Every finding on record at Whitewater Health Services

Based on observation, interview and record review, the facility failed to maintain a clean, homelike environment when it was identified a refrigerator used to supply resident supplement drinks were not cleaned. In addition, during dining, meals were served on trays. This failure had an opportunity to affect all residents who received supplemental drinks and who received meals in the dining rooms.Findings include:During the initial kitchen tour on 6/29/2026 at 10:35 a.m., with cook (C)-A verified the refrigerator in the dining room where the residents house supplement is kept had a large amount of ice built up on the top freezer part with an unknown item within the ice. C-A indicated uncertain who was in charge to clean, monitor or who to report it to. During an interview on 7/01/2026 at 11:45 a.m., maintenance-B said when staff have things that need to be looked at, they are to place a ticket in the TELS. Maintenance-B indicated the TELS is where we would get notified of something needing fixed.During an observation and interview on 7/01/2026 5:50 p.m., administrator verified the ice buildup in the dining room refrigerator.During an interview on 7/01/2026 at 5:55 p.m., administrator, vice president of success (VPS)-A and B verified a TELS request should have been placed for maintenance to review the ice buildup. Administer reviewed the TELS report history and verified it was not reported regarding the ice buildup in the dining refrigerator.TraysDuring an observation on 6/29/2026 at 11:59 a.m., during noon meal, staff bring food to the resident on a tray. The tray includes drinks, dishes with miscellaneous items, and hot plate. The staff place the tray in front of the resident and leave it in front of them. During an observation on 6/29/2026 at 5:34 p.m., supper meals served to residents on trays.During an observation on 6/30/2026 at 12:32 p.m., noon meal was served to residents and left on trays.During an observation and interview on 7/1/01/2026 at 12:00 p.m., registered nurse (RN)-A verified the noon meal was served and food left on the trays and placed in front of the resident. RN-A indicated she recalled this occurring for some time at least two years.During an interview on 7/01/2026 at 7:24 p.m., VPS-A verified the meals are served on trays and left in front of the residents. VPS-A felt it has been like that since before thecurrent administrator. VPS-A confirmed it is not homelike.Facility policy tilted, Safe and Homelike Environment dated 6/16/2022 includes Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean. The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting. General considerations, eliminate the use of meal trays during dining service, unless otherwise requested by the resident.

Based on observation, interview and record review the facility failed to maintain equipment in good working order for 1 kitchen dishwashing system and surrounding area.Findings include:During the initial kitchen tour on 6/29/2026 at 10:35 a.m., [NAME] (C)-A identified dishwater and off to the left underneath counter a metal device with a large amount of water flowing from it. surrounding the device the tile floor was buckled and the trim around the perimeter of the wall was peeled back. C-A indicated maintenance has known of the water leak for about a month.During an observation and interview on 7/01/2026 at 11:45 a.m., maintenance (M)-B was asked to review the leak in the kitchen. After walking in the kitchen, M-B quickly went to the area and turned the water off. M-B was made aware on 6/30/26 from M-A. M-B indicated staff are to use the TELS system (a systems to give updates to maintenance of things needing attention). He reviewed TELS and verified staff did not report. M-B confirmed the damage was not new and should have been reported sooner. M-B indicated a plumber will be coming to assess.During an interview on 7/01/2026 at 5:55 p.m., administrator, vice president of success (VPS)-A and B, indicated the expectation would be staff to report things needing fixed to use the TELS system. Administrator indicated being updated of the plumber called to review the leak in the kitchen and confirmed did not observe the damage themselves.

Based on interview and record review the facility failed to maintain a medical record that was complete, accurate and readily accessible for 1 of 1 resident (R29) reviewed for death record.Findings include:R29's Hospital Discharge summary revealed being discharged to the nursing home on [DATE] in stable condition.R29's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE] reads attempt CPR.R29's death record reads date of death [DATE]R29's Minimum Data Set assessment dated [DATE] indicates death in facility.R29's progress lacked documentation of R29 death in the facility or what had happened.R29's encounter date [DATE] at 9:58 a.m., received call R29 passed away this morning, CPR started, 911 called.State agency asked for R29's incident report and or medical record to include items that would have anything to do with the day of R29's death. Upon follow of request, it was brought to the attention there was no incident report or progress note of what occurred the day of R29's death.During an interview on [DATE] at 6:52 p.m., administrator, [NAME] president of success (VPS) A and B verified the facility did not have documents of what occurred the morning of [DATE] regarding R29 death. VPS-A offered to review a notebook of notes taken during an interdisciplinary team meeting (IDT) discussed the death in facility.

Based on observation, interview and record review, the facility failed to follow care plan interventions requested by the resident for 1 of 1 resident (R5) reviewed for bladder incontinence.Findings include:R5 Quarterly Minimum Data Set (MDS) assessment dated [DATE], included intact cognition, no mood or behaviors, frequently incontinent with no toileting program.R5's care plan focus area for urinary incontinence related to functional incontinence with an intervention of a toileting plan: check and change every 2 hours starting in the am, between meals and at 10:30 p.m., then at 2-3 a.m., last check at 5a.m.During an observation and interview on 6/29/2026 at 3:52 p.m., R5 lying in bed when asked about going to the bathroom, R5 said, she does not make it to the restroom all the time. Staff are to check and change her or go to the bathroom every two hours. R5 continues and said it does not happen all the time and added some staff are better than others. R5's care conference summary dated 4/2/26 reads resident requested care conference to discuss having more input in her cares. R5 felt staff were not listening to her when R5 was telling staff she had a urinary tract infection. Intervention in place was to check on resident every 2 hours to see if she needs to be changed.R5's quarterly Clinical Review Bladder and Bowel assessment dated [DATE] reads bladder incontinent and is wet 1-2 times daily.An email communication provided, including R5, involved the regional ombudsman regarding her cares. The ombudsman attended R5's April care conference where it was discussed R5's toileting and check and change every 2 hours.R5 checks and change at night and every 2-hour, check list was provided for the following dates 6/29/26 through 7/2/26 indicating on 7/1/26 R5 was checked and changed at 6am, 8am, 10am, and noon.During an interview on 7/01/2026 at 8:45 a.m., nursing assistant (NA)-A said R5 had not gotten up for the day yet. When asked the last time R5 was checked and changed, NA-A indicated the night shift at 6am.During an observation on 7/01/2026 at 8:49 a.m., NA-A entered R5's room and walked right out.During an observation on 7/01/2026 at 9:26 a.m., activity staff knocked on the door open, walked in and out then closed door.During an observation and interview on 7/01/2026 at 11:50 a.m., NA-A indicated R5 is up and in her chair. R5 was sitting in her chair. When asked when staff got her up R5 said staff got her up about half hour ago. During an interview on 7/01/2026 at 12:13 p.m., NA-A was asked if R5 was wet with urine when she got her ready for the day. NA-A said yes and R5 was taken to the toilet where she continued to urinate and had a bowel movement. During an interview on 7/01/2026 at 2:04 p.m. NA-A verified she did not check on R5 until 10:30 a.m., NA-A indicated she did go in the room once but, R5 was having breakfast. NA-A confirmed R5's care plan includes check and change every 2 hours. NA-A confirmed she did not follow R5's care plan to check and change her every 2 hours. NA-A indicated they do not chart in real time and must complete at the end of the day. During an interview on 7/01/2026 at 6:05 p.m., administrator vice president of success (VPS)-A and B said they would expect staff to follow the care plan for checking and changing.

Based on interview and record review the facility failed to appropriately assess and reevaluate interventions discussed in a timely manner to help prevent future falls for 1 of 4 residents (R1) reviewed for accidents who had 23 falls.Findings include:R1 admitted to the facility 1/20/2026R1's care plan focus area dated 1/21/26 indicated R1 is at increased risk for actual fall related to history of (h/o) falls, impaired decision making, failure to recognize physical limitations, impaired safety awareness, and attempts to self-transfer. R1's goal is to minimize risk of falls. Original interventions included; ensure R1 is wearing appropriate footwear (gripper socks or shoes), have commonly used articles within easy reach, provide assist to transfer and ambulate as needed, reinforce wheelchair safety as needed such as locking brakes, report development of pain, bruises, change in mental status, ADL function, appetite, or neurological status post fall, and therapy to work on transfer, walking, strengthen.R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], includes mild cognition, no mood or behavior concerns. Requires substantial to max assist where a helper does more than half the effort for toileting, bathing, dressing, and personal hygiene. R1 is dependent on others for putting on and off footwear.During an interview on 6/29/2026 at 12:52 p.m., R1 said staff have told him he has fallen some 17 times since admission. When asked what he was trying to do R1 stated, he dropped glasses, trying to do things for himself instead of calling staff. R1 said the reason he is in the nursing home is due to a fall at home.R1's medical record identified 23 falls with the first one documented on his admission of 1/20/26 through 6/13/26. 21 falls were un-witnessed.R1's first 10 falls lacked a post fall assessment. The first one was not completed until 2/28/26. The assessment included new immediate intervention; would be to keep in common area when up in wheelchair, place slide strips, locking bed, moving bed against the wall, reminders frequently, hourly checks. Education given of the importance to wait for staff members. R1's record revealed interdisciplinary team (IDT) met on 4/28/26 to discuss the 4/28/26 fall. IDT note read the resident fell using the urinal at bedside, 18th fall since admit, and several of them were R1 using the urinal, IDT feels R1 will need to demonstrate the use of the urinal at bedside safely where he doesn't need to stand up. IDT will ask therapy for ideas. Care plan to be updated.R1's therapy note 4/30/26 reads co-treatment details: PT/OT (Physical/Occupational Therapy) cotreat for urinal use and ambulation. R1 stood for 3 minutes to utilize urinal.R1 record lack any further update and R1 continued to fall using his urinal on 5/8/26, and when using the toilet on 6/13/26.During an interview on 7/02/2026 at 12:26 p.m., administrator and vice president of success (VPS)-A and B would expect interventions spoke about at IDT are followed and reviewed.

Based on observation, interview and record review the facility failed to maintain dignity when it was identified a brace was not cleaned regularly for 1 of 1 resident (R1) reviewed for dignity.Findings include:R1's quarterly Minimum Data Set (MDS) assessment, dated 4/11/26, indicated R1 was not cognitively impaired. In addition, needed partial to moderate assistance to dress upper body.R1's care plan includes a focus for ADL (activity of daily living) assist of one staff for dressing, related to recurrent dislocation of right shoulder, and at risk for loss of range of motion and to apply device (specify-immobilizer) per physician orders.R1's orders include, the immobilizer should be removed twice daily, including for showers, to check underlying skin to ensure no rubbing. The immobilizer should be on at all times, otherwise.During an observation on 6/29/2026 at 4:57 p.m. R1 had a brace on right shoulder which wrapped around his trunk. The brace is dirty and or stained.During an observation and interview on 7/01/2026 at 12:03 p.m., registered nurse (RN)-A indicated there is an order to check the skin under the brace for R1 and R1 often removes the brace himself. At times when off it has been washed, although not recently and we try to complete it once a month. R1 was sitting in the dining room eating lunch and RN-A verified the brace was dirty and confirmed it needed to be washed. RN-A indicated it looks to be food from eating and wiping his hands on the brace.During an interview on 7/01/2026 at 12:11 p.m., environmental services (ES)-A indicated they are the ones who wash the braces for the residents but do not dry them. ES-A verified being familiar with R1's brace and said, o' yes, but we have not washed that for a while. During an interview on 7/01/2026 7:22 p.m. vice president of success (VPS)-A and B, verified resident's devices should be washed when identified dirty by staff as it could be an infection control concern.

Based on interview and record review facility failed to notify the physician with a change of condition for 1 of 1 resident (R31) reviewed for discharge.Findings include:R31's Quarterly Minimum Data Set (MDS) assessment, dated 5/7/26 includes intact cognition with no mood or behaviors. R31's focus care plan indicates residents shows potential for discharge, will be discharged to home when clinical and rehabilitation goals are met.R31's physician encounter visit dated 3/24/26, indicates Nursing home discharge. Discharge preparation time spent with patient 40 minutes including the following tasks, reviewed the electronic medical record, updating epic problem list, medication,. time electronically signed 4:35 p.m., with another date and time of 3/27/26 at 2:25 p.m.R31's patient message dated 3/24/26 at 4:36 p.m., indicates discharge recommendation faxed to facility on 3/24/26 at 4:50 p.m.R31's record lacked communication with the provider R31 remained in the facility after signed discharged orders were received.R31's physician became aware R31 remained in the facility on 4/15/26 when R31 was sent to the emergency room (ED).R31's progress note dated 4/16/26 from nurse practitioner reads, does not appear on-call provider was notified of acute change in condition and ED transfer, acknowledged. Note he was seen for SNF (skilled nursing facility) discharge visit by MD (medical doctor) on 3/24/26R31 record revealed they were discharged on 6/6/26.During an interview on 7/01/2026 at 6:13 p.m., administrator, vice president of success (VPS)-A and B verified the order was received to discharge R31. When asked why, they indicated there was a snag in the payor source. Although confirmed they should have updated the physician of the change.During an interview on 7/07/2026 at 2:19 p.m., medical providers social services indicated the facility did not update the medical doctor of the change in condition, admission to the ED or that the resident remained in the nursing home after orders were given to discharge the resident.

Based on observation, interview, and record review, the facility failed to ensure the required nurse staffing information was posted daily. This had the potential to affect all 33 residents residing in the facility and/or visitors who may wish to see the information.Findings include:During an observation on 4/15/26 at 9:59 a.m., the facility nurse staffing information was not observed on the administrator's office door.During an observation on 4/15/26 at 10:16 a.m., the primary areas, hallways, and entrance of the facility was observed, and no facility nurse staffing information was observed.On 4/15/26 at 11:23 a.m., the administrator stated she was responsible for posting nurse staffing information and it would have been located on her office door, but it was not because she had not printed or posted it. It was expected that the nurse staffing information is posted seven days a week.The facility policy titled Nurse Staffing Postage Information revised 10/13/22, indicated staffing information would be readily available in a readable format to residents and visitors at any given time and would be posted on a daily basis.

Based on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 1 of 3 residents (R1) reviewed for an indwelling catheter.Findings include:R1's admission record dated 3/31/26, indicated R1 had benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms.R1's order summary report dated 3/31/26, indicated R1 had an indwelling urinary catheter.R1's care plan dated 4/14/26, indicated R1 had an indwelling foley catheter. R1's medical record lacked evidence to ensure staff were knowledgeable in R1's need for EBPs.During an observation on 4/15/26 at 10:12 a.m., R1 was observed sleeping in his recliner. The door to the room was open and R1's foley catheter leg bag was visible attached to R1's leg. R1 did not have any signage or supplies for EBPs at his door.During an observation on 4/15/26 at 11:40 a.m., physical therapist (PT)-A was in R1's bathroom assisting him out of the bathroom with a gait belt. PT-A assisted R1 to his wheelchair and instructed him to sit as she held his gait belt. PT-A did not have the appropriate personal protective equipment (PPE) on, required when close contact care was provided for a resident who required EBPs.During an interview on 4/15/26 at 1:58 p.m., PT-A stated she would have known if someone was on EBPs by the signage on the door. PT-A did not use PPE when assisting R1 in the bathroom and with transfers because there was no signage on his door stating he was on EBPs.During an interview on 4/15/26 at 10:14 a.m., the director of nursing (DON) stated staff are expected to gown and glove when transferring and assisting someone who is on EBPs to the bathroom.The facility policy titled Enhanced Barrier Precautions revised 8/8/24, indicated EBPs would be initiated for residents who had urinary catheters. Use of personal protective equipment for EBPs would be necessary if staff preformed high-contact care activities including transfers, assisting with toileting, and personal hygiene.

Based on interview and document review, the facility failed to develop a baseline care plan to ensure enhanced barrier precaution (EBP) needs were identified and addressed for 2 of 3 residents (R1 and R2) reviewed for indwelling catheters.Findings include:R1R1's admission record dated 3/31/26, indicated R1 had benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms. R1's order summary report dated 3/31/26, indicated R1 had an indwelling urinary catheter.R1's care plan dated 4/14/26, indicated R1 had an indwelling foley catheter. R1's care plan failed to include R1's need for EBPs as well as interventions related to this need.R1's medical record lacked evidence to ensure staff were knowledgeable in R1's need for EBPs. During an observation on 4/15/26 at 10:12 a.m., R1 was observed sleeping in his recliner. The door to the room was open and R1's foley catheter leg bag was visible attached to R1's leg. R1 did not have any signage or supplies for EBPs at his room door.R2R2's admission record dated 3/27/26, indicated R2 had benign prostatic hyperplasia with lower urinary tract symptoms.R2's order summary report dated 3/27/26, indicated R2 had an indwelling urinary catheter.R2's care plan dated 3/29/26, indicated R2 had an indwelling foley catheter. R2's care plan failed to include R1's need for EBPs as well as interventions related to this need.R2's medical record lacked evidence to ensure staff were knowledgeable in R2's need for EBPs.During an observation on 4/15/26 at 12:04 p.m., R2 was observed in his room in his wheelchair and R2's foley catheter bag was visibly attached under R2's wheelchair. R2 did not have signage or supplies for EBPs at his room door.During an observation on 4/15/26 at 1:24 p.m., the director of nursing (DON) was placing EBP signs on R1 and R2's doors and supplies next to the doors.During an interview on 4/15/26 at 1:25 p.m., DON stated both R1 and R2 should have been on EBPs since admission to the facility due to them having indwelling catheters. The DON was responsible for making sure the care plans reflected the need for EBPs. DON stated she was not sure why the signage was not in place and stated she forgot to put EBPs on R1 and R2's care plans.The facility policy titled Baseline Care Plan revised 9/22/22, indicated the facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for the resident that would meet professional standards of quality of care within 48 hours of admission.

Based on interview and record review, the facility failed to thoroughly investigate allegations of misappropriation of resident medications for five of eight residents (R2, R4, R5, R6, and R8) when the facility found out about these allegations on 6/9/25, placed DON-A on administrative leave pending an investigation. Findings include: During an observation on 6/11/25 at 9:53 a.m. R2's levothyroxine 50 micrograms (mcg) medication card had doses, 30 through 17 removed and tablets one and two were removed. There was nothing written on the doses one and two. R4's potassium chloride 20 milliequivalent (mEq) medication card had doses 30 through five removed and doses one and two were removed. Written on the medication card was 5/18 for resident J.J (R7). R5's glipizide five milligram (mg) medication card had doses 30 through seven removed and dose one was removed at the bottom of the medication card and was initialed LM. R5's clozapine 100 mg medication card had doses 30 through 25 removed and doses five through one were removed. Written on the card was 6/6 D.L. for resident M.T. (R3). Held by a rubber binder was a second medication card with five tablets that was delivered by pharmacy. R6's oxycodone five mg medication card had two doses removed on 6/5 at 11:45 a.m., two tablets that were removed on 6/7 at 1:58 p.m., and two tablets removed on 6/8 at 12:11 a.m. There was no indication as to why two tablets were removed at a time. R2's face sheet dated 6/12/25 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's additional diagnoses included hypothyroidism, hyperlipidemia, and type 2 diabetes mellitus without complications. R2's provider order dated 12/31/24, indicated R2 was prescribed potassium chloride ER tablet extended release 20 milliequivalent (mEq) two tablets in the morning for low potassium levels. R2's provider order dated 12/31/24, indicated R2 was prescribed levothyroxine sodium 25 micrograms (mcg) one time a day related to hypothyroidism. R2's potassium chloride medication card dated 4/28/25, indicated doses nine through seven were removed on 6/5/25 and written on the medication card, the medication was removed for R7. R2's levothyroxine medication card dated 5/18/25 indicated dose 30 through 16 were removed as well as dose two and one. There was no indication as to why dose two and one were removed. R2's provider order dated 5/30/25 indicated R2's potassium chloride ER 20 mEq would be discontinued. R4's face sheet dated 6/12/25 indicated R4 was admitted to the facility on [DATE] with a primary diagnosis of lumbar spina bifida without hydrocephalus. R4's additional diagnoses included calculus of kidney, chronic kidney disease stage 3A, hypokalemia, and hypercalcemia. R4's provider order dated 2/28/25 indicated R4 was prescribed potassium chloride 20 mEq taking two tablets one time a day. R4's potassium chloride medication card dated 4/19/25 indicated doses 30 through five were removed. Doses two and one were removed on 5/18/25 for R7. R5's face sheet dated 6/12/25 indicated R5 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder. R5's additional diagnoses included type 2 diabetes mellitus with other diabetic kidney complications and major depressive disorder. R5's provider orders dated 4/1/25 indicated R5 was prescribed clozapine 100 milligrams (mg) at bedtime released to schizoaffective disorder bipolar type. R5 was prescribed glipizide five mg by mouth in the morning related to type 2 diabetes mellitus without complications. R5's glipizide five mg medication card dated 5/3/25 indicated doses 30 through seven were removed. Dose one was taken with initials LW. It is unknown whose initials LW is. It is unknown what date the glipizide was removed for the unknown resident. R5's clozapine 100 mg medication card dated 5/22/25 indicated doses 30 through 25 were removed. Doses five through one were removed on 6/6/25 for R3. R5's clozapine 100 mg medication card dated 6/5/25 indicated pharmacy filled five tablets. R6's face sheet dated 6/12/25 indicated R6 was admitted to the facility on [DATE] with a primary diagnosis of displaced fracture of lesser trochanter of left femur. R6's additional diagnoses included difficulty walking and age-related osteoporosis without current pathological fracture. R6's provider order dated 4/28/25 indicated R6 was prescribed oxycodone two-point five mg every four hours as needed for a pain score of four through six out of ten. R6 was prescribed five mg every four hours as needed for severe pain with a pain score of seven through ten out of ten. Oxycodone was prescribed for prolonged acute pain and traumatic injury. R6's oxycodone 5 mg medication card dated 5/18/25 indicated there were two tablets removed on 6/7/25 at 1:58 p.m. and two tablets were removed on 6/8/25 at 12:11 a.m. R6's medication administration record (MAR) dated 6/2025 indicated R6 was to be given oxycodone five mg, a half of a tablet (two-point five mg) every four hours as needed for pain. One dose of oxycodone two-point five mg was given on 6/7/25 at 1:57 p.m. by registered nurse (RN)-E. R6 was to be given oxycodone five mg one tablet every four hours as needed for pain. One dose of oxycodone five mg was given on 6/8/25 at 12:28 a.m. by licensed practical nurse (LPN)-A. R8's face sheet dated 6/12/25 indicated R8 was admitted to the facility on [DATE] with a primary diagnosis of encounter or orthopedic aftercare following surgical amputation. R8's additional diagnoses included osteomyelitis of vertebra in the lumbar region, polyneuropathy, and restless legs syndrome. R8 was discharged from the facility on 6/3/25. R8's provider order dated 5/2/25 indicated R8 was prescribed pregabalin ten mL (200 mg total) by mouth twice a day. R3's face sheet dated 6/12/25 indicated R3 was admitted to the facility on [DATE] with a primary diagnosis of other fracture of lower end of right ulna. R3's additional diagnoses included paranoid schizophrenia and anxiety disorder. R3's provider order dated 6/1/25 indicated R3 prescribed clozapine 100 mg five tablets orally at bedtime for paranoid schizophrenia. R3's MAR dated 6/2025 indicated R3 was to take clozapine 100 mg five tablets by mouth at bedtime. R3's clozapine was given on 6/6/25 by LPN-B. R7's face sheet dated 6/12/25 indicated R7 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R7's additional diagnoses included hyperparathyroidism and hyperlipidemia. R7's progress note dated 5/5/25 indicated R7 was prescribed potassium chloride ER 20 mEq taking two tablets by mouth in the morning. R7's MAR dated 5/2025 indicated R7 was to take potassium chloride ER oral tablet extended release 40 mEq in the morning. R7's potassium chloride was given on 5/18/25 by RN-A. R7's MAR dated 6/2025 indicated R7 was to take potassium chloride ER oral tablet extended release 40 mEq by mouth in the morning. R7's potassium chloride was given on 6/5/25 by (RN)-A. During an interview on 6/11/25 at 9:53 a.m., RN-A stated director of nursing (DON)-A directed RN-A several times to borrow medications from other residents to give to another resident. All nurses were given education recently by DON-A about how to borrow medications from residents to give to another resident but could not recall the date that education was. During an interview on 6/11/25 at 12:24 p.m., LPN-A stated if a resident were out of a medication, they would call either the RN on call, DON-A, or RN-C and get direction. The RN on call, DON-A, or RN-C would direct her to borrow medications from another resident to give to that resident. During an interview on 6/11/25 at 12:43 p.m., LPN-B stated when she would run out of a medication for a resident, she would contact the RN on call, and they would give her direction to borrow medications from one resident to give to another resident. LPN-B stated, this happens a lot. The last time LPN-B borrowed medications was about a week ago. R9 had ran out of Pregabalin and R8 would be discharging the next day. DON-A gave direction to borrow R8's medication to give to R9. During an interview on 6/11/25 at 2:08 p.m., RN-C stated she had given direction to several of the nurses to borrow medications from residents to give to other residents if they did not have the medication that needed to be administered. RN-C stated that this practice would happen every other day. During an interview on 6/11/25 at 5:44 p.m., RN-E stated DON-A and RN-C had told him to borrow medications from residents to give to other residents but could not recall the last time this happened. During an interview on 6/12/25 at 10:44 a.m., RN-A stated she has borrowed medications several times from residents to give to other residents but could not recall what medications she borrowed or what residents she took the medications from or what residents she gave the medications to. When a resident does not have a medication in the facility that needed to be administered, RN-A would call DON-A or RN-C, and they would give direction to borrow a resident's medication to give to that resident. When she would borrow medications from other residents, she would take the tablet from bottom of the medication card, initial with the nurses initial, date, time, and the initials of the resident to whom she gave the medication. During an interview on 6/12/25 at 2:24 p.m., DON-B stated he was not part of the facility's investigation, so he was unfamiliar with what was happening in an investigation. DON-B stated human resources (HR)-A was investigating. During an interview on 6/12/25 at 2:40 p.m., HR-A stated he did not do an investigation. HR-A is aware that the facility had placed DON-A on administrative leave pending the investigation. During an email correspondence on 6/16/25 at 6:24 a.m., HR-A stated he had discussed with the facility and team internally and would not be releasing the investigation that the surveyor had requested. Parts of the investigation were still on going and the facility needed to protect themselves and employees as needed. During an interview on 6/16/25 at 1:12 p.m., DON-C stated he has educated some of the nurses about the polies and procedures around medication administration and what to do if they are out of a medication. DON-C stated he was not part of the investigation, but had thought HR-A had completed the investigation. During an interview on 6/16/25 at 1:40 p.m., HR-A stated when the facility found out about the allegation of misappropriation of resident medications, he was not part of the investigation, but HR-B was part of the investigation. HR-A was unaware of any education, corrective action plans, or audits being completed. During an interview on 6/16/25 at 2:03 p.m., HR-B stated she was part of an investigation. HR-B had placed DON-A on administrative leave pending the investigation but was unsure the results of the investigation. HR-B was unaware if the facility had done any education with the nurses. Attempts to contact DON-A on 6/11/25 at 1:32 p.m., 6/12/25 at 9:28 a.m., and 6/16/25 at 9:35 a.m. without success. The facility policy titled Abuse, Neglect and Exploitation indicated misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belonging or money without the resident's consent. Employees would be educated on abuse, neglect, exploitation, and misappropriated of resident property on areas of definitions, preventing, identification, investigation, protection, and reporting. Investigation included identify staff responsible for the investigation, identify and interview all persons involved including the alleged victim(s), alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s), determine if the allegation occurred, the extent, and cause, complete and thorough documentation of the investigation.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure residents medications were ordered in advanced and medications were administered as prescribed for five of eight residents (R2, R4, R5, R6, R8) reviewed when residents were administered other resident's medications when their supply ran out. Findings include: During an observation on 6/11/25 at 9:53 a.m. R2's levothyroxine 50 micrograms (mcg) medication card had doses, 30 through 17 removed and tablets one and two were removed. There was nothing written on the doses one and two. R4's potassium chloride 20 milliequivalent (mEq) medication card had doses 30 through five removed and doses one and two were removed. Written on the medication card was 5/18 for resident J.J (R7). R5's glipizide five milligram (mg) medication card had doses 30 through seven removed and dose one was removed at the bottom of the medication card and was initialed LM. R5's clozapine 100 mg medication card had doses 30 through 25 removed and doses five through one were removed. Written on the card was 6/6 D.L. for resident M.T. (R3). Held by a rubber binder was a second medication card with five tablets that was delivered by pharmacy. R6's oxycodone five mg medication card had two doses removed on 6/5 at 11:45 a.m., two tablets that were removed on 6/7 at 1:58 p.m., and two tablets removed on 6/8 at 12:11 a.m. There was no indication as to why two tablets were removed at a time. During an observation on 6/11/25 at 10:20 a.m. R2's potassium chloride 20 mEq medication card had two doses missing. Written next to the two doses missing included 6/5 for J.J. R2's face sheet dated 6/12/25, indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's additional diagnoses included hypothyroidism, hyperlipidemia, and type 2 diabetes mellitus without complications. R2's brief interview for mental status (BIMS) dated 5/8/25, indicated a score of 14, which indicated R2 was cognitively intact. R2's provider order dated 12/31/24, indicated R2 was prescribed potassium chloride ER tablet extended release, 20 mEq, two tablets in the morning for low potassium levels. R2's provider order dated 12/31/24, indicated R2 was prescribed levothyroxine sodium 25 mcg, one time a day related to hypothyroidism. R2's potassium chloride medication card dated 4/28/25, indicated doses nine through seven were removed on 6/5/25, and written on the medication card, the medication was taken for R7. R2's levothyroxine medication card dated 5/18/25, indicated dose 30 through 16 were removed as well as dose two and one. There was no indication as to why dose two and one was removed. R2's progress note dated 5/30/25, indicated R2's potassium chloride, ER 20 mEq would be discontinued. R2's provider order dated 5/30/25, indicated R2's potassium chloride ER 20 mEq, would be discontinued. R4's face sheet dated 6/12/25, indicated R4 was admitted to the facility on [DATE] with a primary diagnosis of lumbar spina bifida without hydrocephalus. R4's additional diagnoses included calculus of kidney, chronic kidney disease stage 3A, hypokalemia, and hypercalcemia. R4's BIMS dated 5/22/25, indicated a score of 15, which indicated R4 was cognitively intact. R4's provider order dated 2/28/25, indicated R4 was prescribed potassium chloride, 20 mEq, take two tablets one time a day. R4's potassium chloride medication card dated 4/19/25, indicated doses 30 through five were removed. Doses two and one were removed on 5/18/25 for R7. R5's face sheet dated 6/12/25, indicated R5 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder. R5's additional diagnoses included type 2 diabetes mellitus with other diabetic kidney complications and major depressive disorder. R5's BIMS dated 3/17/25, indicated a score of three, which indicated R5 had severe cognitive impairment. R5's provider orders dated 4/1/25, indicated R5 was prescribed clozapine, 100 mg, at bedtime related to schizoaffective disorder bipolar type. R5 was prescribed glipizide, five mg, by mouth in the morning related to type 2 diabetes mellitus without complications. R5's glipizide five mg medication card dated 5/3/25, indicated doses 30 through seven were removed. Dose one was removed with initials LW. It is unknown whose initials LW is. It is unknown what date the glipizide was taken or for which resident. R5's clozapine 100 mg medication card dated 5/22/25 indicated doses 30 through twenty-five were removed. Doses five through one were removed on 6/6/25 for R3. R5's clozapine 100 mg medication card dated 6/5/25 indicated pharmacy filled five tablets. R5's pharmacy receipts indicated on 6/6/25 the pharmacy received a message from DON-A requesting to bill the facility for five tablets of the clozapine one-hundred mg tablets. R6's face sheet dated 6/12/25 indicated R6 was admitted to the facility on [DATE] with a primary diagnosis of displaced fracture of lesser trochanter of left femur. R6's additional diagnoses included difficulty walking and age-related osteoporosis without current pathological fracture. R6's provider order dated 4/28/25 indicated R6 was prescribed oxycodone, two-point five mg, every four hours as needed for a pain score of four through six out of ten. R6 was prescribed five mg every four hours as needed for severe pain with a pain score of seven through ten out of ten. Oxycodone was prescribed for prolonged acute pain and traumatic injury. R6's BIMS dated 5/6/25, indicated a score of zero, which indicated R6 had severe cognitive impairment. R6's oxycodone 5 mg medication card dated 5/18/25 indicated there were two tablets removed on 6/7/25 at 1:58 p.m. and two tablets were removed on 6/8/25 at 12:11 a.m. R6's medication administration record (MAR) dated 5/2025 indicated from 5/13/25 to 5/20/25 the facility used 15 half tablets of the five mg oxycodone tablets and five tablets of the oxycodone five mg tablets. This should have left the facility with two and a half tablets of the five mg tablets left. R6's pharmacy receipts indicated since 1/2025 the pharmacy delivered 15 tablets of oxycodone, five mg, on 5/3/25. On 5/13/25 the pharmacy delivered five mg, ten tablets. On 5/20/25 the pharmacy received a message stating the facility only had two tablets of the oxycodone five mg left. On 5/20/25 the pharmacy delivered oxycodone five mg 28 tablets. R6's MAR dated 6/2025 indicated R6 was to be given oxycodone five mg a half of a tablet (two-point five mg) every four hours as needed for pain. One dose of oxycodone two-point five mg was given on 6/7/25 at 1:57 p.m. by registered nurse (RN)-E. R6 was to be given oxycodone five mg one tablet every four hours as needed for pain. One dose of oxycodone five mg was given on 6/8/25 at 12:28 a.m. by licensed practical nurse (LPN)-A. The does was dependent on the pain scale. This should have left the facility with two and a half tablets of the five mg tablets. R8's face sheet dated 6/12/25, indicated R8 was admitted to the facility on [DATE] with a primary diagnosis of encounter or orthopedic aftercare following surgical amputation. R8's additional diagnoses included osteomyelitis of vertebra in the lumbar region, polyneuropathy, and restless legs syndrome. R8 was discharged from the facility on 6/3/25. R8's provider order dated 5/2/25, indicated R8 was prescribed pregabalin ten mL (200 mg total) by mouth twice a day. R8's medication card was no longer in the facility as she had been discharged . R3's face sheet dated 6/12/25 indicated R3 was admitted to the facility on [DATE], with a primary diagnosis of other fracture of lower end of right ulna. R3's additional diagnoses included paranoid schizophrenia and anxiety disorder. R3's provider order dated 6/1/25, indicated R3 was prescribed clozapine, 100 mg, five tablets orally at bedtime for paranoid schizophrenia. R3's BIMS dated 6/5/25 indicated a score of 13, which indicated R3 was cognitively intact. R3's MAR dated 6/2025 indicated R3 was to take clozapine, 100 mg, five tablets by mouth at bedtime. R3's clozapine was given on 6/6/25 by LPN-B. R3's pharmacy receipts indicated since 1/2025 the pharmacy delivered 25 tablets of clozapine on 6/6/25. R7's face sheet dated 6/12/25 indicated R7 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R7's additional diagnoses included hyperparathyroidism and hyperlipidemia. R7's BIMS dated 4/24/25 indicated a score of zero, which indicated R7 had severe cognitive impairment. R7's progress note dated 5/5/25 indicated R7 was prescribed potassium chloride ER 20 mEq taking two tablets by mouth in the morning. R7's MAR dated 5/2025 indicated R7 was to take potassium chloride ER oral tablet extended release 40 mEq in the morning. R7's potassium chloride was given on 5/18/25 by RN-A. R7's MAR dated 6/2025 indicated R7 was to take potassium chloride ER oral tablet extended release 40 mEq by mouth in the morning. R7's potassium chloride was given on 6/5/25 by (RN)-A. R7's pharmacy receipts indicated since 1/2025 the pharmacy delivered 946 milliliters (mL) of potassium chloride on 1/21/25. On 2/20/25 the pharmacy delivered 946 mL. On 3/27/25 the pharmacy delivered 946 mL. On 5/2/25 the pharmacy delivered 473 mL. On 5/2/25 the pharmacy received a message stating P7 was on hospice and requested a partial refill. On 5/3/25 the pharmacy delivered 30 tablets. On 5/20/25 the pharmacy delivered thirty tablets. On 6/6/25 the pharmacy delivered 30 tablets. R9's face sheet dated 6/12/25 indicated R9 was admitted to the facility on [DATE] with a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure and stage one through stage four chronic kidney disease. R9's additional diagnosis included type 2 diabetes. R9's provider order dated 10/17/24 indicated R9 was prescribed pregabalin 200 mg twice a day related to type 2 diabetes mellitus with diabetic neuropathy. R9's BIMS dated 6/6/25 indicated a score of eight, which indicated R9 had moderate cognitive impairment. R9's pharmacy receipts indicated since 1/2025 the pharmacy delivered 60 pregabalin tablets on 1/14/25. On 2/13/25 the pharmacy delivered 60 tablets. On 3/17/25 the pharmacy delivered 60 tablets. On 4/23/25 the pharmacy delivered 60 tablets. On 5/16/25 the pharmacy delivered 60 tablets. During an interview on 6/11/25 at 9:53 a.m., RN-A stated when a resident is out of a medication, they would re-order the medication once there is eight doses left. If the medication is not available at the time of medication administration, she would look in the emergency medication kit to see if the medication is available. RN-A would also call the pharmacy to check on the status of the medication. RN-A would call the on-call RN, RN-C or DON-A to get direction on the medication administration. RN-A stated she has been given direction by RN-C and DON-A to borrow medications from another resident when the medication is not available for that resident and not available in the emergency medication kit. RN-A has been given that direction several times. RN-A has received education about how to properly borrow medications from other residents but was unsure when this education was. The education was about taking a dose from the resident's medication card at the bottom. The nurse would then date, write the nurses initials, and then the initials of the resident who was given the medication. DON-A. provided this education. During an interview on 6/12/25 at 9:04 a.m., RN-A stated she would re-order a medication once there is eight doses left. The overnight nurses are responsible for re-ordering the medications. To order a medication, a nurse would click the re-order button in the electronic medical record (EMR). If a medication has been re-ordered but was not delivered yet, RN-A would fax the order to the pharmacy. During an interview on 6/11/25 at 11:09 a.m., R2 stated the nurses had not asked if they could borrow any of her medications to give to other residents. R2 was unsure whether she has run out of medications or missed any doses of her medications. During an interview on 6/11/25 at 11:11 a.m., R3 stated the nurses had not asked if they could borrow any of her medications to give to other residents. R3 stated she was unsure whether she had missed any doses of her medications. During an interview on 6/11/25 at 11:16 a.m., R4 stated the nurses had not asked if they could borrow any of his medications to give to other residents. R4 has not ran out of medications that he knows of. During an interview on 6/11/25 at 11:24 a.m., family member (FM)-A stated the nurses had not called him to ask if they could borrow any of R5's medications to give to other residents. FM-A was unsure whether R5 has gone without any medications or ran out of medications. During an interview on 6/11/25 at 12:24 p.m., LPN-A stated if she ran out of a resident medication, she would look in the backstock medication cart. If the medication is not in the backstock medication cart, she would call the pharmacy to check the status of delivery. LPN-A would ask for a stat delivery of the medication. If there is a medication that needs to be administered and the medication is not at the facility, she would consult with the RN-C or DON-A. On 6/6/25 she was to give R3 her clozapine dose. Since R3 was admitted to the day prior, R3's medications were not delivered yet. LPN-A consulted with the nurse practitioner (NP) who could not gain access into R3's EMR yet but would attempt to get into it the following day. The NP could not send the order to the pharmacy at that time. LPN-A consulted with RN-C who told LPN-A to borrow the medication from R5. LPN-A was aware this was a bad practice in nursing, but was following the direction of RN-C. During an interview on 6/11/25 at 12:43 p.m., LPN-B stated when she would run out of a medication for a resident, she would first call the provider. LPN-B stated she has received direction from RN-C and DON-A to borrow medications from residents to give to other residents if they run out of medications. LPN-B stated, this happens a lot. LPN-B stated the last time she borrowed a medication was last week when R9 ran out of his pregabalin and R8 was discharging the next day, so DON-A had told her to borrow the medication from R8 to give to R9. LPN-B stated the facility did not get the medication back to R8 because R8 had discharged that next day. During an interview on 6/11/25 at 12:49 p.m., LPN-C stated she has never borrowed a medication from one resident to give to another resident. During an interview on 6/11/25 at 1:07 p.m., RN-D stated if she ran out of a medication, she would call an on-call provider and the on-call nurse for direction. RN-D stated she had not been told to borrow medications from a resident to give to another resident is they ran out of that medication. During an interview on 6/11/25 at 1:36 p.m., guardian (G)-A stated the nurses had not asked if they could borrow any of R5's medications to give to other residents. G-A stated she is unsure whether R5 has gone without any medications or ran out of his medications. During an interview on 6/11/25 at 1:38 p.m., FM-B stated the nurses had not asked if they could borrow any of R6's medications to give to other residents. FM-B was unsure whether R6 had missed any medication doses. During an interview on 6/11/25 at 1:53 p.m., executive director (ED)-A stated DON-A gave nurses the direction to borrow medications from residents to give to other residents. ED-A stated borrowing medications from a resident to give to another resident has been a long-standing practice in the facility. DON-A had educated nurses on how to properly borrow medications. During an interview on 6/11/25 at 2:08 p.m., RN-C stated DON-A educated the nurses on how to properly borrow medications from residents to give to other residents. The education was in an all-nurses meeting in April 2025. The education was for nurses to take a dose from the bottom of a resident's medication card and dating and writing the initials of the resident who was given that dose of medication. RN-C stated DON-A did not want nurses taking a dose from the top of the medication because she did not want it to look like a medication error to other staff and the state agency. RN-C was unsure how the facility got the medications from the pharmacy to ensure the resident whose medications were borrowed was not short. LPN-A stated this practice has been going on for so long. Borrowing medications from residents had become a common practice within the facility that nurses stopped asking DON-A or herself when there was not a medication in the facility. On 6/2/25, RN-C was informed by DON-A that DON-A had given direction to LPN-A to borrow R8's pregabalin dose to R9 since R8 was discharging soon. On 6/6/25, RN-C received a call from LPN-A that R3 was anxious. LPN-A had already called the provider who could not write the prescription yet and the pharmacy to get a status on the delivery. The pharmacy told LPN-A that the clozapine medication card would not be delivered in time for her next dose. LPN-A gave direction to LPN-A to borrow the clozapine from R5. RN-C relayed the message to DON-A that she gave the direction to LPN-A to borrow the clozapine from R5 to give to R3 and DON-A stated she would call the pharmacy on 6/7/25 stating she dropped the cup of the five tablets on the floor and ask if the pharmacy could replace those medications. During an interview on 6/11/25 at 5:44 p.m., RN-D stated if a resident is missing a medication, they would look in the backstock medication cart. If the medication is not in the backstock medication cart, he would consider looking in the emergency medication kit. RN-D stated RN-C and DON-A had told him to borrow medications from one resident to give to another resident before, but was unsure of the date, resident's name, or situation. RN-D stated he had been educated within the last six months about how to properly borrow medications from other residents. During an interview on 6/12/25 at 9:21 a.m., physician assistant (PA)-A stated he was unaware the facility has been borrowing medications from one resident to give to another resident. PA-A stated the facility recently hired his company to provide medical care and he had only been in the facility two times. PA-A stated he would expect all residents' medications to be given to that resident only, and not shared. During an interview on 6/12/25 at 10:44 a.m., RN-A stated she has borrowed medications from residents to give to other residents several times but could not recall the medication name or the residents involved. Once a provider writes a new order, the provider can give the medication order to any of the nurses and that nurse is responsible for faxing the order to the pharmacy. After the order is faxed to the pharmacy, the nurse will write a progress note in the resident's chart about the medication change. Once the order is faxed, and if it were a hard copy order, the nurse would place that in the resident's chart. Once the pharmacy received the order, the pharmacy will process and deliver the order. The cut off time for same day delivery is 6:00 p.m. Monday through Saturday. If a medication is needed on a Sunday, the nurse would call the pharmacy and then the pharmacy will have the medication delivered from a backup pharmacy. If it is after 6:00 p.m. the medication would be delivered the next day. The pharmacy is open twenty-four hours a day. If a nurse needs a stat delivery on a medication, the nurse would check the emergency medication kit to see if the medication is in there, if not, the nurse would call the pharmacy requesting a stat delivery. If a medication cannot be delivered the same day and it needed to be started immediately, RN-A would check the emergency medication kit. If the medication is not in the emergency medication kit, the nurse would call the provider to ask if the medication can wait until the next day or if the provider wants to make a medication change. If a nurse has to use the emergency medication kit, and the medication is not a narcotic, the nurse would open the emergency medication kit, take the medication needed, and then fill out a form with the resident's name, the medication name, and how many tablets of the medication was taken, and then fax that form to pharmacy so they can replace the medication. If it is a narcotic, the nurse would call the pharmacy to get a code to open the narcotic emergency medication kit and then fill out a form with the resident's name, the medication name, and how many tablets of the medication was taken, and then fax the form to pharmacy so they can replace the medication. Nurse should only take from the emergency medication kit one dose at a time for a resident. Once a medication is delivered, a nurse will receive the medication and then compare the delivery receipt to the medications that were delivered. Once that is completed, the nurse would put the medication cards in the medication cart or the backstock medication cart. During administration if the nurse notices the medication is not in the medication cart and needs to be administered, the nurse would call the on-call RN, RN-C, or DON-A and they would give the nurse direction. RN-A stated every time she has called the on-call RN, RN-C, or DON-A, they would give direction to borrow medications from another resident to give to that resident. Once the medication cards come in for that other resident, they would take however many doses out of the medication card to put back in the resident's medication card the nurse took from by placing the medication in the card and taping it shut. RN-A stated she does now know how the medications are replaced so that the medications are not short all of the time. RN-A stated she thought the RN-C or DON-A calls the pharmacy to say they dropped the medications that they took from the resident so that pharmacy would replace how many doses were borrowed. During an interview on 6/12/25 at 1:06 p.m., pharmacist (PH)-A stated she would receive orders from the facility either in the EMR or via fax. PH-A stated the facility has a daily medication delivery in the evening. PH-A stated the facility has an emergency medication kit that she expects the facility to use if they are out of a resident's medication or it is a new stat order for a medication. The facility's emergency medication kit includes narcotic and non-narcotic medications. PH-A stated she has not received a phone call from the facility stating they had dropped medications and needed replacement but says there are other pharmacists at the pharmacy that also take phone calls. PH-A stated borrowing medications to give to other residents is not a standard of practice that the pharmacy would have. During an interview on 6/12/25 at 2:24 p.m., DON-B stated borrowing of medications is not a standard of practice that the facility would follow as this is misappropriation of medications. It is expected of nursing staff when a resident is out of a medication, to check the emergency medication kit. If the medication is not in the emergency medication kit, the nurse should call the pharmacy and troubleshoot with the pharmacy. During an interview on 6/12/25 at 2:40 p.m. human resources (HR)-A stated he knew DON-A had been placed on administrative leave pending the investigation. During an interview on 6/16/25 at 11:07 a.m., RN-D stated once the provider writs a new order for a resident, the provider will give those orders to the nurse on the floor. The nurse on the floor is responsible for putting those orders in the resident's charts. When a resident is low on a medication, the nurse will order the medication when the resident has eight doses on a medication left. RN-D stated the pharmacy will deliver medications once a day, every day. If a medication is not in the facility when it is time for medication administration, RN-D would check the backstock medication cart. If the medication is not in the backstock medication cart, then RN-D would check the emergency medication kit. If the medication is not in the emergency medication kit, he will call the on- call nurse, RN-C or DON-A. RN-D stated DON-A has hold him previously to borrow medications from residents to give to other residents. RN-D could not recall what date, medications, resident names, or situation when he borrowed these medications. During an interview on 6/16/25 at 1:12 p.m., DON-C stated it is expected that when a nurse runs out of medications, the nurse would call the pharmacy and provider to ask for alternatives to the medication that the nurse may have in the emergency medication kit, the time the medication can be delivered, and if the medication is not going to be delivered, to make a medication error report. DON-C stated the borrowing of medications is considered misappropriation of medications. During an interview on 6/16/25 at 1:40 p.m., HR-A stated he found out on 6/9/25 that nurses were borrowing medications from residents to give to other residents if they ran out of the medications. HR-A stated there has not been any corrective action plans for any of the nurses involved other than placing DON-A on an administrative leave. HR-A stated DON-A has been terminated from the facility following the investigation. During an interview on 6/16/25 at 2:03 p.m. HR-B stated DON-A was placed on administrative leave pending the investigation. After the investigation was completed, DON-A was terminated from the facility. RN-C placed her resignation effective immediately on 6/8/25. Surveyor attempted to contact DON-A on 6/11/25 at 1:32 p.m., 6/12/25 at 9:28 a.m., and 6/16/25 at 9:35 a.m. with no success. Ordering and Receiving Non-Controlled Medications policy dated 1/2025 indicated the facility would reorder medications in advance by writing the medication name and prescription number or applying the peel-off bar-coded label from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to the pharmacy. All medication order changes would be communicated to the pharmacy, timely, to provide the correct quantities and accurate labeling when doses or administration frequencies are modified. If a medication is new, the facility would fax the order in and then inform the pharmacy of the need for prompt delivery. If a medication is a stat order, and if the medication is available in the emergency medication kit, the facility would remove the medication dose needed for administration prior to the next pharmacy delivery. If a medication is not in the emergency medication kit, a stat order is placed to the pharmacy and then the pharmacy is called by the facility requesting a stat delivery. The facility policy titled Medication Administration General Guidelines Section 7.1 dated 01/25 indicated medications supplied for one resident are never administered to another resident. The facility policy titled Medication Ordering and Receiving Form Pharmacy Provider and Ordering and Receiving Non-Controlled Medications Section 3.2 dated 01/25 indicated medications and related products are received from the provider pharmacy on a timely basis and the nursing care center maintain accurate records or medications ordered. The facility contracted pharmacy agreement effective 5/1/23 indicated the facility secured services that included up to eight (8) hours of nurse consulting services representative pharmacy visits quarterly, additional service charges apply. Nurse consulting services are only performed upon facility request. Available services include medication cart audits, documentation review to validate physician orders, medication administration record review, audits to assure accuracy among and between resident charts, treatment cart review, medication room audits and inspection, observation of medication passes, narcotic review, pre-survey audits, root cause analysis to determine process gaps with written solutions, and education training sessions for facility staff.

Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of property for five of eight residents (R2, R4, R5, R6, R8) reviewed when multiple nursing staff took medication belonging to one resident to administer to another resident when their medication supply ran out. Findings include: During an observation on 6/11/25 at 9:53 a.m. R2's levothyroxine 50 micrograms (mcg) medication card had doses, 30 through 17 removed and tablets one and two were removed. There was nothing written on the doses one and two. R4's potassium chloride 20 milliequivalent (mEq) medication card had doses 30 through five removed and doses one and two were removed. Written on the medication card was 5/18 for resident J.J (R7). R5's glipizide five milligram (mg) medication card had doses 30 through seven removed and dose one was removed at the bottom of the medication card and was initialed LM. R5's clozapine 100 mg medication card had doses 30 through 25 removed and doses five through one were removed. Written on the card was 6/6 D.L. for resident M.T. (R3). Held by a rubber binder was a second medication card with five tablets that was delivered by pharmacy. R6's oxycodone five mg medication card had two doses removed on 6/5 at 11:45 a.m., two tablets that were removed on 6/7 at 1:58 p.m., and two tablets removed on 6/8 at 12:11 a.m. There was no indication as to why two tablets were removed at a time. R2's face sheet dated 6/12/25 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's additional diagnoses included hypothyroidism, hyperlipidemia, and type 2 diabetes mellitus without complications. R2's provider order dated 12/31/24, indicated R2 was prescribed potassium chloride ER tablet extended release 20 milliequivalent (mEq) two tablets in the morning for low potassium levels. R2's provider order dated 12/31/24, indicated R2 was prescribed levothyroxine sodium 25 micrograms (mcg) one time a day related to hypothyroidism. R2's potassium chloride medication card dated 4/28/25, indicated doses nine through seven were removed on 6/5/25 and written on the medication card, the medication was removed for R7. R2's levothyroxine medication card dated 5/18/25 indicated dose 30 through 16 were removed as well as dose two and one. There was no indication as to why dose two and one were removed. R2's provider order dated 5/30/25 indicated R2's potassium chloride ER 20 mEq would be discontinued. R4's face sheet dated 6/12/25 indicated R4 was admitted to the facility on [DATE] with a primary diagnosis of lumbar spina bifida without hydrocephalus. R4's additional diagnoses included calculus of kidney, chronic kidney disease stage 3A, hypokalemia, and hypercalcemia. R4's provider order dated 2/28/25 indicated R4 was prescribed potassium chloride 20 mEq taking two tablets one time a day. R4's potassium chloride medication card dated 4/19/25 indicated doses 30 through five were removed. Doses two and one were removed on 5/18/25 for R7. R5's face sheet dated 6/12/25 indicated R5 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder. R5's additional diagnoses included type 2 diabetes mellitus with other diabetic kidney complications and major depressive disorder. R5's provider orders dated 4/1/25 indicated R5 was prescribed clozapine 100 milligrams (mg) at bedtime released to schizoaffective disorder bipolar type. R5 was prescribed glipizide five mg by mouth in the morning related to type 2 diabetes mellitus without complications. R5's glipizide five mg medication card dated 5/3/25 indicated doses 30 through seven were removed. Dose one was taken with initials LW. It is unknown whose initials LW is. It is unknown what date the glipizide was removed for the unknown resident. R5's clozapine 100 mg medication card dated 5/22/25 indicated doses 30 through 25 were removed. Doses five through one were removed on 6/6/25 for R3. R5's clozapine 100 mg medication card dated 6/5/25 indicated pharmacy filled five tablets. R6's face sheet dated 6/12/25 indicated R6 was admitted to the facility on [DATE] with a primary diagnosis of displaced fracture of lesser trochanter of left femur. R6's additional diagnoses included difficulty walking and age-related osteoporosis without current pathological fracture. R6's provider order dated 4/28/25 indicated R6 was prescribed oxycodone two-point five mg every four hours as needed for a pain score of four through six out of ten. R6 was prescribed five mg every four hours as needed for severe pain with a pain score of seven through ten out of ten. Oxycodone was prescribed for prolonged acute pain and traumatic injury. R6's oxycodone 5 mg medication card dated 5/18/25 indicated there were two tablets removed on 6/7/25 at 1:58 p.m. and two tablets were removed on 6/8/25 at 12:11 a.m. R6's medication administration record (MAR) dated 6/2025 indicated R6 was to be given oxycodone five mg, a half of a tablet (two-point five mg) every four hours as needed for pain. One dose of oxycodone two-point five mg was given on 6/7/25 at 1:57 p.m. by registered nurse (RN)-E. R6 was to be given oxycodone five mg one tablet every four hours as needed for pain. One dose of oxycodone five mg was given on 6/8/25 at 12:28 a.m. by licensed practical nurse (LPN)-A. R8's face sheet dated 6/12/25 indicated R8 was admitted to the facility on [DATE] with a primary diagnosis of encounter or orthopedic aftercare following surgical amputation. R8's additional diagnoses included osteomyelitis of vertebra in the lumbar region, polyneuropathy, and restless legs syndrome. R8 was discharged from the facility on 6/3/25. R8's provider order dated 5/2/25 indicated R8 was prescribed pregabalin ten mL (200 mg total) by mouth twice a day. R3's face sheet dated 6/12/25 indicated R3 was admitted to the facility on [DATE] with a primary diagnosis of other fracture of lower end of right ulna. R3's additional diagnoses included paranoid schizophrenia and anxiety disorder. R3's provider order dated 6/1/25 indicated R3 prescribed clozapine 100 mg five tablets orally at bedtime for paranoid schizophrenia. R3's MAR dated 6/2025 indicated R3 was to take clozapine 100 mg five tablets by mouth at bedtime. R3's clozapine was given on 6/6/25 by LPN-B. R7's face sheet dated 6/12/25 indicated R7 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R7's additional diagnoses included hyperparathyroidism and hyperlipidemia. R7's progress note dated 5/5/25 indicated R7 was prescribed potassium chloride ER 20 mEq taking two tablets by mouth in the morning. R7's MAR dated 5/2025 indicated R7 was to take potassium chloride ER oral tablet extended release 40 mEq in the morning. R7's potassium chloride was given on 5/18/25 by RN-A. R7's MAR dated 6/2025 indicated R7 was to take potassium chloride ER oral tablet extended release 40 mEq by mouth in the morning. R7's potassium chloride was given on 6/5/25 by (RN)-A. During an interview on 6/11/25 at 9:53 a.m., RN-A stated director of nursing (DON)-A directed RN-A several times to borrow medications from other residents to give to another resident. All nurses were given education recently by DON-A about how to borrow medications from residents to give to another resident but could not recall the date that education was. During an interview on 6/11/25 at 11:09 a.m., R2 stated the nurses had not asked if they could borrow any of her medications to give to other residents. R2 was unsure whether she has run out of medications or missed any doses of her medications. During an interview on 6/11/25 at 11:11 a.m., R3 stated the nurses had not asked if they could borrow any of her medications to give to other residents. R3 stated she was unsure whether she had missed any doses of her medications. During an interview on 6/11/25 at 11:16 a.m., R4 stated the nurses had not asked if they could borrow any of his medications to give to other residents. R4 has not ran out of medications that he knows of. During an interview on 6/11/25 at 11:24 a.m., family member (FM)-A stated the nurses had not called him to ask if they could borrow any of R5's medications to give to other residents. FM-A was unsure whether R5 has gone without any medications or ran out of medications. During an interview on 6/11/25 at 12:24 p.m., LPN-A stated if a resident were out of a medication, they would call either the RN on call, the DON-A, or RN-C and get direction. The RN on call, DON-A, or RN-C would direct her to borrow medications from another resident to give to that resident. During an interview on 6/11/25 at 12:43 p.m., LPN-B stated when she would run out of a medication for a resident, she would contact the RN on call, and they would give her direction to borrow medications from one resident to give to another resident. LPN-B stated, this happens a lot. The last time LPN-B borrowed medications was about a week ago. R9 had ran out of Pregabalin and R8 would be discharging the next day. DON-A gave direction to borrow R8's medication to give to R9. During an interview on 6/11/25 at 2:08 p.m., RN-C stated she had given direction to several of the nurses to borrow medications from residents to give to other residents if they did not have the medication that needed to be administered. RN-C stated that this practice would happen every other day. During an interview on 6/11/25 at 5:44 p.m., RN-E stated DON-A and RN-C had told him to borrow medications from residents to give to other residents but could not recall the last time this happened. During an interview on 6/12/25 at 10:44 a.m., RN-A stated she has borrowed medications several times from residents to give to other residents but could not recall what medications she borrowed or what residents she took the medications from or what residents she gave the medications to. When a resident does not have a medication in the facility that needed to be administered, RN-A would call DON-A or RN-C, and they would give direction to borrow a resident's medication to give to that resident. When she would borrow medications from other residents, she would take the tablet from bottom of the medication card, initial with the nurses initial, date, time, and the initials of the resident to whom she gave the medication. During an interview on 6/12/25 at 2:24 p.m., DON-B stated he was unsure how long the borrowing of medications had been going on. Attempts to contact DON-A on 6/11/25 at 1:32 p.m., 6/12/25 at 9:28 a.m., and 6/16/25 at 9:35 a.m. without success. The facility policy titled Abuse, Neglect and Exploitation indicated misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belonging or money without the resident's consent.

Based on observation, interview, and record review the facility failed to ensure that alleged violations involving misappropriation of resident medications were reported to the state agency not later than 24 hours of the incidents for five of eight residents (R2, R4, R5, R6, and R8). The facility knew about the misappropriation of resident medications on 6/9/25 and did not report to the state agency. Findings include: During an observation on 6/11/25 at 9:53 a.m. R2's levothyroxine 50 micrograms (mcg) medication card had doses, 30 through 17 removed and tablets one and two were removed. There was nothing written on the doses one and two. R4's potassium chloride 20 milliequivalent (mEq) medication card had doses 30 through five removed and doses one and two were removed. Written on the medication card was 5/18 for resident J.J (R7). R5's glipizide five milligram (mg) medication card had doses 30 through seven removed and dose one was removed at the bottom of the medication card and was initialed LM. R5's clozapine 100 mg medication card had doses 30 through 25 removed and doses five through one were removed. Written on the card was 6/6 D.L. for resident M.T. (R3). Held by a rubber binder was a second medication card with five tablets that was delivered by pharmacy. R6's oxycodone five mg medication card had two doses removed on 6/5 at 11:45 a.m., two tablets that were removed on 6/7 at 1:58 p.m., and two tablets removed on 6/8 at 12:11 a.m. There was no indication as to why two tablets were removed at a time. R2's face sheet dated 6/12/25 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's additional diagnoses included hypothyroidism, hyperlipidemia, and type 2 diabetes mellitus without complications. R2's provider order dated 12/31/24, indicated R2 was prescribed potassium chloride ER tablet extended release 20 milliequivalent (mEq) two tablets in the morning for low potassium levels. R2's provider order dated 12/31/24, indicated R2 was prescribed levothyroxine sodium 25 micrograms (mcg) one time a day related to hypothyroidism. R2's potassium chloride medication card dated 4/28/25, indicated doses nine through seven were removed on 6/5/25 and written on the medication card, the medication was removed for R7. R2's levothyroxine medication card dated 5/18/25 indicated dose 30 through 16 were removed as well as dose two and one. There was no indication as to why dose two and one were removed. R2's provider order dated 5/30/25 indicated R2's potassium chloride ER 20 mEq would be discontinued. R4's face sheet dated 6/12/25 indicated R4 was admitted to the facility on [DATE] with a primary diagnosis of lumbar spina bifida without hydrocephalus. R4's additional diagnoses included calculus of kidney, chronic kidney disease stage 3A, hypokalemia, and hypercalcemia. R4's provider order dated 2/28/25 indicated R4 was prescribed potassium chloride 20 mEq taking two tablets one time a day. R4's potassium chloride medication card dated 4/19/25 indicated doses 30 through five were removed. Doses two and one were removed on 5/18/25 for R7. R5's face sheet dated 6/12/25 indicated R5 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder. R5's additional diagnoses included type 2 diabetes mellitus with other diabetic kidney complications and major depressive disorder. R5's provider orders dated 4/1/25 indicated R5 was prescribed clozapine 100 milligrams (mg) at bedtime released to schizoaffective disorder bipolar type. R5 was prescribed glipizide five mg by mouth in the morning related to type 2 diabetes mellitus without complications. R5's glipizide five mg medication card dated 5/3/25 indicated doses 30 through seven were removed. Dose one was taken with initials LW. It is unknown whose initials LW is. It is unknown what date the glipizide was removed for the unknown resident. R5's clozapine 100 mg medication card dated 5/22/25 indicated doses 30 through 25 were removed. Doses five through one were removed on 6/6/25 for R3. R5's clozapine 100 mg medication card dated 6/5/25 indicated pharmacy filled five tablets. R6's face sheet dated 6/12/25 indicated R6 was admitted to the facility on [DATE] with a primary diagnosis of displaced fracture of lesser trochanter of left femur. R6's additional diagnoses included difficulty walking and age-related osteoporosis without current pathological fracture. R6's provider order dated 4/28/25 indicated R6 was prescribed oxycodone two-point five mg every four hours as needed for a pain score of four through six out of ten. R6 was prescribed five mg every four hours as needed for severe pain with a pain score of seven through ten out of ten. Oxycodone was prescribed for prolonged acute pain and traumatic injury. R6's oxycodone 5 mg medication card dated 5/18/25 indicated there were two tablets removed on 6/7/25 at 1:58 p.m. and two tablets were removed on 6/8/25 at 12:11 a.m. R6's medication administration record (MAR) dated 6/2025 indicated R6 was to be given oxycodone five mg, a half of a tablet (two-point five mg) every four hours as needed for pain. One dose of oxycodone two-point five mg was given on 6/7/25 at 1:57 p.m. by registered nurse (RN)-E. R6 was to be given oxycodone five mg one tablet every four hours as needed for pain. One dose of oxycodone five mg was given on 6/8/25 at 12:28 a.m. by licensed practical nurse (LPN)-A. R8's face sheet dated 6/12/25 indicated R8 was admitted to the facility on [DATE] with a primary diagnosis of encounter or orthopedic aftercare following surgical amputation. R8's additional diagnoses included osteomyelitis of vertebra in the lumbar region, polyneuropathy, and restless legs syndrome. R8 was discharged from the facility on 6/3/25. R8's provider order dated 5/2/25 indicated R8 was prescribed pregabalin ten mL (200 mg total) by mouth twice a day. R3's face sheet dated 6/12/25 indicated R3 was admitted to the facility on [DATE] with a primary diagnosis of other fracture of lower end of right ulna. R3's additional diagnoses included paranoid schizophrenia and anxiety disorder. R3's provider order dated 6/1/25 indicated R3 prescribed clozapine 100 mg five tablets orally at bedtime for paranoid schizophrenia. R3's MAR dated 6/2025 indicated R3 was to take clozapine 100 mg five tablets by mouth at bedtime. R3's clozapine was given on 6/6/25 by LPN-B. R7's face sheet dated 6/12/25 indicated R7 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R7's additional diagnoses included hyperparathyroidism and hyperlipidemia. R7's progress note dated 5/5/25 indicated R7 was prescribed potassium chloride ER 20 mEq taking two tablets by mouth in the morning. R7's MAR dated 5/2025 indicated R7 was to take potassium chloride ER oral tablet extended release 40 mEq in the morning. R7's potassium chloride was given on 5/18/25 by RN-A. R7's MAR dated 6/2025 indicated R7 was to take potassium chloride ER oral tablet extended release 40 mEq by mouth in the morning. R7's potassium chloride was given on 6/5/25 by (RN)-A. During an interview on 6/11/25 at 9:53 a.m., RN-A stated director of nursing (DON)-A directed RN-A several times to borrow medications from other residents to give to another resident. All nurses were given education recently by DON-A about how to borrow medications from residents to give to another resident but could not recall the date that education was. During an interview on 6/11/25 at 11:09 a.m., R2 stated the nurses had not asked if they could borrow any of her medications to give to other residents. R2 was unsure whether she has run out of medications or missed any doses of her medications. During an interview on 6/11/25 at 11:11 a.m., R3 stated the nurses had not asked if they could borrow any of her medications to give to other residents. R3 stated she was unsure whether she had missed any doses of her medications. During an interview on 6/11/25 at 11:16 a.m., R4 stated the nurses had not asked if they could borrow any of his medications to give to other residents. R4 has not ran out of medications that he knows of. During an interview on 6/11/25 at 11:24 a.m., family member (FM)-A stated the nurses had not called him to ask if they could borrow any of R5's medications to give to other residents. FM-A was unsure whether R5 has gone without any medications or ran out of medications. During an interview on 6/11/25 at 12:24 p.m., LPN-A stated if a resident were out of a medication, they would call either the RN on call, the DON-A, or RN-C and get direction. The RN on call, DON-A, or RN-C would direct her to borrow medications from another resident to give to that resident. During an interview on 6/11/25 at 12:43 p.m., LPN-B stated when she would run out of a medication for a resident, she would contact the RN on call, and they would give her direction to borrow medications from one resident to give to another resident. LPN-B stated, this happens a lot. The last time LPN-B borrowed medications was about a week ago. R9 had ran out of Pregabalin and R8 would be discharging the next day. DON-A gave direction to borrow R8's medication to give to R9. During an interview on 6/11/25 at 2:08 p.m., RN-C stated she had given direction to several of the nurses to borrow medications from residents to give to other residents if they did not have the medication that needed to be administered. RN-C stated that this practice would happen every other day. During an interview on 6/11/25 at 5:44 p.m., RN-E stated DON-A and RN-C had told him to borrow medications from residents to give to other residents but could not recall the last time this happened. During an interview on 6/12/25 at 10:44 a.m., RN-A stated she has borrowed medications several times from residents to give to other residents but could not recall what medications she borrowed or what residents she took the medications from or what residents she gave the medications to. When a resident does not have a medication in the facility that needed to be administered, RN-A would call DON-A or RN-C, and they would give direction to borrow a resident's medication to give to that resident. When she would borrow medications from other residents, she would take the tablet from bottom of the medication card, initial with the nurses initial, date, time, and the initials of the resident to whom she gave the medication. During an interview on 6/12/25 at 2:24 p.m., DON-B stated to his knowledge, the misappropriation of medications was never reported, although it should have been. DON-B stated he was unsure how long the borrowing of medications had been going on. During an interview on 6/16/25 at 1:01 p.m., DON-D stated incidents of misappropriation of medications should be reported to the state agency. During an interview on 6/16/25 at 1:12 p.m., DON-C stated misappropriation of medications should be reported to the state agency, but he did not report. During an interview on 6/16/25 at 2:03 p.m., human resources (HR)-B stated she found out on 6/9/25 about the misappropriation of medications. HR-B did not report these incidents to the state agency because she did not have access and did not know how to report to the state agency. HR-B was unsure who would have been responsible for reporting these incidents to the state agency. During an interview on 6/16/25 at 2:40 p.m., HR-A stated he found out about the incident with misappropriation of medications on 6/9/25. HR-A did not report the misappropriation of medication because he was not involved in the investigation. Surveyor attempted to contact DON-A on 6/11/25 at 1:32 p.m., 6/12/25 at 9:28 a.m., and 6/16/25 at 9:35 a.m. without success. The facility policy titled Abuse, Neglect and Exploitation indicated misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belonging or money without the resident's consent. Employees would be educated on abuse, neglect, exploitation, and misappropriated of resident property on areas of definitions, preventing, identification, investigation, protection, and reporting not later than 24 hours if the events that cause the allegation do not involve abuse and dod not result in serious bodily injury.

Based on observation, interview and document review, the facility failed to identify, treat, follow up on pain and offer non-pharmacological interventions for 1 of 1 resident (R125) reviewed for pain management who was newly admitted . Findings include: R125's resident admission Minimum Data Set (MDS) assessment was not completed at time of survey. R125's had intact cognitive. R125 was admitted on [DATE] following a hospital stay, R125's diagnosis include, heart failure, respiratory disease, right lower leg pressure ulcer (reduce blood pressure to body area, leading to skin and tissue damage), left lower leg pressure ulcer, right hip pressure ulcer, perineum (area of sensitive skin between genitals and anus) wound, spinal vertebrae pain, lumbar pain, adult failure to thrive and a new diagnosis of urinary retention requiring a urinary catheter to drain bladder. R125's record lacked a baseline care plan. R125's pain management, treatment and goals was not assessed upon admission. R125's orders included Lyrica (Pregabalin-an anticonvulsant that can be used for nerve pain) 50 milligrams (mg) two times a day for pain, acetaminophen (a pain medication) 1000 mg every 6 hours for pain. Pain level was to be assessed each time the scheduled acetaminophen medication was administered. R125's May treatment administration record (TAR), included document any non-pharmacological pain interventions attempted. Interventions-ice, relaxation/distraction, repositioning, re-medicating, notify MD, diversional activities, music, re-repositioning, warm blanket, stretching, massage, rest, reduce stimuli, and other. R125's TAR included, Resident pain level every shift, use PAINAD (is a five-item observational tool to measure pain in people with dementia. It evaluates breathing, vocalization, facial expression, body language, and consolability) if resident unable to verbalize pain. R125's TAR lacked non-pharmacological pain interventions attempted for the following dates 5/8/25, 5/9/25, 5/10/25, and 5/11/25. R125's Pain Interview with Pain Management Review dated 5/12/25, indicated R125 had pain almost constantly over the past five days with an intensity rating as high as nine out of ten at times. The review of progress notes indicated staff had noticed vocal complaints of pain from R125 daily. The review indicated R125 received scheduled pain medication, but pain assessment was not completed for one of the two pain medications. R125's record included: -5/10/25 at 6:00 p.m., 1000mg acetaminophen was administered with pain rated 8/10. -5/10/25 at 8:00 p.m., 50mg Lyrica -5/10/25 at 10:29 p.m., R125 was calling out in pain, stating her pain is 8/10. -5/11/25 at 12:00 a.m., 1000mg acetaminophen was administered with pain rated 6/10. -5/11/25 at 6:00 a.m., 1000mg acetaminophen was administered with pain rated 5/10. -5/11/25 at 6:09 a.m., resident calling out in pain, stating to staff her pain is 8/10. -5/11/25 at 8:00 a.m., 50mg Lyrica -5/11/25 at 9:47 p.m., resident calling out in pain, stating to staff her pain is unbearable -5/11/25 at 12:00 p.m., 1000mg acetaminophen was administered with pain rated 5/10. -5/11/25 at 2:09 p.m., resident calling out in pain, stating to staff her pain is 8/10. -5/11/25 at 6:00 p.m., 1000mg acetaminophen was administered with pain rated 8/10. -05/11/25 6:32 p.m., resident stated the catheter is unbearable pain -5/11/25 at 8:00 p.m., 50mg Lyrica -5/11/25 at 11:37 p.m., resident calling out in pain -5/12/25 at 12:00 a.m., 1000mg acetaminophen was administered with pain rated 2/10. -5/12/25 at 3:27 a.m., pain is rated 2/10 (bilateral lower extremities, urinary catheter pain (noted to be draining clear yellow urine) -5/12/25 at 6:00 a.m., 1000mg acetaminophen was administered with pain rated 2/10. -5/12/25 at 8:00 a.m., 50mg Lyrica During observation on 5/11/25 at 6:20 p.m.,R125's call was on, nursing assistant (NA)-C entered the room and, told R125 the registered nurse (RN) would be in shortly to help her. R125 could be heard crying out in pain, stated she can't take this pain much longer, shouting out she doesn't understand why her pain isn't being treated. During observation on 5/12/25 at 9:25 a.m., R125 crying out, oh, oh this pain is terrible and ahh, ahh, make it stop During observation on 5/12/25 at 10:02 a.m., R125 called out in pain, ahh, oh , oh , someone help me owww, help it hurts so bad During observation on 5/12/25 at 10:29 a.m., R125 calling out in pain ahh, this hurts so bad, oh, please help me During interview on 5/12/25 at 10:39 a.m., R125 stated she has been in pain all morning, stated she was given acetaminophen and some other medication this morning but the medications are not helping her with her pain. R125 stated her pain is where the urinary catheter is, she described it as a burning pain. R125 stated she is miserable here and just wants the pain to subside even for just a little bit. During interview on 5/13/25 at 10:22 a.m., NA-C stated she will check on each resident as often as she is able. NA-C stated she will update the nurse right away when a resident complains of pain or sounds like the resident is in pain. NA-C stated if she answers the same resident call light again and the resident had not been seen by the nurse NA-C stated she would remind the nurse. In addition, NA-C would assist the resident with anything while waiting for the nurse to give pain medications. NA-C stated she would expect pain to be treated within 10-15 minutes of staff notification. During interview on 5/13/25 at 7:55 a.m., RN-A stated she was unsure how long R125 had her light on and knew R125 was having pain. RN-A stated pain should be treated within 15 minutes of the time the resident tells staff they are experiencing pain. RN-A stated if it was too soon to give pain medications, staff should offer things like ice or heat or other non-pharmacological options to manage the pain. RN-A confirmed if staff offered non-pharmacological options they were to chart and document in the residents record and said sometimes non-pharmacological interventions work better than giving medications. During interview on 5/13/25 at 11:43 a.m., assistant director of nursing (ADON) stated R125 experiences pain frequently, and her pain has been high since arriving to the facility. ADON stated the initial goal was to try non-pharmacological options first. ADON stated it is an expectation if the resident is offered a non-pharmacological option, it is charted, and a follow up assessment completed. ADON confirmed R125 did not have any non-pharmacological options charted as given since her arrival. ADON stated resident pain should be treated with 15-20 minutes of staff notification. Per facility policy titled Pain Management dated 8/9/22, stated staff will recognize when the resident is experiencing pain, evaluate the resident for pain and the cause, manage or prevent pain.

Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection control practices for 1 of 1 resident (R11) reviewed for urinary catheter. Staff failed to ensure a mechanical transfer lift was cleaned and disinfected after resident use for 1 of 1 resident (R125) observed for infection control. Furthermore, staff failed to ensure proper personal protective equipment (PPE) was used for 2 of 2 residents (R125, R126) observed for proper PPE. Findings include: R11 R11's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R11 was cognitively intact with no behaviors, had range of motion limitations to both lower extremities, and was dependent on staff for lower body cares, bed mobility, and transfers. It also indicated R11 had a urinary catheter and colostomy, history of spina bifida (genetic neurologic condition), history of UTI, paraplegia (paralysis of lower extremities due to disorder of the nerves). R11's physician orders indicated R11 required enhanced barrier precautions, provide catheter care every shift, and change catheter system as needed. R11's diagnoses included spina bifida, paraplegia, heart failure, Ileal conduit (surgical opening in the abdomen to allow urine to drain from the kidneys), artificial opening of urinary tract status. R11's urostomy care plan indicated empty when half full, monitor skin around stoma for breakdown, provide ostomy care and change appliance as needed, report any changes in amount and color/odor of urine, use 2 1/4 inch ostomy supplies. R11's infection care plan indicated R11 was at risk for infection related to indwelling catheter and wounds requiring enhanced barrier precautions when performing high-contact care activities. R11's nursing assistant Kardex instructed staff to empty urostomy when half full, use enhanced barrier precautions when performing high contact care activities. During observation and interview on 5/11/25 at 2:07 p.m., R11 was lying in bed connected to a urinary drainage bag that was laying directly on the floor without a barrier preventing contact with the floor. A blue cloth privacy bag was attached to the bedframe next to the drainage bag. R11 indicated he has had a urostomy for a long time and has a history of recurrent kidney issues including infections. During observation on 5/11/25 at 4:47 p.m., R11's drainage bag was observed directly on the floor. R11's progress notes dated 5/13/25 at 1:15 a.m., indicated R11 was sent to the emergency room for an elevated temperature and swelling/redness to left hip. On 5/13/25 at 12:50 p.m., R11 returned from the emergency room with a diagnosis of cellulitis (infection under the surface of the skin) to the left hip and urinary tract infection and was started on a 7 day course of antibiotics. During observation 5/14/25 at 8:45 a.m., R11's catheter bag was observed directly on the floor without a barrier beneath it. Blue cloth privacy bag was tied to the bedframe next to the catheter bag. During interview on 5/14/25 at 9:20 a.m., nursing assistant (NA)-B stated urinary drainage bags should be placed in the cloth privacy bag and hung on the bedframe. NA-B stated placing the catheter bag directly on the floor would be an infection control issue and risk the bag getting run over and damaged. During interview on 5/14/25 at 9:22 a.m., NA-A stated urinary drainage bags should be placed in the cloth bag on the side of the bed and hung from the frame. NA-A stated catheter bags should not be placed directly on the floor due to risk for infection. During interview on 5/14/25 at 9:30 a.m., registered nurse (RN)-A stated catheter bags should be hung below the level of the bladder and in a blue bag on the frame, not directly on the floor. RN-A asked, are you referring to the gentleman in the middle room? and immediately went to R11's room to remove the catheter from the floor. During interview on 5/14/25 at 10:08 a.m., the infection preventionist (IP) stated R11 has a habit of pulling on the tubing of the catheter bag to remove it from the dignity bag and place the catheter bag directly on the floor. The IP stated R11's care plan was updated instructing staff to double check the room and make sure the catheter bag is protected. During interview on 5/14/25 at 10:27 a.m., the director of nursing (DON) and assistant director of nursing (ADON) stated R11 gets very angry when the catheter bag hanging from the bedframe stating he doesn't feel it drains properly unless it is on the floor. The ADON stated staff did compromise with R11 by at least placing the catheter bag in the cloth bag prior to it being placed on the floor. The next morning R11 was upset stating the catheter bag didn't drain properly in the dignity bag and the urine backed up. During observation and interview on 5/14/25 at 11:01 a.m., R11's catheter bag was in the cloth dignity bag attached to the bedframe. R11 stated his preference for the location of the catheter bag depends on the type of bag the facility uses. R11 stated some of the catheter bags the facility uses do not drain as well as he would like unless they are hanging low. R11 stated his catheter bag does not have to be directly on the floor, he just prefers it hang as low as possible. He does not like to use the dignity bag because he feels it doesn't allow proper drainage. R11 observed his catheter bag hanging from the bedframe in the dignity bag at the time of the interview and stated the current bag is draining well and he doesn't have an issue with it hanging from the bedframe. During interview on 5/14/25 at 12:45 p.m., the DON and ADON reiterated R11's wishes keeping the catheter bag on the floor. The corporate vice president of success (VP) stressed the need to have a barrier between the catheter bag and the floor. A policy titled Catheter Care dated 3/15/23 indicated privacy/dignity bags will be available and a catheter drainage bag should be covered or shielded at all times when in use. 51379 Disinfecting Equipment R125's resident admission MDS assessment was not completed at time of survey. R125's cognition was intact. R125 was admitted on [DATE] following hospital admission for acute respiratory failure with hypercapnia (too much carbon dioxide in the blood). R125's admission diagnosis include, heart failure, respiratory disease, right lower leg pressure ulcer (reduce blood pressure to body area, leading to skin and tissue damage), left lower leg pressure ulcer, right hip pressure ulcer, perineum (area of sensitive skin between genitals and anus) wound, spinal vertebrae pain, lumbar pain, adult failure to thrive and a new diagnosis of urinary retention requiring a urinary catheter to drain bladder. During an observation on 5/12/25 at 8:55 a.m., nursing assistant (NA)-D and NA-C answered R125's call light, taking mechanical transfer lift from the hallway without wiping it down, assisted resident to commode, then back to chair. NA-D placed the mechanical transfer lift into the hall without wiping it down or sanitizing. During observation on 5/12/25 at 9:23 a.m., NA-D and NA-C answered call light for another room, the same mechanical transfer lift was used for the 2nd resident without being wiped down or sanitized before or after the 2nd use. During interview on 5/12/25 at 9:33 a.m., NA-D stated facility equipment should be cleaned between residents, this is done to help prevent the spread of infection from resident to resident. NA-D confirmed she had not wiped the lift after using it with R125 and before using it with the 2nd resident. During interview on 5/13/25 at 11:43 a.m., director of nursing (DON) and assistant director of nursing (ADON) stated it is an expectation mechanical lifts are sanitized after use with each resident. Per facility policy titled Standard Precautions Infection Control dated 3/24/23, reusable resident equipment, such as mechanical lifts, should be cleaned and disinfected between residents. Appropriate PPE Donning/Doffing R125's resident admission MDS assessment was not completed at time of survey. R125's cognitive function was intact. R125 was admitted on [DATE] following hospital admission for acute respiratory failure with hypercapnia (too much carbon dioxide in the blood). R125's admission diagnosis include, heart failure, respiratory disease, right lower leg pressure ulcer (reduce blood pressure to body area, leading to skin and tissue damage), left lower leg pressure ulcer, right hip pressure ulcer, perineum (area of sensitive skin between genitals and anus) wound, spinal vertebrae pain, lumbar pain, adult failure to thrive, new diagnosis of urinary retention requiring a urinary catheter to drain bladder, and c-difficile (contagious pathogen in stool). R125 had an order to be placed in a room designated with contact precautions (used for residents with known or suspected infections that pose an increased risk for infection transmission). R125 was placed in a room with contact precautions implemented. R126's resident admission MDS assessment was not completed at time of survey. R126's cognitive function was intact. R126 was admitted on [DATE] following hospital admission after left knee surgery. R126's admission diagnosis includes, type 2 diabetes, chronic kidney disease requiring dialysis, heart failure, irregular heart rate, history of long-term antibiotic use, and known infection of left knee surgical site. R126 had an order to be placed in a room designated with contact precautions . R126 was placed in a room with contact precautions implemented. During observation on 5/12/25 at 1:09 p.m., housekeeping (H)-A donned gown and gloves upon entering room [ROOM NUMBER]. Upon exiting 304, H-A removed gloves, did not take off gown. H-A applied new gloves to clean room [ROOM NUMBER] and did not change gown from the previous room. Upon exiting 306, H-A removed gloves but did not take off gown before moving to clean the 3rd room. H-A applied new gloves to clean room [ROOM NUMBER] but did not change his gown from the previous 2 rooms. Upon exiting 308, H-A removed gown and gloves. During interview on 5/12/25 at 1:27 p.m., H-A stated the process for cleaning each room is the same when you are in the room (wipe stuff down, mop the floor, clean bathroom, empty trash, etc.). H-A stated the process for cleaning contact isolation rooms depends on the specific type of isolation pathogen, generally you need an isolation gown and gloves for cleaning these types of isolation rooms. H-A stated it is an acceptable practice to wear the same gown to clean multiple rooms; would just need to change gloves between rooms. During interview on 5/12/25 at 2:00 p.m., housekeeping supervisor (H)-B stated it is an expectation for housekeepers to change isolation gowns and gloves each time they enter a room to clean. Wearing the same gown for each room could spread different infections to residents. During interview on 5/12/25 at 2:09 p.m., assistant director of nursing (ADON) and corporate vice president of success (VP) stated it is and expectation and facility policy to remove gown and gloves after cleaning each room. This process is done to prevent the spread of infection between residents during the cleaning process. Per facility policy titled Transmission-Based (Isolation) Precautions, dated 9/24/24, donning PPE upon room entry and discarding before exiting the room is done to contain pathogens.

Based on interview and document review, the facility failed to complete and implement a baseline care plan within 48 hours of admission for 1 of 2 residents (R125) reviewed for new admissions. Findings include: R125's face sheet, indicated R125 admitted on [DATE]; diagnosis include, heart failure, respiratory disease, right lower leg pressure ulcer (reduce blood pressure to body area, leading to skin and tissue damage), left lower leg pressure ulcer, right hip pressure ulcer, perineum (area of sensitive skin between genitals and anus) wound, spinal vertebrae pain, lumbar pain, adult failure to thrive and a new diagnosis of urinary retention requiring a urinary catheter to drain bladder. R125's resident admission Minimum Data Set (MDS) assessment was not completed at time of survey. R125's cognitive function was intact. R125's a baseline care plan had not been initiated at time of survey; pain management treatment and goals had not been assessed. During interview on 5/12/25 at 10:39 a.m., R125 stated she has been in pain all morning, stated she was given Tylenol (used to help relieve pain) and some other medication this morning but the medications are not helping her with her pain. R125 stated her pain is where the urinary catheter is, she described it as a burning pain. R125 stated she is miserable here and just wants the pain to subside even for just a little bit. R125 stated no one at the facility had asked her what her pain goals were; she stated her goal would be a pain score of less than 2/10. During interview on 5/13/25 at 11:43 a.m., assistant director of nursing (ADON) and director of nursing (DON) stated R125 experiences pain frequently, and her pain has been high since arriving to the facility. ADON stated the initial goal was to try non-pharmacological options first. DON stated facility staff would be able to locate resident-specific needs in the resident care plan. Upon review, ADON confirmed a resident-specific care plan focus on pain had not been completed at the time of this interview. A facility care plan policy was requested and not received.

Based on observation, interview and record review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed for 1 of 1 resident's (R16) reviewed for medication administration. Findings include: R16's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R16 was cognitively intact. R16's provider orders, included an order for Nystatin antifungal powder to both breasts and groin folds every 12 hours as needed . During observation on 5/14/25 at 7:17 a.m., registered nurse (RN)-A dispensed antifungal powder in a medication cup, walked to R16's room, and handed the medication cup to the director of nursing (DON) who was already in the room. The DON then placed the cup of powder on R16's bedside table and left the room. The DON stated R16 was getting ready for the day and would apply the powder herself when she is ready. During interview on 5/14/25 at 10:55 a.m., RN-A stated she did not think any current residents had a SAM assessment. RN-A stated a SAM assessment is needed to determine if a resident is safe to administer prescribed medications. Once a resident is deemed safe, a provider order is required for medications to be left at bedside. RN-A stated the SAM assessment is important to make sure the resident does not forget to take the medication. RN-A indicate all prescribed medications required a SAM assessment prior to leaving the medication at the bedside. RN-A confirmed R16 did not have a SAM assessment on file. During an interview on 5/14/25 at 11:20 a.m., the assistant director of nursing (ADON) stated residents who chose to have medications left at bedside would require an assessment for safety and a provider order to leave the medication at bedside. The ADON stated there are currently no residents who require a SAM assessment. The ADON stated narcotics are not allowed to be administered independently however all other medications are evaluated on a case by case basis. The ADON stated medications cannot be left with residents unless a SAM is performed to ensure residents are deemed safe to administer the mediation properly. Self-administration assessments are reviewed every 3 months for safety and is documented . Facility policy titled Medication Administration General-Guidelines dated 1/2023, included Residents are allowed to self -administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations.

Based on observation, interview, and document review, the facility failed to ensure the facility's state survey results were kept in a location readily accessible to all residents and/or visitors. This had the potential to affect all 22 residents and/or visitors who could wish to review the information. Findings include: R16's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R16 had intact cognition. During resident council meeting on 5/12/25 at 10:50 a.m., R16 (resident council president) stated she did not know the state survey results were available to be read and confirmed she would be interested in seeing them. During observation and interview on 5/12/25 at 11:21 a.m., social worker (SW) said the facility had a survey binder and was unsure where the binder was located. SW walked out to main atrium and could not readily find the survey results binder. During observation and interview on 5/12/25 at 12:00 p.m., assistant director of nursing (ADON) and corporate vice president of success (VP) had located the survey binder stacked amongst other facility binders, out of sight of residents and others who may want to review. ADON confirmed the survey binder should be in a visible location and easily accessible . A policy regarding posting survey results was requested and not received.

Based on interview and record review, the facility failed to identify, comprehensively assess, implement interventions, and provide timely physician notification for a sudden change in condition for 1 of 3 residents (R1) reviewed for change in condition. This resulted in an immediate jeopardy (IJ) when R1 became unresponsive causing a delay in hospitalization . Immediate Jeopardy (IJ) began on [DATE] when the facility did not complete comprehensive assessments and communicate sudden change of condition to the physician when R1 became unresponsive and remained unresponsive for at least seven (7) hours before the ambulance arrived. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 4:58 p.m. The immediacy of the IJ was removed on [DATE] at 12:43 p.m. but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: R1's hospital after visit summary (AVS) [DATE], identified R1 had been hospitalized for a brain bleed, which caused right sided weakness and altered mentation. Mental status improved throughout hospitalization and R1 was discharged to facility. R1's face sheet identified R1 was admitted to the facility with nontraumatic intracerebral hemorrhage (brain bleed), mixed receptive-expressive language disorder, hemiplegia and hemiparesis affecting right dominant side, weakness, dysphagia-(swallowing disorder), compression of brain, encephalopathy-(brain dysfunction that causes altered mental state), and cerebral amyloid angiopathy-(myloid protein builds up in the blood vessels in the brain causing bleeding inside the brain). R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and displayed symptoms of delirium that included inattention and disorganized thinking. R1 had adequate hearing and vision, and had clear speech. R1 required substantial assistance with activities of daily living and was frequently incontinent of bowel and bladder. R1's care plan dated [DATE], identified a focus of cognitive loss and delay in responding related to: effects of intracerebral hemorrhage. Interventions included to allow adequate time to respond. Do not rush or supply words. Provide cueing and prompting for such things as activities, personal care. Repeat communication using more that one method (words, gestures, facial expressions). R1's recorded vital signs sheet identified on [DATE], at 3:00 a.m. blood pressure ,d+[DATE] (BP normal ,d+[DATE]), pulse 117 (P normal ,d+[DATE]), Temperature 100.7 (T normal ,d+[DATE] F), respirations 20 (R normal ,d+[DATE]), oxygen saturations 92% (O2 normal ,d+[DATE]%). There was no progress note or assessment that identified R1's condition or rational why vital signs were taken at 3:00 a.m. R1's recorded vital signs on [DATE] at 9:48 a.m., included: BP ,d+[DATE], P 100, T 101.6, Res 20, and 02 93%. R1's progress note on [DATE] at 10:16 a.m. identified, resident unresponsive this morning. Lung sounds clear. No cough. COVID test negative. Fever of 101.6., B/P ,d+[DATE], HR 100, R20 93% on room air. Cool rags applied. Notified MD [medical doctor] and RN [registered nurse] on call. At 10:25 a.m. the progress note identified the physician had responded with orders to collect a UA/UC. R1's medication administration record (MAR) identified LPN-A administered 650 milligrams Tylenol suppository at 10:17 a.m. and then at 10:18 a.m. documented the Tylenol was effective. On [DATE] at 12:48 p.m., R1's recorded vital signs included BP ,d+[DATE], P 117, T 98, Res 20, 02 95%. R1's progress note at 1:05 p.m. included, R1 had a fever, some difficulty breathing, and does not wake up or respond to stimuli. At 1:30 p.m. R1 had left via ambulance. R1's ambulance run report dated [DATE], identified Emergency Medical Services (EMS) crew arrived at 1:30 p.m. on scene and R1 was alone in room, no family or staff present. Initial assessment identified a Glasgow Coma Scale (GCS) of 3 (tool that measures a persons level of consciousness after a brain injury) the lowest possible score indicating deep coma or death. Sternal rub attempted with no response from R1. Rapid carotid pulse, skin diaphoretic (sweaty), warm to the touch, and pale. EMS applied cold packs bilaterally to neck, and axillary areas. Facility staff reported to EMS R1 had been in this condition since last night sometime. EMS requested intercept from secondary EMS crew due to R1's medical needs. R1's secondary EMS run on [DATE], identified EMS crew member from secondary EMS joined EMS crew from first ambulance at 1:41 p.m. and remained until arrived at the hospital at 2:05 p.m. EMS report R1 was unresponsive but breathing spontaneously with a steady pulse, GCS remained 3. During an interview on [DATE] at 1:16 p.m., nursing assistant (NA)-A and NA-B stated they were both familiar with R1. NA-A stated R1's normal routine was to get up in recliner during the morning and look outside. R1 was not usually difficult to arouse if she was sleeping. When NA's would reposition R1, she would wake up and talk to us. NA-A and NA-B both stated on [DATE] during the day shift, R1 went out of the facility for appointments and had been talking and drinking thickened liquids. Neither NA noticed any change in R1 since she was admitted to the facility. NA-A and NA-B both stated NA-C gave report to them on [DATE] at 6:00 a.m. and reported R1 had been unresponsive and limp. NA-A and NA-B went to R1's room at 6:30 a.m., performed morning cares, noted R1 was warm to touch. NA-B stated they reported R1's condition to LPN-A around 6:45 a.m. During a phone interview on [DATE] at 2:39 p.m., NA-C stated between 12:00 a.m.-1:30 a.m. on [DATE], R1 did not respond to her except in moans and she seemed very sleepy. NA-C just thought R1 was tired because she had out of the facility on [DATE] for quite awhile. NA-C explained when she went back to check on R1 between 2:30 to 3:30 a.m. she noticed R1 was very lethargic, warm, flushed, and weak. NA-C was concerned because that was not normal, so she reported the information to licensed practical nurse (LPN)-B. When she did shift report on [DATE] at 6:00 a.m., she explained all of R1's changes (very lethargic, warm, flushed, and weak) to NA-A and NA-B who were assigned to care for R1 for day shift. During a phone interview on [DATE] at 2:18 p.m., LPN-B stated between 2:,d+[DATE]:00 a.m. on [DATE], NA-C reported to her R1 was not answering her and would not wake up. LPN-B went to R1's room and took her vital signs which were within R1's normal limits. Although LPN-B stated when she collected R1's vital signs, R1 was not as responsive as she would have liked to have seen her, R1 was at her baseline and there was nothing unusual or different. LPN-B further explained she did not find R1's lack of responsiveness unusual because R1 would not always wake up for her during the night with light shoulder rubs or a quieter voice. LPN-B indicated she had not completed a neurological assessment and did not provide intervention to lower R1's temperature. During an interview on [DATE] at 2:56 p.m., LPN-A stated at the shift report on [DATE], at 6:00 a.m. LPN-B did not say anything unusual happened with R1 during the night. LPN-A stated NA-A and NA-B had come to her after they were done washing R1 up reporting they thought R1 had a fever just before 7:00 a.m However, LPN-A had started R1's tube feeding at 7:00 a.m. and did not notice a difference in R1 as the NA's reported. LPN-B did not take R1's vital signs despite NA's reporting of a fever nor complete a neurological assessment. During an interview on [DATE] at 1:16 p.m., NA-A and NA-B, NA-A stated after the 6:45 a.m. check they returned to R1's room sometime after 9:00 a.m. R1 was still unresponsive, limp, and warm to the touch during cares. NA's indicated they reported their concerns to LPN-A. During an interview on [DATE] at 2:56 p.m., LPN-A stated NA-A and NA-B reported they thought R1 had a fever around 9:00 a.m. or 10:00 a.m. LPN-A stated she then went to R1's room and took R1's vital signs; R1's temperature was 101.6. R1 was unresponsive. She would not wake up, I did a sternal rub and no response from that. I just figured she was kind of sleeping because of the fever. LPN-A performed a Covid test with negative results. LPN-B notified DON and medical doctor (MD)-A. LPN-A had reported to the DON and MD-A R1 had a fever and was really sleepy. LPN-A stated MD-A ordered a urine analysis/urine culture (UA/UC-test to determine presence of urinary tract infection/type of bacteria that is found in the urine) to be collected. LPN-A stated she did not tell the DON and MD-A she was not able to arouse R1 with a sternal rub. During the interview on [DATE] at 2:56 p.m., LPN-A stated R1 did not move, flinch, groan, or moan when she cathed R1 to collect urine for the UA/UC on [DATE]. LPN-A stated R1 just seemed to be sleeping really hard and had a fever. LPN-A did not perform a neurological assessment. During an interview on [DATE] at 1:16 p.m., NA-A and NA-B stated the next time they returned to R1's room sometime after lunch (12:,d+[DATE]:00 p.m) and changed R1's sheets because they were wet with perspiration. NA-A and NA-B noted R1 had sounded gurgly and was breathing heavily, remained unresponsive, and limp. NA's stated that is when LPN-A had called the ambulance. During a phone interview on [DATE] at 11:18 a.m., emergency medical system personal (EMS)-A indicated on [DATE], an ambulance was dispatched to the facility for a resident who was unresponsive. When they arrived onsite at approximately 1:30 p.m. R1 was unresponsive. Facility staff reported R1 had been in that state since the night before. R1's temperature was 100.2 when she was loaded her into the ambulance and never regained consciousness. During a phone interview on [DATE] at 12:16 p.m., MD-A stated LPN-A contacted her by message on [DATE]; the message said R1 was not as responsive and had a temperature of 102.9. Based on the information LPN-A gave to her she gave the order to get a UA/UC. MD-A stated it was not unusual for someone with a recent stroke to be a little more unarousable if they were to get an infection. However, at the time of the report from LPN-A, she was not aware LPN-A was not able to arouse R1 with a sternal rub. MD-A stated I would have sent her in [to the ED] then if I had known that. During an interview on [DATE] at 2:56 p.m., LPN-A explained around 12:30 p.m. she went into check on R1. R1's breathing became irregular; it was rapid, then calm, then rapid. LPN indicated she had described R1's condition to DON and MD as sleepiness because she was not sure R1's consciousness level had changed until right before we sent her to the hospital. R1's hospital records printed [DATE], identified a new large intraparenchymal hemorrhage (type of brain bleed) centered on the right parietal lobe as well as extension into the posterior right frontal and temporal lobes with extensive vasogenic edema (a type of brain swelling). Additionally, a second smaller intraparenchymal hemorrhage involving the inferior left occipital lobe with the associated vasogenic edema was found. R1 was intubated and mechanical ventilation began until family could arrive at bedside. R1 expired on [DATE] at 10:39 p.m. from nontraumatic Intracranial Hemorrhage. During an interview on [DATE] at 1:22 p.m., DON stated LPN-A called and said R1 had a fever and was not responding normally. DON verified LPN-A did not notify her that R1 was unresponsive to a sternal rub. DON indicated the physician should have been notified earlier when R1 was not responsive. Had she had more details she would have directed LPN to complete a neurological assessment. DON would expect staff to communicate efficiently so the physician could order the right treatments. DON expected complete assessments and evaluations as RN's or assist LPN's with what they are able to complete according to their scope. The facility Change in Condition of the Resident policy revised [DATE], identified the facility should immediately inform the resident; consult with the resident's physician; and notify the resident representative(s) when there is . a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications. When a resident presents with a change in condition: 2. assess/evaluate the resident. This assessment/evaluation could include but is not limited to: a. VS. oxygen saturations, blood glucose level f. alteration in level of consciousness, ability to respond 6. Ensure change in condition is included on the 24-hour report to be reviewed later by interdisciplinary team. Documentation needs to include, but is not limited to the following: 1. Description of change in condition and assessment or observation findings. The IJ that began on [DATE] was removed on [DATE] at 12:43 p.m. when it was verified the facility implemented the following: -DON reviewed all resident progress notes for change of condition on [DATE]. -Medical Director and VP of Success, Executive Director, DON reviewed change of condition policy with no changes recommended -staff education re: -deviation from baseline such as a shift from normal -change of condition such as difficulty breathing nurse will complete VS, assess, notify MD of residents condition with documentation to include: date and time of incident, time of condition onset, observation and assessment findings including VS, baseline function and change in usual status, include in note what was communicated and what orders were rec'd. -education on the Stop and Watch system through PointClickCare -shift report changed to include nurse and nursing assistants together

Based on interview and document review, the facility failed to ensure a system was in place to clearly identify resident wishes for code status, cardiopulmonary resuscitation (CPR), for 6 of 34 residents (R13, R10, R32, R184, R26 and R86) reviewed for advanced directives. This failure resulted in an immediate jeopardy (IJ) for R13, R10, and R32, when their medical records failed to identify the residents wishes accurately. In addition to the residents in immediate jeopardy, the facility failed to ensure R184, R26, and R86's code status wishes were addressed with the resident or ordered by the physician. The IJ began on [DATE], when R13 was admitted to the facility and the facility failed to address code status, therefore considering him to be Full Code status, when R13 wished not to be resuscitated if his heart were to stop. R10 had returned from the hospital on [DATE], and had both Full Code and DNR (Do Not Resuscitate) directions in the medical record. R32 had directions for Full Code on a POLST (provider orders for life sustaining treatment) dated [DATE], a physician order dated [DATE] indicating DNR, a care plan dated [DATE] indicating the code status was on hold. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 2:35 p.m. The IJ was removed on [DATE], at 4:30 p.m. but noncompliance remained at the lower scope and severity of an E- pattern scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R13's admission MDS dated [DATE], included cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R13's physician's orders in the EHR on [DATE] failed to include any order for advanced directives or code status. The code status banner in the EHR did not indicate a wish for CPR or DNR. R13's paper medical chart contained a POLST which was signed by the facility's medical director (MD)-A on [DATE], but the form was blank and not filled out. R13's wishes were not expressed on the physician signed form. When interviewed on [DATE], at 2:35 p.m. R13 stated, nobody at the facility has asked about code status, but R13 would want to be considered DNR. R10's quarterly Minimum Data Set (MDS) dated [DATE], included moderate cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10 had a discharge, return anticipated MDS which indicated he had an unplanned discharge to an acute care hospital on [DATE]. An entry tracking MDS indicated he had returned to the facility from the hospital on [DATE]. R10's care plan dated [DATE], with a date initiated of [DATE], identified, [R10] has an advanced directive. Full Code, Long term artificial nutrition, IV/IM [intravenous/intramuscular] antibiotics. The goal was listed as, Resident wishes will be honored. Staff were directed, Full Code [CPR] Long term artificial nutrition, IV/IM antibiotics. Follow facility protocol for identification of code status. Review code status at least quarterly and as directed by resident's/responsible party's wishes. R10's physician orders in the electronic health record (EHR) did not include any order for code status when reviewed on [DATE]. The banner in the EHR also did not identify if R10's wishes were for full code (cardiopulmonary resuscitation) or for DNR (do not resuscitate). When interviewed on [DATE], at 4:44 p.m. licensed practical nurse (LPN)-B stated in the event of [CONDITION(S)], they nurse locates the residents desired code status by going to the paper medical record and locating a POLST (Provider Orders for Life-Sustaining Treatment). LPN-B retrieved R10's paper medical record and located a POLST in the front of the chart. This POLST was dated [DATE], and identified R10 wished to have cardiopulmonary resuscitation (CPR) and full medical treatment, additional preferences were checked off as long-term artificial nutrition by tube and use of IV/IM antibiotic treatment. The POLST indicated a discussion was held with R10 and his health care agent and was signed by the health care agent - family member (FM)-D. The provider had signed this form on [DATE]. A second POLST was also located, this one was signed by the social worker (SW)-B and R10 on [DATE]. However, there was a note scribbled next to cardiopulmonary resuscitation (CPR) and the note included, Discussed with PT [patient] with daughter [DATE] [unknown which year]. The box for Attempt Resuscitation had an X in it, which was crossed off, and the box for Do Not Attempt resuscitation/DNR (allow natural death) also had an X in it and was circled. Under additional preferences, both the box for Use IV/IM antibiotic treatment and Oral antibiotics only (no IV/IM) both had an X in them. LPN-B stated the POLST's were conflicting and staff would not know what to do in the event of [CONDITION(S)], A mistake is going to happen, we are going to do CPR when we are not supposed to. LPN-B stated if she noted any conflicting orders, she would report it to the director of nursing (DON). On [DATE], at 2:35 p.m. R10's medical record was reviewed and remained unchanged with the conflicting POLST's and no physician order addressing code status was located. R32's annual MDS dated [DATE], severe cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R32's order summary dated [DATE], included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], R32's paper medical record contained a POLST dated [DATE], which indicated R32 wished to have CPR performed. R32's care plan dated [DATE], included, Code Status: Changed again from Full CODE to DNR/DNI per MD and POA [power of attorney] as of [DATE]. However, listed under interventions directed staff, ON HOLD: DNR/DNI, Comfort Cares, No artificial nutrition, IV/IM ATB [antibiotics]. It was unclear if the full code or DNR/DNI status was on hold. R184's admission MDS dated [DATE], included moderate cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] When reviewed on [DATE], R184's EMR and paper medical record failed to include any advanced directives or POLST. When interviewed on [DATE], at 5:42 p.m. R184 stated, if was found with no pulse and was not breathing they would like CPR performed. When interviewed on [DATE], at 7:22 p.m. R184's family member (FM)-E stated R184 would like to have CPR performed. The facility had not addressed this with either R184 or FM-E. R26's admission MDS dated [DATE], included cognitively intact with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R26's Physician Orders in the EHR on [DATE], included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no apparent written or verbal order from the physician. R26's paper medical record contained a POLST dated [DATE]. The POLST was blank/not filled out, however MD-A and LPN-B had signed the POLST and dated it with [DATE]. Even though the POLST was signed by the physician, R26's wishes were not on the form. When interviewed on [DATE], at 7:01 p.m. licensed practical nurse (LPN)-C she stated she was going around trying to find the orders for all of the POLST's and getting information for the residents. LPN-C stated she had to fill out some of them (the POLST's) herself as it was so important to have those. LPN-C stated most of the time when the POLST's were in a resident's chart they were not filled out. LPN-C stated she did her best to update them but could not get to everybody. LPN-C stated she'd previously shared her concerns with the DON, executive director, and the social worker. LPN-C stated it caused her anxiety because staff would not know what to do in an emergency. LPN-C stated if no code status was found in a medical record, the staff would be expected to perform CPR if they were found to have no pulse and no respirations. When interviewed on [DATE], at 4:19 p.m. LPN-A stated, it was not the facility's policy to put the resident's code status into the electronic record in point click care (PCC). LPN-A said she became aware that LPN-C had entered, verbal orders for code status in a number of residents' charts but was unsure when this had happened. LPN-A also stated there was a, system issue for code status of residents. LPN-C verified R26's current POLST was blank and had been signed by the physician and nurse. LPN-C stated the facility staff would need to initiate CPR if needed, as you can't ask an unresponsive resident their code status. When interviewed on [DATE], at 3:21 p.m. LPN-B stated, she was the admission nurse that completed the POLST upon admission with R26 but did not recall what R26 has said. LPN-B verified the POLST did not indicate R26's code status as the form was blank. LPN-B stated she would look in the hard (paper) chart for the POLST and if the POLST was blank, she would have needed to look in the computer and verified there was a verbal order that indicated full code. LPN-B stated she would have started CPR as the EHR had indicated R26 was full code. When interviewed on [DATE], at 4:12 p.m. LPN-D stated she would look at the POLST in the front of the resident's medical record for a resident's code status. LPN-D stated, if the POLST was blank, you should initiate CPR until you know their CPR status. LPN-D stated the charge nurse completed the POLST upon admission. When interviewed on [DATE], at 1:37 p.m. the DON stated, In the state of Minnesota, we would do CPR if we do not have a signed POLST. The DON stated the POLST was reviewed with the resident or representative upon admission and, We need to make sure we are checking what they want for code status. The DON stated the nurse that prepares the POLST document with the resident wishes is supposed to sign it on the back, and then route it to the physician for signature. The physician should not sign a blank POLST form prior the resident wishes added to the form. R86's baseline care plan indicated R86 was alert and orientated and was admitted to the facility on [DATE]. R86's POLST in the paper medical record dated [DATE], indicated R86 wished to have an Attempt Resuscitation (CPR) order in the case of [CONDITION(S)] with selective treatment. This form was signed by LPN-B and R86 on [DATE]. There was no signature from a physician. When interviewed on [DATE], at 8:53 a.m. DON stated the admitting nurse meets with the resident to discuss the POLST, educate the resident and determine what their wishes were. The DON stated once that was completed, the physician has a book we put the POLST in for it to be signed. The DON stated the physician comes to the facility on Tuesdays and Thursday and will sign items placed in a book. The DON verified R86 was admitted on [DATE], and did not have the POLST signed as of yet. When interviewed on [DATE], at 1:15 p.m. the facility medical director (MD-A) and R10's physician, stated in the case of newly admitted residents, the facility should first review to see if the resident had come to the facility with a pre-existing POLST. If not, the facility should review any medical orders, or orders from a recent hospital stay for an indication of what has previously been ordered. MD-A stated an expectation for the facility to discuss any pre-existing POLST or pre-existing medical orders with the new resident to ensure their current wishes, and contact the provider of any new orders needed following admission. MD-A stated, she had been receiving a POLST for signature from a nurse or social worker, but thought it was usually the admitting nurse who would send it for review. MD-A stated she was in her office three days per week so any form coming to the office might take ,d+[DATE] hours to come to her attention, but said more recently, the POLST forms were not being sent to the office, but were being placed in a doctor's rounds book at the facility and would not be available for her review until the next date she made rounds. MD-A confirmed that a physician may not sign a blank POLST and allow the facility to fill it in after it was signed. MD-A confirmed that she had done so and stated, that is my error. That is on me. The facility policy titled, Living Will/Advance Directives/Life-Sustaining Treatment Orders dated [DATE], identified residents would be offered an option of completing a Living Will or Advance Directive if they have not already done so, upon admission. A POLST is a set of medical orders that are developed and documented following a resident's (or the resident's designated decision-maker) conversation with his/her physician. The POLST form provides for communication to all health care professionals as tot he resident's wishes. The immediate jeopardy that began on [DATE] was removed on [DATE], when it could be determined that the facility had implemented an appropriate removal plan including correcting/clarifying the orders for R10, R13, R26, R32, R86, R184 and all other residents currently residing in the building. Additionally, the facility reviewed it's policy and identified that going forward, code status orders would be reviewed upon admission, but if a resident was not willing or able to make a decision upon admission, their code status would default to perform CPR in the case of [CONDITION(S)], but resident wishes would be reviewed again within ,d+[DATE] hours and then weekly until a decision had been made. The facility reviewed all current resident's codes status wishes with residents or responsible parties and obtained a physician's order which was placed in the resident charts, and ensured any POLST form was accurate, complete and signed. As well as any conflicting information was clarified and corrected. Facility staff were educated in the policy and procedures for code status and POLST, and a plan was in place to educate any staff prior to working their next shift if not available during initial training. An audit system was designed and the medical director was instructed and updated.

Based on observation, interview and document review, the facility failed to notify the medical provider and obtain wound care orders when 1 of 1 residents (R10) reviewed for pressure ulcers, had developed a new coccyx pressure ulcer, and failed to transcribe and follow orders from a provider for a newly developed heel ulcer. This failure resulted in actual harm when R10's coccyx pressure ulcer became larger and the heel ulcer deteriorated from a stage 2 to a stage 3 ulcer. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Stage I pressure ulcer (An observable, pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) Stage II pressure ulcers (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 blister.) Stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) R10's quarterly Minimum Data Set (MDS) dated [DATE], included moderate cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's MDS indicated he required extensive assistance with most activities of daily living (ADL's) and rejected cares 1-3 days during the 7 day assessment period. R10 was at risk for pressure ulcers, but did not have any current pressure ulcers. R10's care plan dated 9/1/21, included, [R10] has skin breakdown related to immobility, incontinence and decreased sensation. R10's goal was, Resident will develop clean and intact skin. Staff were instructed, Apply protective or barrier lotion after incontinence, .Assist resident to turn and reposition every 2-3 hours. May refuse at times. Staff are to educate [R10] and reapproach. Change incontinence product ASAP after voiding or a bowel movement. Will refuse at times. Staff are to educate and reapproach. Increase out of bed activity as tolerated. Inspect skin integrity every day. Keep bed linen, clean, dry, and free of wrinkles. Keep skin clean and dry. Maintain adequate nutrition and hydration. Provide measure to decrease pressure/irritation to skin: 1)pressure reduction mattress. 2)pressure reduction chair cushion. The care plan lacked identification or staff direction for actual pressure ulcers. R10's progress note dated 10/5/21, identified R10 had been to the, cast room, and was to continue with no weight bearing on the right side and to elevate leg for [CONDITION(S)] control. The note also identified R10 had some loose stools soiling the cast and a call was placed to advise if needs to return to cast room for new cast. According to a wound tracker document in R10's EHR dated 10/6/21, R10 had an open pressure ulcer on his coccyx (lower part of spine/tailbone). No previous documentation in the medical record was found. The wound measurements were written as 2.5 cm by 1 cm with 0.1 cm depth, identified as a stage II. The document indicated R10's pressure ulcer as having both, slough and granulation tissue (Slough is necrotic tissue that does not occur in superficial wounds and is part of the [CONDITION(S)] process generally seen in chronic wounds. Granulation tissue is a sign of tissue regeneration not generally seen in superficial wounds). The form indicated R10's family was notified of the wound, but did not indicate the physician was notified. R10's Cast Visit provider note dated 10/7/21, R10 had been to the Department of Orthopedic Surgery and was seen by a certified nurse practitioner (CNP)-A in order to remove a soiled cast on his right leg. CNP-A wrote, the skin about the lower extremity has one very small superficial skin tear anterior and a developing heel ulcer. The heel ulcer is stable and improving since the last visit. The document included the following directions for care: today patient was placed into a stockinette [dressing similar to a thin sock to provide skin protection] and knee immobilizer, a [MEDICATION(S)] heel dressing with a multi-Podus boot [a product that lifts the heel to prevent pressure]. I recommend that they remove the knee immobilizer and stockinette and check his skin twice daily. They are also to remove the multi-Podus boot twice daily to check his skin. The facility can change the [MEDICATION(S)] heel dressing once weekly. He is to have no pressure on his heel. R10's physician Order Summary Sheet from the electronic health record (EHR) on 10/11/21, did not include any direction or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's treatment administration record (TAR) and medication administration records (MAR) from 10/6/21 to 10/11/21, failed to identify any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's TAR had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This was initialed as being completed on 10/4/21 and 10/11/21. According to a wound tracker document in R10's EHR dated 10/12/21, the coccyx wound was measured at being 2.2 cm by 2.5 cm with a depth of 0.2 cm, still rated as a, stage II pressure ulcer, but condition listed as, worsening. The document did not provide any indication of the cares being provided, but did include, R10 should lay down after meals. The document did not indicate the medical provider was notified of R10's condition. During an observation of morning cares 10/13/21, 7:14 a.m. a nursing assistant (NA)-C and an unidentified NA came into R10's room to provide morning cares. He was laying on his back in his bed. R10 had a scab on his left shin, and had a large plastic leg immobilizer on his right leg, held in place with straps, and a stocking type dressing covered his leg so the skin could not be visualized at that time. There was nothing in place to prevent pressure to R10's right leg except for the splint itself. NAs both stated the immobilizer was not to be removed as he had a fractured leg. NAs assisted R10 to turn towards his right, affected side, so they could wash his buttocks. A square foam dressing, approximately 3 inches by 3 inches and 1/4 inch thick was observed on R10's coccyx, but was not adhered to the skin along the edges and was quite loose along the bottom edge. During cares, R10 began to have a bowel movement which oozed up under the loose edge of the dressing and the unidentified NA removed the dressing. R10's entire left buttock was observed to be slightly pink and mottled. A shallow ulcer about the size of a quarter was observed after removal of the foam dressing. The wound was situated between the left ischium and the coccyx. The top layers of skin were missing and the wound bed was a bright red color. The dressing had a small amount of bloody drainage soaked into the foam. After the NAs finished washing R10's buttocks, they returned him to his previous position on his back. The unidentified NA threw away the soiled dressing, and NA-C said they would need to report to the nurse that R10 needed a new dressing on his wound. Neither NA knew how long he had had the wound on his buttocks. Neither one knew of any other wounds except for the small scab on R10's left shin. When interviewed on 10/13/21, at 8:26 a.m. licensed practical nurse (LPN)-B stated R10 had had the long splint on his leg for approximately a week or more, and said they were not to remove the splint even though it was merely held in place by Velcro straps. LPN-B stated R10 was at risk for skin breakdown due to the application of the splint and it was important to monitor his condition, but said they were only able to check the skin that was not covered by the straps or splint. LPN-B stated she was aware that R10 had a wound on his buttocks and had seen it several days before. LPN-B said she was unable to find a physician's order for the care of the wound, but stated they had been applying a [MEDICATION(S)] dressing to R10's open wound near his coccyx ([MEDICATION(S)] is a trade name and can mean a variety of dressing types, the most common are a foam dressing meant to be held in place with some other type of dressing, or a self-adhesive, occlusive foam dressing). LPN-B stated that when a new wound is identified, or a wound is getting worse, the nurse should report it to the director of nursing (DON) and call the medical provider to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-B stated the removal of R10's dressing that morning, and need for wound care had not been reported to her and she would have been the nurse it should have been reported to. When interviewed on 10/13/21, at 8:51 a.m. a registered nurse consultant (NC) confirmed that R10's physician orders did not include any order for the care of the wound on his buttocks. NC stated the expected process for nurses to follow in the event of a newly identified pressure ulcer were to notify the medical provider for wound care orders, and add new interventions to the resident's care plan. The resident's name should be added to the facility wound list and initial measurements should be taken, followed by weekly measurements to monitor the efficacy or the treatment order. NC confirmed that recommendations for care of a right heel ulcer provided by the orthopedic services cast room on 10/7/21, including removal of the splint for observation and skin care, for care of a right heel pressure ulcer and for no pressure to the right heel had not been transcribed from the paper note into R10's physician's orders and thus these recommendations for care had not been communicated to nursing staff through the EHR, and could not be confirmed to have been provided. According to an interview 10/13/21, 9:17 a.m. DON stated immediately prior to interview DON and NC had gone to R10's room, removed his boot and the dressing applied on 10/7/21. DON stated she had not known about the right heel pressure ulcer prior to 10/13/21 and had not read the recommendations from CNP-A before that day. DON confirmed CNP-A's documentation indicated the wound had been just developing and was healing on 10/7/21, but confirmed the condition of the wound had deteriorated. DON said, It's a stage III by now (pressure ulcers are graded from stage I, superficial redness that does not go away, to stage IV, a deep tissue injury involving tendons, ligament and bone. A stage III wound extends through all layers of the skin into the subcutaneous tissue, but not to tendons or bone). DON stated an expectation for nurses to review any papers accompanying a resident from any medical appointment upon their return to the facility. DON was unable to confirm that CNP-A's recommendations for care were actual orders, but said the nurse on duty should have contacted their medical director (MD)-A who is also R10's physician to verify orders following the appointment. DON stated the nurse should have then entered the orders into the EHR and should also have reported to the nurse manager and the DON, but said this had not occurred. DON stated she had replaced the soiled [MEDICATION(S)] on R10's heel, but had not removed the brace or replaced the stockinette due to pain, saying, I am going to be in touch with (MD)-A about how to proceed. During the 10/13/21, 9:17 a.m. interview, DON described expectations of nursing staff when a new pressure ulcer or wound were identified. DON said the nurse in charge at the time the wound was found was responsible to take measurements of the wound and document this information and a description of the wound in a progress note. DON said the facility did not have any standing orders for wound care so the nurse on duty would need to notify the medical provider in order to get treatment orders for the wound. DON said the nurse should also notify the DON who was responsible to monitor and assess the wound weekly, and document in their pressure injury tracker. DON stated she had become aware of R10's wound on his bottom and had applied a [MEDICATION(S)] dressing; however, DON confirmed she had not notified the physician and did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] When interviewed on 10/13/21, at 1:15 p.m. R10's physician and the facility's medical director MD-A stated she was aware that R10 had a pressure ulcer on his right heel and stated the documentation from CNP-A during the visit to the Orthopedic Surgery Cast Room should have been considered as medical provider orders, and should have been transcribed and followed as orders. MD-A stated there was no problems with the recommendations written by CNP-A and no reason for the facility to contact the facility medical director to review or confirm those orders. MD-A stated she had not seen R10's heel wound, but said, according to CNP-A's description on 10/7/21 and the DON's description on 10/13/21, the condition of the pressure ulcer had worsened since he was seen by CNP-A. MD-A stated an expectation for the facility to notify the medical provider if a resident's pressure wounds were not improving, were worsening or if a new pressure ulcer developed. MD-A confirmed she had not been notified of R10's change in condition until that morning but had previously received a copy of his 10/7/21 cast room visit notes from the Orthopedic Services. Facility did not provide a policy related to notification of wounds to provider, or transcribing and following physician orders.

Based on observation, interview and document review, the facility failed to ensure residents were free from physical abuse for 1 of 2 residents (R4) reviewed for abuse when R4 had received cares in a rough manner and was slapped in the face. This resulted in an immediate jeopardy (IJ) situation for R4 who was totally dependent on staff for all cares and cognitively unable to report any abuse. The immediate jeopardy began on 7/8/21 when it was identified by family member (FM)-D, R4 was treated rough while receiving cares and was identified on 7/15/21. The facility administrator and the director of nursing (DON) were notified of the immediate jeopardy at 6:19 p.m. on 7/15/21. The immediate jeopardy was removed on 7/12/21, and the deficient practice corrected prior to the start of the survey and was therefore Past Noncompliance. Findings include: R4's admission Record indicated following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's care plan included [R4] is a vulnerable adult and is at risk for abuse/maltreatment r/t [related to] age, nursing home placement, Alzheimer's Dementia, and impaired mobility. She is dependent on staff to report episodes of abuse/maltreatment. She is dependent on staff to help remove her from potentially dangerous situations. During an observation on 7/15/21, at 9:45 a.m. R4 was seen resting in bed, an attempt was made to interview R4, but did not answer any questions. R4's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She still has behavioral issues where she will moan repeatedly in the same tone. It is bothersome to other residents and I witnessed that in the lobby today. She is unsteady. She has had slow weight loss which is expected due to her advancing dementia. She does not appear to be any pain [sic]. The note also indicated R4's prognosis was poor. Review of an email from FM-D to administrator dated on 7/8/21, at 10:26 a.m. requesting trained medication aid (TMA)-A not be alone with R4. FM-D included feeling TMA-A has a lack of empathy and no respect for R4. FM-D included TMA-A doesn't hurt her that I can tell but he is very rough with her and she is always extremely upset with the way he treats her. R4's progress note dated on 7/8/21, at 10:45 a.m. a registered nurse clinical consultant (RNCC) wrote: Spoke with [FM-D] regarding concerns she had about care she had observed. She reports she observed [TMA-A] providing care with little empathy and that she did not believe he was hurting [R4], she did feel he was too rough with care. Assured her we will look into the concern and communicate further with her once we have investigated and that caregiver will not be in the facility until investigation is completed. She repeated she did not feel he was hurting her, just that it looked like he was antagonizing on her the video [sic] when helping her dress. During an interview on 7/15/21, at 9:55 a.m. a registered nurse (RN-B ) stated that any reported maltreatment or abuse of a resident should be immediately reported after making sure the person was safe. According to an interview on 7/15/21, at 12:40 p.m. the social worker (SW-A) stated she had not been in contact with FM-D in relation to her allegation of rough handling. SW-A stated that due to the gravity of the situation she was not initially made aware of the incident, but had since been filled in. SW-A stated she was unaware of any previous complaints against TMA-A, but stated residents had said TMA-A was a very large and strong person. During an interview on 7/15/21, at 12:49 p.m. administrator reported FM-D had contacted him on 7/8/21 in the morning, asking for his Email address and indicating she did not want R4 to be cared for by TMA-A anymore. Administrator stated he then received an Email from FM-D with her concerns. Administrator stated that a conference call was then arranged with himself, the director of nursing (DON) and RNCC in attendance. At that time, FM-D told them she had placed a camera in R4's room. FM-D told the facility the camera was motion activated and would capture a minute long video that was stored in a chip in the camera and FM-D could view it remotely. Administrator said FM-D told them she had two videos in which TMA-A appeared to be handling R4 in a rough manner and after seeing the second one, FM-D decided to report the behavior to the facility. The administrator said they had asked to view the videos and FM-D brought her phone in on 7/9/21 and they were able to watch them. The administrator described what he saw as this: TMA-A picking R4 up out of bed like a little kid (administrator demonstrated picking up a child in a cradle hold) and added that is not a typical transfer. TMA-A was getting her dressed and tugging on her arms and her sleeves. TMA-A was putting R4's shirt on; he pulled behind her shoulders, kind of aggressive, and quick (administrator mimed pulling someone suddenly forward with one arm and yanking clothing down). TMA-A could have been more careful. At the end of first video, he looked like he hit her in the face. TMA-A had put a shirt on with a collar up, TMA-A made a motion across her face (administrator acted out the motion, hand open, arm extended and moving rapidly from one side to another in a typical slapping motion). Then she reacted. It's possible he was pulling her collar straight, but it looked like he hit her. The administrator also reported what he had observed when he viewed the second video on FM-D's phone: In that one, it starts out, he had thrown the covers on the bed; it looks like he threw them over her face, but then he whips them off. Then he picks her up in the same way, and the same yanking on the arms and pulling/pushing from the back of the neck forward to get the shirt pulled down. She was being resistant, but that is her norm. Administrator indicated they were not in possession of the videos. He also stated they had called and suspended TMA-A as soon as they were aware of the allegation. Furthermore, administrator stated TMA-A had called them on 7/9/21 and gave his two-week termination notice, saying he was going to work at a different facility where he had been offered more money. On 7/13/21, the administrator stated both he and DON attempted to call TMA-A as they had completed their investigation and they planned to tell TMA-A that his termination was immediate, but he did not respond to their phone calls. DON added that when TMA-A had made the slapping motion in the first video, it looked as though R4 raised her arm as if to protect herself. DON stated R4 was mostly non-verbal with dementia and needed staff to anticipate her needs. She stated it was difficult for R4 to understand others, but would tolerate the provision of cares if people would take their time. She stated they had assessed R4 for any injuries after the incident, but did not see any, and no change in behavior was noted. DON stated one other resident (R5) had complained of TMA-A's care at some time in the past, likely a year or so previous. R5 had said TMA-A rushed through cares and he didn't want TMA-A to wrap his legs anymore as his legs were sensitive and TMA-A's hurry irritated them. According to an interview with R5 on 7/15/21, 4:20 p.m. he was unable to remember any specific concerns he may have had with TMA-A. R5's quarterly MDS assessment dated [DATE] indicated he was mildly cognitively impaired An attempted was made to contact TMA-A on 7/15/21 at 12:01 p.m. and a voice mail was left asking for a return call, but no call was received. Two attempts were made to contact FM-D on 7/15/21 and one on 7/16/21, but there was no answer and the voicemail box was full so there was no ability to leave a message. An Email was also sent to FM-D request a return call with no response. The facility had implemented intervention in response to the situation by 7/12/21; therefore, this is an issue of past non-compliance. Interventions verified as having been implemented by the provider included immediate suspension of TMA-A, assessment of R4's physical condition, police notification, education on abuse prevention and reporting to staff, the initiation of care audits of persons similar to R4, and interviews of alert and oriented residents to continue for a period of two months. TMA-A was terminated from employment. Facility policy titled Abuse Prevention Program, dated February 2019. The policy mission statement indicates, our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The past noncompliance immediate jeopardy began on 7/8/21. The immediate jeopardy was removed and the deficient practice corrected by 7/12/21, after the facility implemented a systemic plan that included the following actions: implemented an action plan to provide for R4's safety, TMA-A is no longer working at the facility, facility reviewed abuse policy and procedures and completed education and training to include staff burn out.

Based on observation, interview and document review the facility failed to prevent an elopement and provide safety for 1 or 2 residents (R1) identified at risk for elopement who successfully eloped from the building and was found outside. This deficient practices resulted in immediate jeopardy for R1. The IJ began on 7/7/21 at 7:00 p.m. when R1 exited the building and staff were unaware until staff saw R1 through a window and alerted staff of R1 being outside. The IJ was identified on 7/16/21 and the administrator and director of nursing (DON) were notified of the immediate jeopardy at 2:23 p.m. on 7/16/21. The IJ was removed on 7/19/21, but noncompliance remained at the lower scope and severity level of D, isolated with the potential to cause more than minimal harm. Findings include: R1's Admission Record, included diagnosis of Alzheimer's disease, anxiety, disorder,bilateral [CONDITION(S)] of knee (bony degeneration of both knee joints) and type 2 Diabetes Mellitus. R1's care plan dated 8/30/19 with revision, for self-care deficit r/t [related to] cognitive deficits, impaired mobility as evidenced by R1 reliance on staff to assist with bathing, grooming and dressing. Intervention included R1 was independent in wheelchair locomotion. R1 is an elopement risk as evidenced by hx [history] of attempts to leave the building unattended, wanders aimlessly, impaired safety awareness and disorientated to place d/t [due to] Alzheimer's dementia. Interventions included: observe for comments about finding the truck as this may signal he will attempt to go into parking lot to look for his truck. Date initiated 07/08/2021; BEHAVIOR HISTORY: May try to leave facility unescorted (FYI), Redirect as necessary, approach resident from the front and talk to resident in a calm reassuring manner. R1 will wear wander guard (test functional status per protocol). Educate family/visitors to advise when leaving patient following visit, encourage socialization with others and provide recreational programming, Engage in activities/tasks to keep occupied. R1's Progress note dated 6/7/21, 10:03 a.m. indicated staff responded when hearing R1's alarm and found him in his bathroom on the toilets after self-transferring. The note indicated he had not used his call-light and, has poor personal safety awareness and believes he is able to be independent in room . R1's Progress note dated 6/11/21, 10:30 p.m. indicated R1's alarm was going off and his wheelchair (W/C) was observed outside a public bathroom and R1 was observed standing in the restroom. R1's Physician's Progress note by medical doctor (MD-D) on 6/29/2021 R1 was being seen for recertification of his nursing home stay. The note indicated he was suffering a lower respiratory infection at time of MD visit and that R1 was noted to have Alzheimer's dementia requiring 24-hour supervision. He needs a lot of redirection and guidance as he tries to leave the building. R1's Progress note dated 7/7/21, 7:30 p.m. indicated, Resident escaped out the front door. The alarm did not go off. Staff was alerted that resident was outside. Staff went outside and brought him in and did head to toe assessment [sic] and found no injuries. Nurse notified family, DON and DR. Maintance [sic] came and checked alarm and new Wanderguard was put on resident. According to a Nursing Home Incident Report Summary, date of incident 7/7/21, 7:15 p.m. a description of the incident was: resident was observed outside of window in parking lot by window. Staff responded and escorted back into building. Upon returning to building, wander guard system alerted, upon exiting, between 7pm and 7:15 p.m., the wander system did not trigger. Action taken to protect the resident was listed as: maintenance came to building and checked the wander system with multiple ankle bracelets. Replaced ankle bracelet and attached additional bracelet to frame of wheelchair. Both of which were validated as operational. A request was made for the facility investigation and evaluation of R1's 7/7/21 elopement incident. A document was provided titled Critical Event Analysis and Action Plan Worksheet signed on 7/8/21. The document indicated facility concentrated on the malfunction of the alarm, but failed to explore any issues related to supervision of R1 on the evening of 7/7/21 or interventions provided aside from the Wanderguard on that evening. The document indicated actions to take in relation to monitoring Wanderguard tags for placement and function, but stated only that nurses would be educated about that action. The document failed to include any all staff education or update to R1's care plan aside from the Wanderguard. A Wandering Risk Assessment was completed by the facility on 7/8/21 with a score of moderate risk for wandering and no listed score for elopement risk. The assessment tool failed to identify that R1 made multiple attempts to leave the facility or that he had succeeded in leaving on 7/7/21, although it continued to identify a care plan focus area of elopement. A previous Wandering Risk Assessment completed on 3/1/21 resulted in an identical score with no comment on R1's attempts to leave the facility. On 7/15/21, 9:15 a.m. R1 was observed to be leaving the dining area of the facility independently and moving towards the main entrance of the facility. R1 was observed to have Wanderguard tag attached to the right side of his W/C and wearing one on his left ankle. A staff person approached and said to R1, we can ' t go in there right now, how about you stay out here with us. R1 asked, where can I go then? Staff brought him to watch television about 10 feet from where he had been previously. On 7/15/21, 10:05 a.m. R1 was observed to have moved from the television area to the beginning of the West Wing of the building, about 20 feet from the main entrance. He was unable or did not respond to any questions at that time. On 7/15/21, 10:45 a.m. R1 was observed to have moved from the West Wing across the front lobby area to sit in a small hallway 20-30 feet from the main entrance and was napping in his chair. According to an interview on 7/15/21, at 12:12 p.m. a licensed practical nurse (LPN-A) stated on 7/7/21, R1 was sitting in the start of the East Wing headed away from the lobby. LPN-A stated it was a busy time of the shift and she was on her way to assist a different resident at about 7:00 p.m. Shortly afterwards she stated staff were alerted by a resident that they had seen R1 outside of the facility. LPN-A reported she immediately went to get him, and he was found in the parking lot approximately 200 feet from the entrance. R1 had moved along the driveway the direction delivery trucks go, but had turned up into a small parking area where the facility bus is parked. When questioned by LPN-A about his reason for being outside, R1 replied, I was trying to get on the bus. LPN-A stated the Wanderguard alarm system had not sounded when R1 left the building, but did sound when R1 was assisted back in through the front entrance. LPN-A stated it was important to check the function of the Wanderguard tag, and it should be checked every shift; however, prior to the 7/7/21 incident they had not been checking it that often, nor were they documenting when they did check them. LPN-A said in her estimation R1 would attempt to get out the front entrance daily, and there were times when she was working that they would hear the front alarm sound multiple times during a shift when R1 would attempt to leave. According to an interview 7/15/21, 12:20 p.m. a family member (FM-B) stated about R1, he's like an escape artist. During an interview 7/16/21, 11:40 a.m. LPN-B stated she was aware of R1's elopement risk, but was unsure of any new interventions to keep him safe, first saying they may have moved him to a different room, then added she remembered he was now wearing two alarm tags instead of one. She stated she had not received any recent training related to elopements, but usually only works every other weekend. She stated she thought they were to check the Wanderguard alarms daily and that this was not a new practice. According to an interview 7/16/21, 11:42 a.m. a nursing assistant (NA-A) said she was aware that someone in the building had recently eloped but did not know any specifics. NA-A said she had not had any training on elopement since she had been in orientation (May 2020), and stated a resident who eloped from the building was at risk of being out in the street and getting hit by a car or of having a fall. NA-A said it was important for them to know where residents were at all times. NA-A reported that she was not a regularly scheduled employee, but worked on-call. According to an interview 7/16/21, 11:50 a.m. a registered nurse (RN-A) stated she worked at two other facilities and had training on what to do in case of elopement at those facilities, and thought she had training here after an elopement sometime in the past year, but she was unsure of the date. RN-A said nurses were to check to be sure the resident's Wanderguard tags were in place, but said they had not been checking the function of the tags to sound the alarm. During an interview 7/16/21, 12:33 the DON described the facilities education and training program, stating they used an on-line education system called Relias and all staff received a monthly assignment to complete; however, she was unsure if the Relias training included any content about elopement. DON also said she was unsure if part time staff completed their assigned training. DON said the facility provided elopement drills. DON said they tried to have the elopement drills done on a variety of shifts and that all frontline staff were expected to participate in those drills. DON also stated they had a communication sheets that would provide information to staff on any changes in facility and information such as recent elopement, and that it was the responsibility of all nursing staff to read those if they had not been working recently. DON stated they had initiated training following R1's elopement on 7/7/21 although indicated some front line may not have received the training. According to an interview 7/16/21, 1:35 p.m. the administrator stated an expectation for all staff, from all departments to have been re-trained on elopement whenever a resident left the building unescorted. Administrator stated that training should include a review of the facility policy and procedures as well as training on how to check Wanderguard tag placement and how to replace them if needed. Administrator confirmed this day he was just now training LPN-B, NA-A and RN-A on the policy and procedures of elopement. He said, yes, this was the first time those staff had been here for a while so I was talking to them about elopement and eye-protection. I guess they hadn't been in the building since the previous concern [R1's elopement]. When asked why he was completing the education now the administrator stated, he needed to make sure he gave the elopement education to dietary staff and therapy staff. The administrator confirmed that he had not yet done so and said, our first priority is for care staff as they have the most interaction. The administrator confirmed the facility had been performing elopement drills and stated an expectation for all staff in the building to be involved in a drill when it was being performed. He stated all staff from all shifts should receive training and feel comfortable in the expected response. The administrator reviewed documentation of a facility drill held 5/19/21 and confirmed that the participants, the maintenance director, DON, MDS-C, social worker and a therapy staff were not front line staff, and the document did not indicate all staff in the facility had participated in the drill. A request was made for documentation of completed training related to R1's 7/7/21 elopement. On 7/15/21 a document was received titled training log/in-service-date of training 7/9/21. Content check placement of Wanderguard. The objective was listed as, nursing staff are to check placement of Wanderguard's each shift and document on TAR [treatment administration record]. No further education information was provided, and the sheet was signed by the DON and four nurses, and one trained medication aid. No NAs were listed, no other department staff had signed attendance. On 7/16/21 the document was provided again in the afternoon and at that time had three additional nurses and three NAs added to the training list. A request was made for evidence of staff completion of Relias training modules; however, the DON stated on 7/16/21 that their Relias modules did not contain content on elopement. Policy titled, North Shore Healthcare, Elopement dated 7/7/2015. The policy purpose was listed as to safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill will be held quarterly. The document indicated that once a patient/resident was located a head to toe assessments should be done and the social service designee should assess for emotional distress. Furthermore, the document indicated the resident should be provided one to one supervision until further arrangements could be made to ensure the resident's safety. The immediate jeopardy that began on 7/7/21 was removed on 7/19/21 when it could be verified the facility had implemented an appropriate removal plan including re-assessment of R1's elopement risk, a review of policies and re-education to all staff on the elopement policy, the initiation of, and continued plan for elopement drills and audits of resident wandering risk assessment and care plans. Additionally, a Quality Assurance committee met to discuss and review the plan on 7/17/21.

Based on observation, interview and document review, the facility failed to complete a thorough fall investigation to determine root cause, and failed to implement appropriate interventions, to minimize and/or prevent falls with injury for 2 of 3 residents (R26, R27) reviewed for falls. The facility's failure resulted in harm to R26 when she sustained a head injury as a result of a fall. Findings include: R26's facility Admission Record dated 6/21/19, included [DIAGNOSES REDACTED]. R26's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R26 had severe cognitive impairment. The MDS also indicated R26 required extensive assistance of one staff member for bed mobility, dressing, personal hygiene and required extensive assistance of two or more staff for transfers and toileting, was frequently incontinent of bladder, was always continent of bowel, and was not ambulatory. R26's fall incident reports were reviewed dating back to 4/24/19. The record identified R26 had sustained four falls prior to a fall 5/3/19, that resulted in major head injury requiring hospitalization and surgical interventions. The record indicated R26 had sustained six subsequent falls following readmission to the facility on [DATE]. During an observation on 6/17/19, at 1:12 p.m. R26 was seated in her wheelchair in a common area with her eyes closed, and slightly leaning forward. R26 was observed to have [MEDICAL CONDITION]/scabs on her nose and forehead with surrounding yellow/blue bruising. At 2:29 p.m., R26 was observed to be sitting up on the edge of her bed. The bed mattress was observed to be bolstered (a perimeter mattress), and the bed was observed in the low position, with no mat on the floor. At 6:41 p.m., R26 was observed laying in bed with the bed in the low position, her wheelchair was next to the head of the bed and was observed not to have an anti-rollback device in place. During an observation on 6/18/19, at 7:55 a.m. R26 was sitting on the edge of her bed without a safety alarm sounding. From outside the door to the room, R26 could be heard saying help me in a quiet voice. At 8:03 a.m., R26's movements sounded the safety alarm, and within 2 minutes, an unidentified aide responded to the alarm and assisted R26 to her wheelchair. During an observation on 6/19/19, at 8:10 a.m. R26 sat in her wheelchair in the lobby, with her eyes closed leaning forward. R26 was observed to intermittently open her eyes, lift her head, then close her eyes again. R26 was observed to keep her head down and leaned forward. During the observation, the social worker approached and asked R26 whether she wanted anything to drink, R26 didn't answer but asked if the bus was coming. At 8:19 a.m., R26 was wheeled into the dining room. Review R26's current Care Plan included: (R26) has impaired mobility and is at risk for falls related to dementia, weakness, and abnormal gait/mobility. Interventions included: Ensure she is wearing appropriate footwear when up (shoes, gripper socks, slippers). Family will provide non-skid shoes. (Initiated 8/17/18); Encourage to transfer and change positions slowly. (Initiated 10/1/18); Encourage resident to be in common areas as tolerated to increase observation. (Initiated 10/16/18, with review 6/20/19); Provide assist to transfer and ambulate as needed. (Initiated 2/6/19); Reinforce need to call for assistance. (Initiated 2/6/19); Encourage to leave door open when in room during the day to allow unobtrusive visual checks for safety. (Initiated 2/13/19, with review 4/24/19); Therapy eval and treat as ordered. (Initiated: 4/3/19); Bed Mobility: Independent. She can lay down, sit up, turn, reposition, and boost up in bed without assistance. Bed is to be placed at appropriate height so that feet are flat on the floor when sitting on the edge of the bed. (Initiated 4/4/18); Report development of pain, bruises, change in mental status, ADL(activities of daily living) function, appetite, or neurological status [REDACTED]. (Initiated 4/23/19); Use wheelchair as needed for fatigue (Initiated 4/24/19); Have commonly used articles within easy reach. (Initiated 4/24/19). A 4/27/19 Incident Report indicated R26 had an unwitnessed fall without injury. The note indicated R26 was noted to be sitting on the floor between her bed and another bed in the room. The report indicated the floor was dry but R26 did not have her shoes on. Vital signs were taken and the resident's temperature was recorded as 99.8 degrees Fahrenheit. Immediate actions taken included: Resident assisted off the floor and to bed, and appropriate notifications were made. Predisposing factors identified included: Impaired memory, gait imbalance, improper footwear, transferring self, and responding to toileting needs. A corresponding progress note dated 4/27/19 at 2:05 a.m., indicated R26 had fallen and included: Remind resident to use call light when needing help. Also suggested to staff to toilet resident on rounds. The incident investigation was reviewed and lacked documented assessment of the root causes of the fall such as, were current interventions in place at time of fall; investigation of why R26 may have been attempting to ambulate, and the investigation documentation failed to address any why the resident was not wearing appropriate footwear. In addition, although the progress note 4/27/19 at 2:05 a.m., had included suggestion for R26 to be toileted at night, this intervention was not added to the care plan. During an interview on 6/20/19, at 9:30 a.m. R26's fall record was reviewed with registered nurse consultant (RNC)-A. RNC-A indicated the investigation was not thorough, causal factors were identified however, lacked root cause analysis. RNC-A stated because of R26's cognition the intervention to remind her to use the call light was not appropriate and confirmed the care plan was not revised to include modifications to R26's toileting plan. RNC-A stated when a resident had a fall, the nurse responding filled out an incident report, and attempted to identify root causes of the fall, and put immediate interventions in place to prevent or/decrease the risk of reoccurrence, then revised the care plan. RNC-C stated incidents were then reviewed by the interdisciplinary team to determine any further assessment/evaluation required, or any other interventions that might be approrpriate to put in place. An incident report dated 4/28/19 at 2:08 p.m., indicated R26 had an unwitnessed fall without injury. The report indicated a nurse was called to the room by the therapist due to resident found sitting on the floor outside her bathroom door. Immediate action taken was identified as including: Vitals taken, temp 101.7 degrees Fahrenheit, neuro checks started because R26 stated she hit her head, transferred R26 off the floor, walked to recliner, appropriate notifications completed. Predisposing factors included: impaired memory, weakness, gait imbalance, call light improperly used, ambulating without assistance, and improper footwear. R26's progress note dated 4/28/19, at 3:20 p.m. indicated the physician had been called and had given an order to either send R26 to the emergency room , or to collect a urine sample. The notes indicated R26's family had elected to treat her in the facility. A subsequent progress note at 4:59 p.m. indicated a urine specimen was collected and R26 received a dose of [MEDICATION NAME] (antibiotic). The record lacked documentation of any immediate interventions implemented to prevent or reduce the risk falls other than initiation of the antibiotic. There was no further documented evaluation of the resident's failure to have appropriate footwear on. An incident report dated 4/29/19 at 1:00 a.m., indicated R26 had an unwitnessed fall with no injuries. The report indicated R26 was yelling for help and was found sitting on the floor next to her bed, wearing shoes and had her walker next to her, call light within reach, no trip hazards, and floors were dry. Immediate interventions identified included: Resident was assessed for injuries and abnormalities, vital signs taken and noted elevation in temperature, neuro within normal limits, assisted off the floor, assisted back to bed, and administered Tylenol. Predisposing factors included: confused, gait imbalance, impaired memory, recent illness, current infection, weakness, dementia, and transferring self. Another incident report dated 4/29/19 indicated R26 had an unwitnessed fall without injury. The report indicated R26 was found to be on the floor at 1:30 p.m. Immediate interventions identified included: Resident assessed; was alert and oriented, neuro checks stable, vitals stable, Tylenol was administered, and appropriate notifications completed. Predisposing factors included: gait imbalance, impaired memory, recent illness, weakness, dementia, and transferring self. R26's care plan indicated a scoop mattress (perimeter edged) was implemented as a fall intervention. In addition, a progress note dated 4/29/19, at 4:04 p.m. indicated R26 had a room change to be closer to the nurse's station. R26's progress note dated 4/30/19, at 10:29 p.m. indicated R26 required 2 people to transfer and was very fearful of falling. The progress note also included, has pressure mat alarm on in bed and when in easy chair to alert staff when she is restless or trying to transfer self. During an interview on 6/20/19, at 9:30 a.m. RNC-A referenced the record and verified the incident reports lacked a thorough investigation, and identified causal factors without identification of possible root cause other than acute illness. RNC-A also stated implementation of an immediate intervention was not evident after the fall on 4/28, and the scoop mattress was added 4/29/19 as a result of R26 rolling out of bed. RNC-A also confirmed R26 had been moved closer to the nurse's station for closer observation 4/29/19. R26 had an Incident Report dated 5/3/19 at 2:30 p.m. which indicated R26 had an unwitnessed fall resulting in a bruise to the left lower leg. The report indicated R26 had been discovered in her room sitting on the floor with her back resting against the front of the chair, an alarm was seen on the seat of the chair, and the resident was observed rubbing the back of her head. Immediate action taken included: notified doctor, alarm replaced with different alarm and neuro and vitals initiated. Predisposing factors included: fall alarm improperly placed/not functioning, dementia, and ambulating without assistance. Review of R26's progress notes did not include any further analysis or assessment. Based on the documentation it could not be ascertained if the alarm had sounded, or what action plan was put in place to prevent any potential problems with the alarm. R26 had another incident report dated 5/3/19, at 4:30 p.m. which indicated R26 had an unwitnessed fall, and no injury was noted on the incident report. The note indicated R26 was found sitting on the floor in the hallway at the doorway to her room with her back against the wall, and her feet straight out. The incident report included, Resident is charted to be independent with walker. Resident is very unsteady and when she was assisted to stand, she had to be against the wall until her w/c (wheelchair) could be brought to her .Resident ambulating without assist. Alarm sounding. Resident was unaware she had fallen. Resident then stated she was going to make the morning coffee like she always does. Alert to self. Confusion noted. Immediate action included: assessed resident and vitals taken. Predisposing factors included: fall alarm sounding, fall alarm on and properly functioning, rugs/carpeting, confused, gait imbalance, drowsy, weakness dementia, ambulating without assist, using walker, wandering, hallucination/delusions. R26's corresponding progress note dated 5/3/19, at 4:30 p.m. indicated R26 complained of her head hurting. The note indicated the physician was called and gave orders to send R26 to the emergency room for evaluation if the family wanted. The progress note verified R26 had been transferred to the emergency room . A progress note dated 5/4/19, at 9:31 p.m. indicated the hospital had contacted the nursing home to report R26 had sustained a sub-dermal hematoma, 1.7 cm (centimeters) in diameter, and the plan was to be evaluated on Monday for possible surgery. Review of the 5/3/19 incident record lacked evidence a root cause analysis of the fall had been completed. During an interview on 6/20/19, at 9:30 a.m. RNC-A reviewed the record and indicated there was no evidence of care plan revision following R26's fall 5/3/19. R26's Progress notes indicated R26 had returned from the hospital on [DATE]. RNC-A stated when someone returns from the hospital typically a care plan review was completed to ensure appropriateness of interventions R26's progress note dated 5/20/19, at 10:35 p.m. indicated R26 had an unwitnessed fall at 3:30 p.m. that resulted in a goose egg on her right side of forehead The note indicated R26's family did not want her to be sent in for an evaluation in the emergency room . The note further indicated R26's physician would not provide an order for [REDACTED]. The corresponding incident report dated 5/20/19, indicated R26 had been heard yelling for help, and staff saw the resident laying on her side on the floor holding her head. Immediate action taken included: vital signs, appropriate notifications made, and range of motion was completed. The predisposing factors included all the previously identified factors from other incident reports. R26's progress note dated 5/21/19 indicated R26 recieved 1:1 supervision, had two person assist for transfers, a bed/chair alarm was turned on, and the bed was in the lowest position. During an interview on 6/20/19, at 9:30 a.m. RNC-A reviewed the record and indicated the 5/20/19 incident had not been thoroughly investigated. RNC-A said although causal factors had been identified, a root cause analysis was not. RNC-A further stated immediate interventions were not identified, and there were no care plan revisions. However, progress notes indicated on 5/21/19, R26 was supervised 1:1 by staff. R26's progress note dated 5/22/19, indicated family member voiced concerns in regards to falls and therapy was going to be discontinued related to failure to thrive. A subsequent progress note on 5/22/19, indicated [MEDICATION NAME] (an antipsychotic medication) was ordered for every day at 4:00 p.m. for anxiety and agitation. R26's progress note dated 5/24/19, at 1:50 p.m. indicated R26 had an unwitnessed fall, staff heard the resident fall in room and found her on her knees facing the nightstand. The note indicated R26 had stated she wanted to get up, and also indicated, No alarm sounding .chair alarm was not turned on. The note also indicated R26 had a bump on the right side of her head so ice was applied. No corresponding incident report was completed for this incident and there was no evidence an investigation was initiated to determine causative factors. In addition, there was no evidence the care plan was reviewed to ensure interventions, including use of alarms were identified. During an interview on 6/20/19, at 9:30 a.m. RNC-A reviewed R26's record and stated the root cause of the 5/24/1/9 fall was the alarm was not on, and the immediate intervention was to ensure alarms were on and the bed was maintained in the low position. A progress note dated 6/7/19, indicated R26 was anxious in the morning, attempted to self-transfer multiple times, required 1:1 with redirection, and complained of pain lower extremities. The note indicated R26 had received [MEDICATION NAME], later became anxious, the physician was notified and increased R26's [MEDICATION NAME] 12.5 mg as needed to twice per day. R26's progress note dated 6/10/19, at 4:15 a.m. indicated R26 had an unwitnessed fall in her room. R26 was found lying on her back, blood coming from her nose, with skin tears noted to forehead at hairline and bridge of nose. The note indicated R26's oxygen saturations were 86%. The note also indicated R26 had a skin tear to the right arm, chin was red, and nose had began to swell and discolor; R26 was sent to the emergency room for further evaluation. A subsequent progress note at 10:07 p.m. indicated when R26 returned from the emergency room , neuro checks were initiated and R26 was kept in the commons area where she could be watched, and safety alarms were turned on. During an interview on 6/20/19, at 9:30 a.m. RNC-A reviewed the record and indicated R26 had intermittent increased supervision, and reinforced care plan intervention of increased supervision. RNC-A stated no fall mat had been in place at the time of the fall, but an intervention for fall mat use was added 6/19/19. R26's progress note dated 6/17/19, at 12:14 a.m. indicated R26 had an unwitnessed fall that resulted in the scab on her nose re-opening and bleeding as well as a new small skin tear on the forearm. The note indicated staff had heard somebody yelling out and the alarm had sounded. R26 was found laying on the floor in the lounge area close to the nurses' station. The note indicated vital signs were obtained and neuro checks were initiated. R26's corresponding incident report dated 6/16/19 included the details from the progress note and predisposing factors were the same as previous Incident Report documents. Immediate action taken included: R26 was assisted back to wheelchair with two people. However, there was no root cause analysis documented to identify any predisposing factors, or review of interventions in place at the time of the fall. During an interview on 6/20/19, at 9:30 a.m. RNC-A reviewed the record and stated the care plan was revised to have the bed in the lowest position when the mat was added to the care plan on 6/19/19. RNC-A indicated the family has voiced concerns about the number of falls, stated hospice will be bringing in a Broda chair on 6/21/19, that would help with positioning and comfort. RNC-A indicated the facility was also working with hospice to get a volunteer to sit with the resident to prevent falls. During a subsequent interview at 3:30 p.m. RNC-A confirmed R26 had not been assessed for a toileting plan and/or schedule. RNC-C stated ever two hour toileting schedule would be implemented until established until an individualized toileting schedule could be implemented, in order to reduce the risk of self-transfers related to toileting needs. During an interview on 6/20/19, at 11:45 a.m. nursing assistants (NA)-B and NA-D stated R26 had a safety alarm in chair and bed, bed in low position, and did not have a fall mat next to bed. Both stated they check on R26 when they go past her room. NA-B stated R26 seemed to get agitated when she was tired, and would have body movements back and forth. NA-B stated R26 was more restless after she came back from the hospital and they'd had to increase 1:1 time with her. NA-B indicated staff would bring her to the lobby when aides could not constantly watch her and the nurse would watch her. NA-B and NA-D stated R26 used to be independent with walking up. During an interview on 6/19/19, at 12:29 p.m. hospice licensed practical nurse (LPN)-A stated an awareness of R26's falls. LPN-A stated R26 had agitation, the facility and hospice agency were adjusting medications to ascertain what was causing agitation and further stated the [MEDICATION NAME] had not really been effective. LPN-A stated the hospice agency was trying to get someone to sit the resident to increase supervision and meet R26's needs until a different wheelchair that would help with positioning and comfort could be obtained on 6/21/19. During an interview on 6/20/19, at 2:53 p.m. hospice registered nurse (RN)-D stated she was R26's hospice case manager. RN-D stated that the facility and hospice agency had talked about R26's falls in an interdisciplinary meeting and additional safety measures could be implemented. RN-D stated things are very dynamic and fluctuating. We attempted to adjust pain medication because we thought the restlessness was pain related, and we've found the [MEDICATION NAME] not to be very effective. RN-D stated sometimes there didn't seem to be enough staff, and it was sometimes hard to find any staff because they would be in a different room. During an interview on 6/20/19, at 12:49 p.m. R26's family member (FM)-2 stated she very concerned about the number of R26's falls and felt extremely frustrated. FM-2 stated on 6/14/19, she was at the facility visiting from 10:30 a.m. until 12:30 p.m., and R26 started getting restless and asked to go to the bathroom. FM-2 stated she turned on the call light, after 20 minutes of waiting FM-2 went to go find somebody. FM-2 stated the nursing assistant (NA) apologized and told her there was only two aides working and the NA would be down in a minute to help. FM-2 stated she waited with R26, R26 attempted to stand up several times. FM-2 stated after that she found a staff member and helped R26 to the bathroom. FM-2 indicated the total wait time was about 40 minutes. FM-2 stated after R26 went to the bathroom she calmed down and was not restless anymore. FM-2 stated R26 did not have a loud voice and was not able to yell out for help to go to the bathroom, so the only option was to fall on the floor because then staff would show up quickly. FM-2 stated on another visit R26 was in the lobby in her wheelchair asleep and bent over in her wheelchair where she could have done a forward roll onto the floor; FM-2 sat her back up. FM-2 then stated she routinely visits, seemed very short staffed, and believed if there was adequate staffing some of R26's falls could have been avoided. FM-2 stated when the facility called to notify of a fall, the facility would not discuss what happened or new interventions to prevent and/or reduce the risk of falls. FM-2 stated she didn't think to ask them for details of the fall. FM-2 stated R26 stated she talked to administration about her concerns the other day. R27's facility Admission Record dated 6/21/19, indicated R27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R27's admission Minimum (MDS) data set [DATE], indicated R27 did not have cognitive impairment. The MDS indicated R27 required extensive assistance of two or more staff for bed mobility, transfers, toileting, and required extensive assistance of one staff for personal hygiene, dressing, and eating. The MDS indicated R27 had balance impairment during transitions, was not steady and only able to stabilize with staff assistance. The MDS further indicated R27 had falls in the last month prior to admission and had falls after admission. R27's record was reviewed and lacked a baseline care plan. R27's hospice care plan dated 5/21/19, indicated R27 was at high risk for falls. Interventions included educate on maintaining proper lighting, management of oxygen equipment and tubing, organization of environment to prevent falls, and home safety and fall prevention. R27's care plan for falls was initiated on 5/30/19. The care plan indicated R27 was at risk for falls related to cognition, unaware of safety needs, deconditioning/weakness and history of falls. Interventions included: follow therapy recommendations (5/30/19), offer periods of rest, or offer to lay resident down after meal (5/30/19), place call light or communication device within reach (5/30/19), provide bedside commode for elimination needs (6/5/19), review information on past falls to attempt to determine cause of falls for prevention and to minimize injuries (5/30/19), and call don't fall sign in room (6/5/19). During an observation on 6/18/19, at 4:35 p.m. R27 sat in recliner with feet up. R27 call light was on the left side of the chair, and R27 had a slipper on the right foot only. R27's admission progress note dated 5/17/19, at 2:45 p.m. indicated R27 was at risk for falls, a fall mat was placed after the family member left. R27's progress note dated 5/20/19, at 7:03 a.m. included Resident noted to have a fall no new injuries noted due to fall resident slept well all night. R27's progress note dated 5/20/19, at 11:02 p.m. indicated the note was a late entry for 5/20/19, at 10:54 p.m. The note included, Resident fell out of bed or was trying to get out of bed. No one saw the fall. Writer was notified by another resident who was passing by his room. No injury was noted. Based on the record and documentation it could not be ascertained if R27 had two separate falls on 5/20/19 and or had a fall previous to 5/20/19, that was being followed up on. Corresponding incident report was requested and not received for a fall. R27's progress note dated 5/26/19, at 10:32 a.m. indicated R27 had an unwitnessed fall with no injuries. The note indicated R27 had been found on his knees leaning on his bed; R27 had stated that he was trying to get into bed and slid out of the wheelchair. Corresponding incident report dated 5/26/19 included the aforementioned documentation. Predisposing factors included: gait imbalance, weakness, and transferring self. The immediate action taken included: offer resident to lie down. R27's progress note dated 5/28/19, at 9:58 p.m. included, Resident is on follow up for: fell on the (sic) 5/27/19. The note included, Keep remind resident to call for help. Call light within reached (sic), bed in lowest position. Based on the documentation in the record it could not be ascertained if R27 had a fall on 5/27/19; progress notes did not mention a fall on that day. R27's progress note dated 5/30/19 included, Hospice was notified of resident's unwitnessed fall on 5/29/19. Based on the documentation in the record it could not be ascertained if R27 had a fall on 5/29/19; progress notes did not mention a fall on that day. R27's progress note dated 6/6/19, at 2:01 p.m. indicated R27 had an unwitnessed fall that resulted in a dime-sized bruise on right buttock and hit head. The note indicated R27 was calling out for help and the activities director found him sitting on the floor in front of bed facing the doorway. R27 stated that he was attempting to use the bathroom, call light was not on at the time of the fall and he had been in the recliner. The note also indicated R27 was re-educated on call light and a sign was placed Call don't fall sign in his room. Corresponding incident report dated 6/6/19 included the aforementioned documentation. Predisposing factors included; weakness, recent illness, transferring self, and responding to toileting needs. The immediate action taken included the intervention identified in the progress note. During an observation on 6/20/19, at 7:16 a.m. registered nurse (RN)-C was in R27's room. R27 laid in bed, was not up near the head of the bed, heels rested directly on the mattress, pillows were not observed along R27's sides. Nursing assistant (NA)-B entered the room, R27 was boosted to the top of the bed and NA-B placed a pillow along R27's right side and underneath his legs. During an interview on 6/20/19, at 7:22 a.m. NA-C stated R27's fall interventions included mat on the floor, pillows on both of his sides, and check on him frequently every time we pass the room to make sure he isn't on the edge of the bed or restless while he is in his wheelchair. During an interview on 6/20/19, at 12:30 p.m. family member (FM)-4 indicated visited often with R27. FM-4 stated the reason why it was decided to place R27 in a facility was because R27 fell a lot at home and didn't think it was safe anymore. FM-4 stated R27 often times would forget and was not aware of his limitations and wouldn't ask for help. FM-4 indicated that falls were still a concern and that it was worrisome. During an interview on 6/20/19, registered nurse consultant (RNC)-A reviewed R27's record and corresponding incident reports. RNC-A verified lack of baseline care plan and initiation of fall care plan until after the falls occurred. RNC-A the incident reports and/or documentation lacked a thorough investigation to determine root cause of the fall and a baseline care plan should have been developed and implemented. RNC-A indicated there was an incident report filled out on 5/20/19, (requested not received). The facility's 5/20/19 Fall Prevention and Management Guidelines included: The facility will maintain a fall prevention and management program. In as much as it is in power of the facility, the facility will prevent and/or manage the resident's risk for falls. The facility's guidelines included Key Elements of the Fall Prevention and Management Program, which included Assessments. The Assessment category included: a fall risk assessment would be completed upon a fall, and Continence protocol as indicated, Toilet schedule: implement as needed, assessments for mental status, pain management, Review record of [DIAGNOSES REDACTED]. Pharmacological assessment and review, Environmental , Analysis/assess level of risk assessment. The guideline also included approach of Dynamic Treatment Plan Specific interventions based on results of fall assessments and individual resident's preferences. Evaluation Complete post fall evaluation after every fall or near fall or assisted fall. A fall investigation or Post Fall Assessment must be completed. These need to include: physical assessment, all contributing factors to the fall, medication changes , mental status changes , new diagnoses. The guideline also indicated to collectively review, identify, and analyze trends in resident falls.

Based on observation, interview and record review, the facility failed to implement appropriate interventions including supervision, eating assistance and/or appropriate textured food/fluids in order to prevent choking/aspiration of fluid and foods for 2 of 2 residents (R12, R51) who had been identified as at risk. The facility's failure to implement these interventions resulted in an immediate jeopardy situation for R12 and R51. The immediate jeopardy began on 7/13/15 when it was first observed the facility failed to provide the necessary supervision, needed assistance, and food consistency for R12 and/or R51 during meal service observations. The facility administrator, a corporate executive administrator, and a clinical services specialist from the corporate office were notified of the immediate jeopardy at 5:32 p.m. on 7/14/15. The immediate jeopardy was removed on July 16, 2015 but noncompliance remained at the lower scope and severity level of D - isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R12 and R51's medical records were reviewed. Speech language pathologist (SLP) and physician progress notes [REDACTED]. According to R51's medical record, R51 had been treated for [REDACTED]. At the time of admission, R12 had been identified as having a [DIAGNOSES REDACTED]. Although these resident's had specific interventions in place for supervision, assistance, and modified diets, the facility failed to ensure these interventions were implemented consistently. R12 was observed during the evening meal on 7/13/15, at 6:22 p.m. to sit at the dining room table independently drinking hot chocolate with no staff supervision. R12 was observed to begin to cough very loudly after a drink of the hot chocolate and the hot chocolate was observed to run out of his mouth. Nursing assistant (NA)-C, who had been passing out wipes to other residents in the dining room came over to R12, handed R12 a wipe and left the area. NA-C did not ask R12 if he was okay, or whether he was having difficulty swallowing the hot chocolate. At 6:52 p.m. on 7/13/15, R12 again began to cough while eating. This time the cough was more violent and a pinkish/red colored liquid spewed from his mouth. There were no staff available in the immediate area, R12's face turned red as he continued to cough. Registered nurse (RN)-B came to the table about 2 minutes after the coughing had started and at 7:00 p.m., RN-B removed R12 (in his wheelchair) from the dining room while he continued to cough. R12 was taken out to the lobby. RN-B then re-entered the dining room and asked about what R12 had been served. RN-B stated the red apple sauce R12 had received was considered pureed fruit, and that the substance in the glass was a thicker than pudding thick fluid. At 7:04 a.m., R12 was observed seated alone in the lobby at a small table against the wall. He had stopped coughing and his face color had returned to normal. R12 was noted to be facing towards the wall making him less easily visible by staff who might be in the area. RN-B had his food tray brought out and placed in front of him. Again R12 was left unsupervised with his meal. No staff were in the direct vicinity of R12, a licensed practical nurse (LPN)-A, was observed standing at a medication cart 15-20 feet away with her back to R12. At 7:11 p.m. R12 remained in the lobby area alone. A clinical psychologist (CP)-A was observed to approach R12 to remove his dinner tray at 7:13 p.m. At that time, the surveyor asked CP-A whether she'd had any formal training to assist residents with eating. CP-A stated she had not had any training for assisting residents to eat, but was removing the resident's tray because the surveyors were watching the resident. During a breakfast meal observation on 7/14/15 at 9:03 a.m., R12 was observed to sit at the dining room table with his breakfast tray in front of him. There was no staff sitting with the resident or observed to be supervising the resident. R12 took a bite of cream of wheat, held it in his mouth for approximately 3 seconds and began to cough. Cereal was observed to drip out of his mouth and run down his chin. At 9:05 a.m. NA-C was observed to come over to R12 and whether he wanted a napkin. NA-C was heard to instruct R12 to tuck and swallow. NA-C stayed at R12's table until 9:07 a.m. when she left R12's table and sat down at another table to feed a different resident. At 9:09 a.m. As R12 continued to eat his breakfast, he was observed to take several bites of food and hold it in his mouth for long periods of time before swallowing. R12 did not use the chin-tuck procedure while eating nor did staff monitor R12 while he was eating/chewing/swallowing or cue him to use the chin-tuck procedure. NA-C did not return to R12's table until 9:13 a.m. During an interview on 7/14/15, at 9:24 a.m. Registered Dietician (RD)-A explained the baseline consistency for pureed food is applesauce, but verified the consistency of food and fluids for R12 should be pudding thick consistency. RD-A stated thickener should be added as needed to R12's food and fluid consistency was prepared as the physician had ordered. RD-A also stated, people who have aspiration precautions, including R12, need direct supervision in the dining room. During observation of lunch on 7/14/15 at 12:34 p.m., R12 sat at the table with a spoon in his mouth. No staff were present at the table or in direct view of R12 during this time. R12's meal tray included pureed carrots served at a honey thick consistency. During an interview on 7/14/15 at 2:27 p.m., dietary assistant (DA)-A stated the dietary staff determined the consistency of R12's food by sticking a spoon in the food, and if the spoon stands straight up, it would be considered pudding thick. DA-A acknowledged she had served R12's carrots without having verified the consistency. Following the facility's notification of the IJ, R12 was observed at 6:10 p.m. on 7/14/15 at the supper meal. R12 was seated at the dining table and was moaning loudly. RN-B was sitting between R12 and R51. R12 had attempted to take a heaping spoonful bite of cranberry juice. Although RN-B instructed R12 to take smaller bites, she did not instruct the resident to tuck his chin and swallow. Instead, R12 was observed to hold the cranberry juice in his mouth for approximately 7 seconds before swallowing. R12 took another bite that was smaller, chewed the bite, and was again observed to hold it in his mouth for several seconds. R12 took four more bites and each time held the food for several seconds in his mouth before swallowing. Throughout the observation, RN-B did not encourage R12 to use the chin-tuck technique. At 6:32 p.m. RN-B picked up R12's spoon and attempted to feed him. At 6:33 p.m. During the observation RN-B was also observed to assist R51 with eating. While RN-B was assisting R51, R12 resumed feeding himself. When RN-B returned to assist R12, she was observed to put food on the spoon and place bites in R12's mouth while there was still food in R12's mouth. R12 had food running out of his mouth, and was observed to hold food in his mouth at the same time. No instruction was provided for R12 to use chin-tuck then to swallow. At 6:39 p.m. R12 was observed to take a bite and to hold it in his mouth. R12 cried out Ahh and then began to cough. R12 then closed his mouth for a few seconds and when he opened his mouth again, a large amount of tan colored liquid drained out of his mouth onto his clothing protector. At 7:15 p.m. R12 was removed from the dining area and set in the lobby area. During an interview with RN-B at 7:21 p.m. on 7/14/15, RN-B told the surveyor R12 had experienced a brief choking episode in the dining room. RN-B stated she and two nursing assistants had intervened. RN-B stated R12 had several bites of food in his mouth at the time. When the surveyor inquired, How did he get that much food in his mouth? RN-B stated, He was eating right along and I thought he was swallowing but he didn't swallow. I was watching pretty close. On 7/14/15, at 8:01 p.m. the director of nursing and administrator were informed of the concerns noted during the supper meal with R12. During an observation of the breakfast meal on 7/15/15, at 8:20 a.m. R12 had been sitting at the dining room table with no staff member present at the table. Although R12 was served the correct consistency beverages, when R12 grabbed his spoon and attempted to remove a heaping bite of cranberry juice from the glass, RN-B walked by the table and only gave a verbal cue for R12 to take smaller bites. RN-B then walked away from the table without assisting R12 to take smaller bites of food, and without ensuring staff were present with R12 to supervise as he ate his meal. At 8:26 a.m. the surveyor brought to the attention of RD-A and RN-A that there was no one to supervise the resident as he attempted to eat the thickened drinks he had been served. At 8:27 a.m. RN-A was observed to sit down between R51 and R12 and stated, I am sitting here because the drinks were prematurely delivered to the table . At 8:36 a.m. R12's meal was placed in front of him, and as he independently took a bite, he experienced a coughing incident. At that time, RN-A gave verbal cues to R12 to follow the chin tuck procedure. At 8:39 a.m. RN-A was observed to assist R51. At 8:41 a.m. NA-G sat down next to R51, however at 8:45 a.m. NA-G moved to the other side of the table to assist another resident, then walked away from the table to wash her hands. When NA-G left the table, RN-A also got up and moved to the other side of the table to assist the other resident leaving R12 without any assistance. NA-G returned to the table, however sat on the other side with her back to R12. After R12 had taken a couple of bites of food, copious amounts of saliva were observed to drain from his mouth. At that point the surveyor intervened and informed RD-A of the concern with R12 not being supervised while independently eating. RD-A got RN-B to sit with R12 at 8:58 a.m. until R12 had completed his meal. R12 was admitted to the facility on [DATE] according to the facility admission record with [DIAGNOSES REDACTED]. R12's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R12 had moderate cognitive impairment with a Brief Interview for Mental Status score of 10 which indicates confusion. The MDS indicated R12 had unclear speech, but responded adequately to simple direct communication. In addition, the MDS indicated [REDACTED]. R12's quarterly nutrition assessment dated [DATE], indicated he had a swallowing disorder and required thickened liquids. The assessment included, .Puree diet with pudding thick liquids, no white rice, no milk with meals .r/t (related to) ongoing difficulties with swallowing. The record also indicated R12 had received speech therapy services from 2/18 through 5/6/15, for medical [DIAGNOSES REDACTED]. 4/6/15- R12 choked four times during the session, had delayed swallowing of 2-3 seconds. In addition, the note indicated education was given to staff on holding spoon in mouth for 2 seconds to elicit swallow, adding moisture to meats if needed, and providing smaller bites. 4/7/15- education was given to staff to present food from the resident's right side and to use the spoon for liquids. 4/8/15-required maximum (max) amount of verbal cues to use chin tuck, displayed anxiety related to coughing during meal, and one episode of coughing related to staff feeding too fast. In addition the treatment note read, Pt (patient) does not appear to be a good candidate for self-feeding, at this time continue POC (plan of care) with increase in staff education to decrease risk of aspiration. 4/9/15- The note indicated R12 held medications in his mouth and required maximum verbal and visual cues to swallow. The note also indicated the resident had 3 coughing episodes and then became anxious. The speech therapist orders dated 4/10/15, were communicated on a form entitled Rehab Recommendations and included: Pureed diet with honey thick liquids, Patient (R12) must have staff sitting by him at meals, cue for patient to tuck chin on swallow, clear mouth prior to next bite, use a spoon for drinks, and take small bites (help with bite size as needed). On 4/13/15 speech therapy had changed the order from honey thick liquids to pudding thick liquids. 4/15/15 - .education was given to staff for cuing compensatory strategies (these would include taking small bites and sips, alternate bites and sips, avoid slurping and drinking through straws, sitting upright, chin tuck also known as head flexion, etc.) to assist R12 in swallowing safely, R12 had increased coughing when he fed himself, and education was given to staff 'on need for increased supervision during meals' in case of aspiration or airway blockage. 4/23/15 - .maximum anterior oral spillage. Coming out right side. Max pocketing on right side. Verbally walked him through swallow (technique). R12's care plan was provided by the facility on 7/14/15. The care plan indicated R12 had difficulty swallowing related to a cardiovascular accident. The care plan interventions included for staff to use the physician ordered diet of pureed with pudding thick liquids, no white rice, and no milk with meals. The care plan further instructed staff to encourage to follow SLP (speech language pathologist) recommendations, monitor coughing during meals, eating assistance of 1, allow rsdt (resident) to attempt to feed self with staff assist as needed. The care plan had not been revised to include the SLP's specific recommendations identified on 4/10/15. R51 was observed at 9:13 a.m. 7/14/15, during the breakfast meal to be sitting at the dining table eating his meal independently. R51 was observed to have honey thickened fluids, scrambled eggs and oatmeal. There was not a staff person at the table to supervise R51. R51 was observed to take a bite of oatmeal and to chew. Almost immediately R51 began to cough. R51 was observed to take another bite of oatmeal and again coughed several times. Facility staff in the dining room were assisting other residents and did not check on R51 when he had these coughing episodes. At 9:19 a.m. a nursing assistant, (NA)-C, first came to R51's table but did not intervene for R51, but assisted one of his tablemate's with eating. During an evening meal observation on 7/14/15, at 6:13 p.m. R51 was observed seated at the dining room table drinking what appeared to be honey thickened hot chocolate. Registered nurse (RN)-B sat between R51 and R12. At 6:23 p.m. R51's food, which was observed to be the appropriate consistency, was placed in front of him. From 6:23 p.m. to 6:28 p.m. R51 ate independently without any verbal cues from RN-B. R51 was observed to take large bites, and to take additional bites before swallowing what was in his mouth. At 6:28 p.m. RN-B turned to face R51 and instructed R51 to take smaller bites. At that time R51 moved the food to center of R51's plate and removed food that had fallen into R51's lap with a fork, and placed it back onto R51's plate. At 7:01 p.m. R51 started to cough and his face turned red. RN-B instructed R51 he needed to stop coughing before taking another bite. R51 waited until the coughing had stopped then took a drink, and again coughed several times but did not turn red. At 7:08 p.m. R51 took another drink and again began coughing, however staff did not give any verbal cues to use the chin tuck procedure prior to swallowing. At 7:11 p.m. on 7/14/15, the director of nursing (DON) brought R51 out of the dining room in his wheelchair and placed him in front of the television and gave him a tissue. R51 coughed twice, as the DON walked away. At 7:13 p.m. R51 was observed to start coughing again, and after approximately 30 seconds his face turned red, clear liquid drained from his mouth, and R51 used the tissue to wipe his face. The coughing ceased after R51 wiped his face. During an interview with RN-B at 7:21 p.m. on 7/14/15, following the evening meal, RN-B stated, .towards the end of the meal he (R51) started sputtering, so I patted him on the back and he coughed and got it out of his throat, so he's alright, you can hear it cleared. When asked how she could tell it had cleared, RN-B stated, You can tell that he cleared it because you couldn't hear it gurgling anymore. During an observation of the breakfast meal on 7/15/15, at 8:20 a.m. R51 was again observed sitting at the dining room with no staff members present at the table. R51 was served the beverages of the correct consistency which he began to drink independently without staff supervision. RN-B was observed to walk by the table and provide verbal cues to R12, but did not offer any cues or assistance to R51. At 8:26 a.m. on 7/15/15, RD-A was questioned about R51 having received his beverages prior to staff availability to assist him. RD-A stated she was not sure how that had happened. At 8:27 a.m. RN-A sat between R51 and R12 and stated, I am sitting here because the drinks were prematurely delivered to the table. At 8:36 a.m. R51's meal was placed in front of him and at 8:39 a.m. NA-G sat next to the R51 who had helped himself to a heaping spoonful of French toast. When R51 had put the bite in his mouth, RN-A who was also sitting at the table looked at NA-G and said, Tell him (R51) to take smaller bites. NA-G looked at R51 and told him to take smaller bites. At 8:45 a.m. NA-G moved away from R51 to assist his tablemate. R51 continued to eat independently without verbal cues. NA-G then walked away from the table to wash her hands. At the same time, RN-A got up and went to the other side of the table to assist R51's tablemate. When NA-G returned to the table, she sat at the opposite side from R51. At 8:58 a.m. RN-A continued to assist the tablemate (R12) with her back to R51. From 8:45 a.m. until 8:58 a.m. R51 was observed to eat independently, and was observed to take large amounts of food with each bite taken. At 8:58 R51 started coughing and his face turned red, RN-A suggested at that time that it would be good to get a therapy referral for adequate chair positioning while eating. R51's record was reviewed and the admission face sheet indicated R51 had been admitted to the facility on [DATE]. In addition, according to the facility admission record, R51's [DIAGNOSES REDACTED]. A Physician Visit note dated 5/12/15, indicated R51 had been seen that day because of a cough and low-grade temperature. The physician's exam revealed crackles in right mid lung field and occasional expiratory wheeze. The physician documentation indicated R51 had been diagnosed with [REDACTED]. A nursing progress note dated 5/23/15 read, .is able to fed (feed) self after set up, is at the feeder table for supervision. Eats slowly, is on nectar thick liquids. R51's annual Minimum Data Set ((MDS) dated [DATE], indicated R51 usually made self-understood however, had difficulty communicating some words or finishing thoughts, but was able if prompted and given time, to usually be understood by others. The MDS indicated R51 may miss some parts or intent of messages but comprehended most conversation. R51 was identified by the MDS to have a brief interview for mental status (BIMS) score of 11 which indicated mild cognitive impairment. The MDS further indicated R51 required limited physical assistance from one staff member for eating. R51's nutritional assessment dated [DATE], identified a history of swallowing disorder. The assessment indicated the resident had a physician prescribed diet of mechanical soft with puree meets and vegetables with honey thick liquids, no added salt, no magic cups. The nutritional assessment summary note included, .Resident has had some changes to diet d/t (due to) an occurrence (sic) of aspiration pneumonia in May (2015).Resident is assisted at meal times now. The record indicated R51 had received speech therapy from 3/3 through 4/17/15, to decrease signs and symptoms of penetration/aspiration, according to the Speech Therapy Progress and Updated Plan of Care form dated 3/3/15. Speech therapy notes dated 3/19/15, included a written recommendation to change R51's diet from nectar thick liquids to honey thick liquids. On 3/24/15 speech therapy had made an additional recommendation to change R51's diet to mechanical soft with pureed vegetables and meats, and honey thick liquids. The recommendation included, Supervision needed at meals, make sure eggs are pureed not scrambled. Speech therapy progress notes dated 4/17/15, indicated R51 utilized, safe swallowing strategies with 90% accuracy with minimal verbal cues. R51's care plan provided by the facility on 7/14/15, identified a problem area of swallowing difficulties related to dysphagia and aspiration pneumonia. The care plan interventions directed staff to provide a diet of honey thick liquids, puree meats and vegetables, no magic cups, and to provide assistance at meals as the resident would allow. In addition the care plan indicated R51 was to sit at the 'assisted dining table'. The care plan had not been revised to include the specific speech therapy recommendations identified on 3/24/15. During an interview with dietary assistant (DA)-A at 2:27 p.m. on 7/14/15, DA-A stated she was not aware R51 was not supposed to have scrambled eggs, but should have received eggs of a pureed consistency and did not. During an interview with NA-K on 7/14/15 at 2:15 p.m. she stated, Usually every day there are just two (identified R12 & R51) that cough, (R12) more often that (R51) .R51 does good on his own eating, I don't need to sit by him when he eats. During an interview with NA-C on 7/14/15 at 2:15 p.m. she stated, R12 needs and should get direct supervision- he needs to be told to tuck his chin and swallow, he holds food in his mouth, what is happening right now is there isn't enough staff members to feed 10 people so we have to basically go back and forth. There are only two aides in the dining room during meals, sometimes management will help during the day but not during the evening. A nurse might help pass trays but they never are in the dining room during the whole meal service. NA-C stated both R12 and R51 cough at every meal at least 3 to 4 times. NA-C explained R51 needed supervision and cueing then said, He's not as bad as (R12) in reference to coughing. During an interview on 7/14/15 at 2:19 p.m., NA-H was asked about R12 and R51's coughing during meals. She stated often R12 and R51 have coughing/choking episodes while eating. NA-H stated the coughing usually occurred because they both (R12 and R51) eat too fast. During an interview on 7/14/15 at 7:15 p.m., NA-I stated she normally worked the evening shift and verified there are usually only two NA's in the dining room. NA-I stated a nurse might be able to help if they were done passing medications, but stated most of the time it is just the two aides. During an interview on 7/14/15, at 7:21 p.m., NA-J stated she worked on the evening shift and that there are usually just two staff in the dining room to assist all of the residents that need assistance with eating. NA-J stated the nursing assistants have to move back and forth between the two tables. NA-J also stated R12 likes to keep shoveling food in his mouth and takes big bites and that is usually when food comes up. NA-J then explained prevention measures for R12 and R51 were to give verbal cues. A facility policy Eating Support was reviewed and did not identify guidelines to assist residents who required changes to textured diets or supervision of residents who were at risk for choking and/or aspiration. A policy pertaining to aspiration precautions was requested, however on 7/17/15, at 9:56 a.m. RD-A and DON stated the facility did not have a policy. The immediate jeopardy that began on 7/13/15, was removed on 7/16/15, when it was determined the facility had completed assessments for R12 and R51 to rule determine their aspiration risks, had revised the residents' care plans to include current speech therapy recommendations, it was verified staff had been re-educated to understand the importance of supervision of the residents during meals, and had been re-educated to resident specific interventions for prevention of aspiration, and observation of a meal reflected appropriate implementation of interventions. However, noncompliance remained at the lower scope and severity level of D - isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm due to the facility's population including residents with swallowing difficulty.