bowel incontinence. Staff were directed to turn, reposition, check and change for incontinence every 2 hours. The care plan also directed staff to apply barrier cream to peri area daily, monitor the wound weekly and as needed, and to update the physician within two weeks if there was no evidence of healing. Review of the undated NA Work List directed the staff to turn and position R5 every two hours, was incontinent of stool and was to be checked and changed every two hours. Although the physician progress notes [REDACTED]. During interview on 3/3/16, at 11:11 a.m. RN-B stated she had not completed physician rounds on 2/24/16, with MD-B, and was unaware of the recommendation to provide better pericare and barrier protection for R5. RN-B stated there were some interventions in place, but acknowledged that new [DIAGNOSES REDACTED]. plan, even though the area was first identified in the medical record on 2/21/16, 11 days earlier. During interview on 3/3/16, at 5:10 p.m. NA-J stated that she works with R5 routinely on different shifts and was aware to turn and reposition him every 2 hours so he was off his buttocks and to check for bowel incontinence every two hours. NA-J indicated she was not directed to provide pericare more frequently because of R5's skin concerns, or to use a different skin barrier. NA-J stated, We get report at the beginning of each shift, and no one has directed the staff to do anything different for (R5's) skin concern. Even though R5 was dependent on staff for activities of daily living, and was frequently incontinent of bowel and had two existing areas of skin maceration. Both the primary physician (MD-B) and the wound care medical doctor (MD-A) identified the need for better peri-care and barrier protection. Theses interventions were not implemented and the existing skin maceration had increased in size, with an additional area developing in the peri gluteal fold which resulted in actual harm for R5. A procedure, titled: Wound Prevention and Management, effective July 2015, outlines the Turning and Repositioning Program for residents who are unable to turn and reposition independently. This is to occur between 15 minutes before or 15 minutes after the predetermined times. Communicate the individualized turning and repositioning schedule using: Skin Integrity Assessment; prevention and Treatment Care Plan, Care Deliver Guide/Nursing Assistant Assignment Sheet. R23's admission record dated 9/30/15, included [DIAGNOSES REDACTED]. R23's annual MDS dated [DATE], identified R23 had severe cognitive impairment, and the quarterly MDS, dated [DATE], identified R23 required extensive assistance for activities of daily living, and had no venous or arterial ulcers present. During an observation on 3/2/16, at 1:32 p.m. R23 was sitting in his wheelchair in the hallway near the nurse's station with wraps noted to both lower extremities. Review of R23's Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other forms,completed for each leg and dated 10/2/15, identified the wounds were present on admission, identified as excoriation, and had large amounts of purulent, red, foul odor drainage. The right lower extremity wound was 30 cm (centimeters) in length and 43 cm in width, and the left lower extremity wound was 45 cm in length and 43 cm in width. There were no additional Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other forms completed by the facility regarding these areas. Even though the form directed staff to complete weekly assessments, and to include the date, length, width, depth, color of drainage, color, odor, tunneling/undermining with depth, both forms were blank. Review of the facility EHSI Skin Assessment form for R23 dated 11/25/15, identified a picture of the front and back side of a body with hand drawn lines and arrows to both lower legs, with weeping wounds, weeping legs written beside the picture. An Admission Skin assessment dated [DATE], included hand drawn marks on both lower legs with, [MEDICAL CONDITION] written beside the picture. There were no further skin assessment forms identified for R23's bilateral lower extremities. Review of R23's Comprehensive Care Plan Review Summary, dated 10/20/15, 1/7/16 and 1/19/16, under Skin/Wound, included, No skin/wound issues since last review. However the record review indicated R23 had ongoing treatments to his bilateral weepy legs. R23's Skin Integrity Assessment: Prevention and Treatment Care Plan, dated 1/7/16, included, [MEDICAL CONDITION] BLE (bilateral lower extremity) [MEDICAL CONDITION] (with) weeping. Review of progress notes from 11/3/15 through 2/21/16, identified R23's legs were clean, dressed and treatment applied. There was no mention of size, location, color, drainage, or odor of R23's bilateral lower legs until the 2/22/16, progress notes. The 2/22/16, progress note identified, Res (resident) legs are continually getting worse .Legs have musky smell, and pants & socks were so soaked (with) LE (lower extremity) drainage they were dripping on the floor. There were no additional notes that identified the appearance of R23 bilateral lower extremities from 2/23/16 until 3/3/16, even though the 2/22/16, notes identified his legs had a musky smell and socks and pants were soaked with drainage. R23's physician's orders [REDACTED]. R23's Medication Administration Record [REDACTED]. During an interview on 3/3/16, at 10:11 a.m. RN-H stated she was unsure how long R23's legs have been weeping, she has only been at the facility since December 2015. She also indicated the assessment and monitoring of R23's lower extremity weeping area should be monitored in the nursing progress notes, and/or Treatment Administration Record (TAR) at least weekly. The location, size, drainage, color, odor, and description of the area should be monitored. RN-H stated, They (staff) should be documenting what we are assessing, that would be my expectation. Review of R23's TAR's dated 11/15, 12/15, 1/16, and 2/16, lacked documentation of assessment or monitoring of R23's bilateral lower extremities to determine if they were improving or not. During interview on 03/03/16, at 11:22 a.m. RN-M stated R23's legs are soaked twice a day, cleaned, dried and [MEDICATION NAME] ointment is placed on the areas. They use ABD pads (thick absorbent dressing that soaks up large volume of fluid), because there is so much drainage, and then wrap the area with kerlix from his knee to ankles. Although R23 currently had weeping bilateral lower extremities are soaked and washed twice a day, and being treated with different ointments, [MEDICATION NAME] and Atractain. The facility has not consistently monitored R23's weeping legs, and skin condition for location, size, drainage, periwound condition, wound edges, signs and symptoms of infection, pain or odor to determine if R23's legs were healing and if the current treatment was effective for R23. Review of the facility's procedure: Lower Extremity Ulcer Intervention and Treatment, dated 7/15, directed staff to document the progression of wound healing by measuring length, width, and depth of the wound, and documentation should include drainage/exudate, color, odor, tunneling/undermining, periwound condition, wound edges, anatomical location, pain, signs and symptoms of infection, and wound base tissue. Also included, Regardless of who is doing the wound treatment, Nursing Services will do the weekly assessment. [MEDICAL TREATMENT] R86's significant change Minimum Data Set ((MDS) dated [DATE], identified R86 had intact cognition and received [MEDICAL TREATMENT] services. During interview on 3/2/16, at 8:18 a.m. R86 stated she just started [MEDICAL TREATMENT] when she had been hospitalized recently, and currently had a port in her chest the [MEDICAL TREATMENT] center was managing for her. When interviewed on 3/2/16, at 12:51 p.m. registered nurse (RN)-E stated R86 started [MEDICAL TREATMENT] when she was recently hospitalized , and used a port on her right chest wall for access. RN-E stated the facility used a binder (a communication book) to help manage R86's care with her [MEDICAL TREATMENT], and they send the binder with R86 to her [MEDICAL TREATMENT] treatments. Review of R86's [MEDICAL TREATMENT] Treatment record dated 2/23/16, identified R86 had received a total of eight [MEDICAL TREATMENT] treatments at the off-site [MEDICAL TREATMENT] clinic. An undated blank [MEDICAL TREATMENT] Center Communication Record, a tool used to ensure collaboration of care with the off-site [MEDICAL TREATMENT] clinic, was reviewed. The form used three spaces for the facility and [MEDICAL TREATMENT] center to document pertinent results and notes for R86's care including vital signs, nutrition, and medications. R86's records were reviewed and identified the following: On 2/5/16, the facility nurses completed R86's pre/post [MEDICAL TREATMENT] documentation, however the [MEDICAL TREATMENT] nurse did not record any information on R86's treatment, including any completed lab work, if any access complications, of changes in condition, or how she tolerated her [MEDICAL TREATMENT] treatment even though R86 was a new [MEDICAL TREATMENT] patient. The spaces to record these items were left blank. On 2/8/16, the facility nurse completed R86's pre-[MEDICAL TREATMENT] documentation, however the [MEDICAL TREATMENT] nurse and returning facility nurse did not record any information on record of how R86 tolerated the treatment since she was new to [MEDICAL TREATMENT]. The spaces to record the completed vital signs, treatment complications, and any completed lab work was left blank. On 2/10/16, the facility nurses completed R86's pre and post [MEDICAL TREATMENT] documentation, however the [MEDICAL TREATMENT] nurse did not record any information on R86's treatment, including any completed lab work, if any access complications, or changes in condition even though R86 was new to [MEDICAL TREATMENT]. The spaces to record these items were left blank. On 2/29/16, the facility nurse completed R86's pre-[MEDICAL TREATMENT] documentation, and the [MEDICAL TREATMENT] nurse complete their documentation. However, the returning facility nurse did not complete any documentation including identifying if any signs or symptoms of bleeding, low blood volume, or pain were present even though R86 was a new [MEDICAL TREATMENT] patient. The spaces to record these items was left blank. There were no treatment records identified on 2/12/16, 2/15/16, 2/17/16, 2/19/16, or 2/22/16 although R86's [MEDICAL TREATMENT] Treatment record identified she received services on these dates. When interviewed on 3/3/16, at 9:24 a.m. RN-E stated staff are instructed to, Send the binder with (R86) to her [MEDICAL TREATMENT] treatments, and everything pertaining to her [MEDICAL TREATMENT] records, Stays in the binder. RN-E reviewed R86's [MEDICAL TREATMENT] communication records identified above and stated, people haven't been filling it out. RN-E stated the entire record should of been completed because it was, Supposed to be our communication tool with the off-site [MEDICAL TREATMENT] clinic. This was their form of communication, and they not communicate through telephone, about R86 even though she was a new [MEDICAL TREATMENT] patient. During interview on 3/3/16, at 9:33 a.m. the [MEDICAL TREATMENT] nurse (DN) stated the clinic did not complete the record consistently because there was, Just not enough room on the record to do so. Further, DN stated she was unaware if the communication record was something the facility was to be completing or not. When interviewed on 3/3/16, at 1:09 p.m. RN-B stated R86's [MEDICAL TREATMENT] communication book (binder) was used for communication between the facility and off-site [MEDICAL TREATMENT] clinic and it was, Supposed to be completed adding it was, A communication tool between the center and us (facility). Although R86 was new to [MEDICAL TREATMENT] treatments and had received eight treatments, there was no coordination of care completed with the [MEDICAL TREATMENT] center and facility to ensure R86 tolerated her [MEDICAL TREATMENT] runs which started February 8, 2016. A facility policy on [MEDICAL TREATMENT] care was requested, but none was provided.