Every finding on record at Amethyst Health of Wausau

Based on observation, interview and record review the facility did not ensure a clean homelike environment for 3 resident areas in the facility and 7 resident (R10, R11, R13, R14, R15, R16 and R6) rooms and/or bathrooms.-The facility's carpeted resident hallway down [NAME] hall was observed to be soiled. -The facility's carpeted resident lounge area [NAME] Sunroom on [NAME] hall was observed to be soiled. -The facility's main resident dining room Fireside room area was observed to be soiled. -R10, R11, R14, R15, R16, and R6's personal rooms were observed to be soiled and were not cleaned daily.-R16 and R13's bathroom had what appeared to be free standing dirty water around the base of the toilet with urine stains/odors in the bathroom.-R8 voiced concern regarding a spider in the dining room. This is evidenced by: Facility policy titled, Cleaning and Disinfecting Residents' Rooms, dated 08/2013 states in part: .General Guidelines: Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.Environmental surfaces will be disinfected or cleaned on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.Example 1On 08/03/26 at 11:03 AM, Surveyor observed [NAME] Hall. Surveyor observed R10's room to be unkempt with a used napkin on the floor located near the trash can, a pile of crushed chocolate candy crumbs near the bathroom door, cereal crumbs and a pill under the bedside table, and a used glove under R10's bed. Surveyor asked R10 if they were aware of the pill on the floor. R10 stated they were unaware of the pill on the floor.On 08/03/26 at 11:32 AM, Surveyor interviewed R10 regarding the cleanliness of the facility and how often housekeeping is in the room to clean. R10 stated R10's room always has dirt and trash on the floor. R10 reported housekeeping cleans sometimes but not every day. Surveyor asked R10 if they have ever asked for their room to be cleaned. R10 stated they never ask because eventually the room will be cleaned. R10 stated the room could be cleaned more frequently and the garbage on the floor is unsightly.On 08/03/26 at 1:01 PM, Surveyor interviewed Certified Nurse Assistant (CNA) I and asked who is responsible to keep resident rooms clean such as R10's. CNA I reported it is a joint effort between all CNAs, nurses, and housekeeping. CNA I reported when CNA I sees things on the ground in resident rooms, CNA I will clean it up. CNA I was unaware R10's room had debris and trash on floor. On 08/03/26 at 11:36 AM, Surveyor showed Director of Nursing (DON) B, who was working as the acting Registered Nurse (RN) on [NAME] Hall, R10's floor in room. Surveyor pointed out all the debris, candy, and medication on the floor and asked DON B if R10's room was clean. DON B stated it the room was not clean, and medication should not be left on the floor. Example 2On 08/03/26 at 11:06 AM, Surveyor observed the main dining room Fireside room off from Rotunda lounge to be soiled. Surveyor noted food crumbs on the floor, along the baseboards, and heat registers with dust and food debris. Surveyor noted spiders and dead beetles littering the Fireside room. The Surveyor observed a large spider web near the front entrance of the dining room. The spider web contained a quarter-sized spider and several dead bugs. Additionally, a large spider web with dead bugs was observed near the exit door in the dining room.On 08/03/26 at 1:29 PM, Surveyor completed a walk through to check areas of concern with housekeeping. Surveyor entered the main dining room Fireside room to observe if dining room was cleaned. Surveyor observed debris and dead bugs still along the floorboards and under tables.Surveyor observed R8 self-propelling to a table with a puzzle. A large spider web was observed near the table where R8 was located. R8 pulled up to the table and suddenly was startled by the spider web. R8 screeched, Ahhh. Surveyor approached R8 and asked if everything was ok. R8 immediately pointed and stated, Look at that big web. Surveyor asked R8 about the cleanliness of the facility. R8 stated there are bugs all over, but that spider web has to go. R8 stated, It is big. Example 3On 08/03/26 at 11:15 AM, Surveyor observed a carpeted hallway down [NAME] Hall which is used by residents and staff. Surveyor observed shredded paper, an opened alcohol wipe package, dirt, food crumbs, liquid stains, live and dead bugs, throughout the carpeted hallway. Surveyor observed spider webs and bugs at the exit door across from R13's room. On 08/03/26 at 11:16 AM, Surveyor observed a carpeted resident lounge area [[NAME] Sunroom] on the [NAME] Hall to have spider webs and live bugs throughout the area. Surveyor observed spider webs covering one of the chairs in the sunroom. Surveyor observed puzzles, magazines, and cards on the tables for resident activities. Surveyor observed a garbage can full of trash from fast food restaurants, and gloves.Example 4On 08/03/26 at 11:19 AM, Surveyor observed R11's room and found used gloves under R11's bed. Surveyor observed a blue wrapper lying on the middle of R11's floor in room. Surveyor observed R11's brush lying on floor near bed. On 08/03/26 at 1:31 PM, Surveyor went back to R11's room and observed R11's room to still have used gloves under their bed. Surveyor observed a blue wrapper lying on the middle of R11's floor in room. Surveyor observed R11's brush lying on floor near bed. Example 5On 08/03/26 at 11:20 AM, Surveyor observed a used medicine cup, a straw wrapper, and food crumbs on the floor in R14's room. Example 6On 08/03/26 at 11:26 AM, Surveyor observed [NAME] Hall exit door to have spider webs in the corners with dead beetles in the spider webs. Example 7On 08/03/26 at 11:30 AM, Surveyor observed paint chipping down R15's wall in R15's room with paint flakes in a pile against the wall behind R15's bed. Surveyor observed debris and crumbs all over R15's room around bedside table and bathroom door. Example 8 On 08/03/26 at 1:41 PM, Surveyor entered R16's room and observed a used plastic cup under R16's bed and debris all over the floor that appeared to be food crumbs. Surveyor asked R16 if they were concerned with their room having trash on the floor and under the bed. R16 stated they are concerned with their toilet not working and that the bathroom is dirty. Surveyor observed R16's bathroom to have an odor of urine and observed urine stains all over R16's bathroom floor. R16 stated they do not use the bathroom anymore because R16 must share with R13 and it is disgusting. Surveyor asked R16 what bathroom they use. R16 stated staff have given R16 their own bathroom down the hall in an unoccupied room. R16 stated the toilet has not been flushing correctly and always leaks all over the floor. Surveyor observed what appeared to be a blackish grey stain with free standing liquid all around the base of the toilet. Surveyor asked R16 how long the bathroom has been in this condition. R16 stated the bathroom is dirty and not very functional with constant leaking for a month or so. Example 9On 08/03/26 at 1:45 PM, Surveyor observed food crumbs and debris along the entire floor, between R6's bed, window, and bathroom. Surveyor interviewed R6 and asked if they were concerned with all the crumbs of food and debris found on their floor. R6 shrugged shoulders and said, Well what are you going to do. Surveyor asked R6 how often housekeeping comes into room. R6 stated they are unsure.On 08/03/26 at 11:41 AM, Surveyor interviewed Housekeeper F and asked about the normal routine for day-to-day cleaning. Housekeeper F stated they have been working short staffed for a while but usually have 2 housekeepers on duty every day. Housekeeper F stated all resident rooms are cleaned daily. All halls, such as [NAME] and [NAME] Hall, have hand railings, fixtures, bathrooms, and nurse's stations cleaned. Surveyor asked Housekeeper F how often the hallways and the sunrooms are cleaned. Housekeeper F stated they are unsure how often but probably weekly. Surveyor asked Housekeeper F to explain how Housekeeper F knows what to clean each day. Housekeeper F pulled their task list and showed Surveyor a task list which states in part: -Twice daily wipe high touch areas. -Keep hall floor clear of debris. -[NAME] and [NAME] Hall (Step 5 and step 8). Step 5 procedures include: Pull trash/replace liner, horizontal surfaces, vertical surfaces, dust mop/sweep, damp mop, and step 8 vacuum. Surveyor asked Housekeeper F their check off list for the day. Housekeeper F stated the check off list is not finished yet as their shift is completed at 2:30 PM. Housekeeper F stated, I will provide my check off list once completed. On 08/03/26 at 2:47 PM, Surveyor received Housekeeper F's check off list. Housekeeper F's check off list dated 08/03/26, states in part, [NAME] Hall dining room, and rooms 2-5,10, 14, 19, 87-93 were checked off as cleaned. Wiped handrails for [NAME] Hall. Rooms 1, 6-9,11-13, 15-18, 75-86 were not checked off as cleaned. Vacuuming [NAME] and [NAME] Hall was not checked off as cleaned.Surveyor requested the last 3 months of housekeeping check-off lists.On 07/17/26-07/26/26, Housekeeping check off list not completed due to housekeeper on vacation. Housekeeper F's check off list dated 07/27/26, states in part, [NAME] Hall dining room, and rooms 75-93 were checked off as cleaned. rooms [ROOM NUMBERS] checked off as cleaned. Rooms 1-13, 15-18 not checked off as cleaned. Vacuuming [NAME] and [NAME] Hall was not checked off as cleaned. On 08/03/26 at 3:34 PM, Surveyor interviewed Maintenance Director J and asked to tour the building with Surveyor. Surveyor showed Maintenance Director J the [NAME] hallway, [NAME] sunroom, Fireside dining room, [NAME]/[NAME] resident rooms R6, R15, R10, R11, and R14 as well as R13 and R16's bathroom. Surveyor asked Maintenance Director J what their expectation is for cleaning the high traffic areas. Maintenance Director J stated, I did not know about all the spider webs and that resident rooms and bathrooms were not being cleaned appropriately. Maintenance Director J reported facility is working on performance improvement and has started by hiring new housekeeping staff and trying to find a different manager to manage housekeeping. Maintenance Director J stated it does not excuse the mess around the building. Surveyor reviewed Housekeeper F's check-off list and asked Maintenance Director J to explain how often resident rooms are to be cleaned. Maintenance Director J stated the expectations are that all residents' rooms are cleaned daily. Maintenance Director J reported facility is aware housekeeping is having staffing issues and that Maintenance Director J cannot be the manager of housekeeping and director of maintenance. Surveyor asked for Maintenance Director J's process for deep cleaning commons areas like the [NAME] sunroom and Fireside dining room since Maintenance Director J and Surveyor observed spider webs and food crumbs. Maintenance Director J stated deep cleaning is supposed to occur weekly and should be checked off on the housekeepers' daily task list. Surveyor asked Maintenance Director J to clarify what is on the daily check-off list. Maintenance Director J stated they would need to grab a check-off list. Maintenance Director J grabbed a check-off list and reviewed with Surveyor. Maintenance Director J stated housekeepers clean all resident rooms daily. Maintenance Director J reported [NAME] Hall should be vacuumed and mopped but does not specify how often to clean. Check-off list does not specify [NAME] Hall either, but Maintenance Director J stated housekeepers know it applies the same. Maintenance Director J stated some housekeepers will document the [NAME] Hall complete as well. Maintenance Director J stated the check-off list does not have any direction on deep cleaning the main dining room [Fireside] or dusting for spiders and dust. Maintenance Director J stated the check-off list only covers cleaning tables and floor as needed. Surveyor asked Maintenance Director J if they knew when the last time anything was deep cleaned. Maintenance Director J stated they would need to gather the last couple of months check-off lists and review. Maintenance Director J stated this is why it is too much for Maintenance Director J to manage because there should be no reason for spider webs and debris all throughout the building.

Based on observation, interview and record review, food was not prepared in accordance with professional standards for food service safety. Surveyor observed a large hole in the kitchen ceiling. The hole was partially covered with plastic. Insulation and chunks of paint were chipped and hanging from the ceiling above food prep areas. This deficient practice has the potential to affect all 36 residents currently residing in the facility and who receive their meals from the main kitchen.Findings include:Facility policy titled, Construction and Renovation-Maintaining Air Quality and Safety, dated 12/06 states in part: .Purpose: To prevent and control airborne opportunistic infections (e.g., Legionnaire's Disease, healthcare-acquired Aspergillosis) caused by air handling systems or due to construction, renovation, remediation, repair, and demolition. 1. All new and renovated air handling systems will be designed following the American Institute of Architects standards and state or local requirements. 5. Air duct grills will be cleaned regularly, according to the facility maintenance schedule. 6. The administrator will ensure that all construction, renovation, remediation, repair, and demolition projects are reviewed to determine the need for dust-control procedures and barrier precautions.On 08/03/26 at 1:36 PM, Surveyor interviewed Anonymous Staff P (AS) who complained about the facility performing construction in the facility kitchen without properly covering surfaces in the kitchen where staff prep food. AS P stated maintenance tore open the kitchen ceiling and had insulation all over the floor and counters without proper barrier precautions. Surveyor asked AS P when the facility opened the kitchen ceiling. AS P stated the kitchen ceiling was torn open last Thursday on 07/30/26. Surveyor asked how AS P knows that barriers were not placed correctly in the kitchen. AS P shared a photo taken of two men working on the ceiling in the kitchen and Surveyor observed insulation all over the counter and floor in the kitchen. AS P stated the facility continued to prep and serve food out of the kitchen while construction was going on and continues to still serve food out of kitchen without it being thoroughly cleaned.On 08/03/26 at 2:16 PM, Surveyor entered the facility kitchen and observed the kitchen ceiling. Surveyor observed the following:~A hole in the ceiling. ~ Forced air was coming out of the ceiling rattling the plastic wrap that was hanging from the hole.~Insulation particles sitting on top of the plastic.~Insulation particles on the ground in the main area of kitchen following out to the back door of the kitchen.~Insulation sticking out in a large gap between sheet rock on the ceiling.~A quarter size insulation particle on kitchen countertop near the active coffee maker machine.~ Gray plastic hanging out of ceiling near the kitchen exit door above dry storage shelves.~White paint chips falling on floor throughout the whole kitchen above prep and serving areas. On 08/03/26 at 2:20 PM, Surveyor interviewed Dietary Manager (DM) Q and asked DM Q when the facility tore open the ceiling in the kitchen. DM Q stated the kitchen ceiling was torn open a couple weeks ago. Surveyor asked DM Q to observe kitchen floors and counters behind the coffee maker where Surveyor observed insulation particles. Surveyor asked DM Q if the kitchen was deep cleaned after maintenance opened kitchen ceiling. DM Q stated they have not had a chance or time to perform a deep cleaning as they are working short staffed in the kitchen.On 08/03/26 at 2:25 PM, Surveyor had Nursing Home Administrator (NHA) A and Regional NHA B follow Surveyor in kitchen to ask about the hole in the ceiling. Surveyor interviewed Regional NHA B and asked when the kitchen ceiling was open and has the kitchen been in operation since the ceiling was opened by maintenance. Regional NHA B stated the kitchen ceiling was having some issues a couple weeks ago. The maintenance man from the sistering facility came in and opened the kitchen ceiling to figure out the cause of the leaking and paint chipping throughout the kitchen ceiling. Surveyor asked if the maintenance crew placed protective barriers to protect contamination of kitchen prep areas while they team was working. Surveyor asked why there was insulation floating around in the kitchen after a couple weeks. Regional NHA B stated the maintenance crew had to come back again last Saturday on 08/01/26 and re-open the kitchen ceiling again. Surveyor showed NHA A and Regional NHA B the insulation particles that were behind the coffee maker and on the floor of the kitchen. Regional NHA B asked DM Q if they had deep cleaned prior to prepping and serving food. DM Q stated to NHA B they did some cleaning but must have missed the insulation particles on the counter and floor. Surveyor asked Regional NHA B if kitchen was clean. Regional NHA B stated the facility has been trying to work with contractors to get quotes to fix the ceiling and not sure how else staff are supposed to prep and serve food to residents until the issue is fixed. Regional NHA B stated the facility will try the rehab the kitchenette for prepping and serving residents until facility finds a solution.On 08/03/26 at 2:45 PM, Surveyor interviewed Maintenance Director J and asked what issues or concerns were found with the kitchen ceiling and when it was opened. Maintenance Director J stated they had nothing to do with the kitchen ceiling construction and told Regional NHA B they would not participate in the construction of the kitchen ceiling because they felt the kitchen ceiling needed to be fixed by a contractor and not the maintenance crew that came in from the sistering facility. Maintenance Director J stated they were not present for the construction of kitchen ceiling but Maintenance Director J understands insulation sticking out of the ceiling, chipped paint falling, and insulation particles all over the kitchen counters and floors is not acceptable. Maintenance Director J stated they will tape up the crack on ceiling where the insulation particles are hanging from, cover all paint chips and cracks with cardboard until the facility can figure out a better solution.On 08/04/26 at 8:15 AM, Surveyor entered facility kitchen and observed duct tape over the chipping paint and cardboard stapled to part of the opening in the ceiling. Staff replaced the plastic covering the hole in the ceiling with new plastic and duct taped one side leaving one side open. On 08/04/26 at 8:45 AM, Regional NHA B came into conference room and provided Surveyor with a third-party restoration service that came in the evening on 08/03/26 to perform a deep cleaning of the facility kitchen. Regional NHA B reported to Surveyor facility has been calling local contractors to come look to see how fast the kitchen ceiling can be repaired.Surveyor reviewed facility's third-party restoration services invoice, dated 08/03/26, which indicated third-party restoration arrived around 8:30 PM, and performed emergency restoration and cleaning of the affected kitchen area. Restoration services included removal and disposal of loose insulation materials, removal of paint chips and other construction-related debris, removal of drywall dust, drywall fragments, and miscellaneous particulate matter. Detailed cleaning of food preparation surfaces, equipment exteriors, shelving, and surrounding work areas. HEPA vacuuming of affected surfaces to capture fine airborne particles. Wet wiping and sanitizing of all impacted non-porous surfaces. Floor cleaning and debris removal throughout the affected kitchen space. Final inspection to verify all visible contaminants and restoration debris had been removed. Based on restoration completed and final inspection, third-party restoration services certified that the facility's affected kitchen area have been restored to a clean and safe condition. The kitchen is deemed suitable to resume normal operations, including preparation, cooking, and serving of food.

Based on observation, interview, and record review, the facility did not ensure effective pest control. This has the potential to affect all 36 residents.-The facility's carpeted resident hallway on [NAME] Hall was observed to have active spider webs and dead beetles along the corners.-The facility's carpeted resident lounge sunroom on [NAME] Hall was observed to have active spider webs and dead beetles along the corners, the exit, and on resident common area chairs.-The facility's main resident dining room (Fireside) area was observed to have active spider webs and dead beetles along the corners and near the dining room tables.This is evidenced by: On 08/03/26 at 11:06 AM, Surveyor observed the main dining room [Fireside] to be covered with dead beetles on the floor alongside walls at the bottom where the floor meets the wall and the heat registers. Surveyor observed, in the dining room near a table by the window of the front entrance door, a big spider web with dead bugs in the spider web with a live spider crawling around. Surveyor observed near the exit door in the dining room a large spider web with bugs in it.On 08/03/26 at 11:15 AM, during a tour of the facility, Surveyor observed carpeting on [NAME] Hall to have live and dead bugs throughout the hallway. Surveyor observed spider webs and bugs at the exit door across from R13's room.On 08/03/26 at 11:16 AM, Surveyor observed carpeting in the sunroom on the [NAME] Hall to have spider webs and live bugs throughout the area. Surveyor observed spider webs covering one of the chairs in the sunroom. On 08/03/26 at 11:26 AM, Surveyor observed an exit door on [NAME] Hall to have spider webs in the corners with dead beetles intertwined in the spider webs.On 08/03/26 at 11:41 AM, Surveyor interviewed Housekeeper F and asked about the normal routine of day-to-day cleaning. Housekeeper F stated they have been working short staffed for a while but usually have two housekeepers on duty every day. Housekeeper F stated all halls, such as [NAME] and [NAME] Halls, are cleaned, including hand railings, fixtures, bathrooms, and nurse's stations. Surveyor asked Housekeeper F how often the hallways and the sunrooms are cleaned. Housekeeper F stated they are unsure how often but probably weekly. Surveyor asked Housekeeper F to explain how Housekeeper knows what to clean for the day to day to tasks. Housekeeper F showed Surveyor a task list.Surveyor reviewed housekeeping check list, which states:-Twice daily wipe high touch areas.-Keep hall floors clear of debris.-[NAME] and [NAME] Hall: procedures include Pull trash/replace liner, horizontal surfaces, vertical surfaces, dust mop/sweep, damp mop, and vacuum.Surveyor continued interviewing after reviewing the check list with Housekeeper F and asked if they could provide Surveyor with their check list for the day. Housekeeper F stated the check list is not finished yet as their shift is not over until 2:30 PM. Housekeeper F stated, I will provide my check list once completed.On 08/03/26 at 1:29 PM, Surveyor continued checking areas of concern with housekeeping. Surveyor entered the main dining room [Fireside] to observe if dining room was cleaned. Surveyor observed debris and dead bugs still along the floorboards and under tables. Surveyor observed R8 wheeling self to a table with a puzzle next to the big spider web that was observed near the window of the front entrance door. R8 pulled up to the table and was startled by the spider web. R8 screeched, Ahhh. Surveyor approached R8 and asked if everything was ok. R8 immediately pointed and stated, Look at that big web. Gross. Surveyor asked how R8 feels about the spider web and if there have been a lot of bugs in the facility. R8 stated there are bugs all over, but that spider web has to go. R8 stated, It is big.On 08/03/26 at 2:47 PM, Surveyor received Housekeeper F's check list.Housekeeper F's check list dated 08/03/26, states [NAME] Hall dining room, and rooms 2-5,10, 14, 19, and 87-93 were checked as cleaned. [NAME] Hall railings were checked as having been cleaned. Rooms 1, 6-9,11-13, 15-18, 75-86 not checked off as cleaned. Vacuuming [NAME] and [NAME] Hall not checked off as cleaned.Surveyor received last 3 months of housekeeping check lists.On 07/17/26-07/26/26, Housekeeping check list not completed due to housekeeper on vacation.Housekeeper F's check off list dated 07/27/26, states [NAME] Hall dining room, and rooms 75-93 checked off as having been cleaned. rooms [ROOM NUMBERS] checked off as cleaned. Rooms 1-13, 15-18 not checked off cleaned. Vacuuming of [NAME] and [NAME] Hall not checked off.On 08/03/26 at 3:34 PM, Surveyor interviewed Maintenance Director J and asked them to tour the building with Surveyor. Surveyor showed Maintenance Director J [NAME] hallway, [NAME] sunroom, and Fireside dining room. Surveyor asked Maintenance Director J's expectation for cleaning the high traffic areas. Maintenance Director J stated, I did not know about all the spider webs around and that resident rooms and bathrooms were not being cleaned appropriately. Maintenance Director J stated facility is working on performance improvement and has started by hiring new housekeeping staff and trying to find a different manager for housekeeping. Surveyor asked for Maintenance Director J's process for deep cleaning commons areas like the [NAME] sunroom and Fireside dining room. Maintenance Director J stated deep cleaning is supposed to be done weekly and should be checked off on the housekeepers' daily task list. Surveyor asked Maintenance Director J to clarify what is on the daily check-off list. Maintenance Director J grabbed a check list and stated all resident rooms are cleaned daily by housekeepers. Maintenance Director J stated [NAME] Hall should be vacuumed and mopped but does not specify how often it is to be cleaned. Check list does not specify [NAME] Hall either, but Maintenance Director J stated housekeepers know it applies the same. Maintenance Director J stated some housekeepers will document the [NAME] Hall complete as well. Maintenance Director J stated the check list does not have any direction on deep cleaning the main dining room [Fireside] or dusting for spiders and dust. Maintenance Director J stated the check list only covers cleaning tables and floor as needed. Maintenance Director J stated this is why it is too much for Maintenance Director J to manage because there should be no reason to have spider webs and debris throughout the building.Surveyor asked Maintenance Director J about pest control and how often pest control comes. Maintenance Director J stated the company comes monthly to check rodent traps. Surveyor asked Maintenance Director J if the company sprays potential bugs around the facility. Maintenance Director J stated they reached out to the company to spray the facility for bugs as there was a complaint about potential cockroaches. Maintenance Director J stated company reached out via telephone and Maintenance Director J sent pictures of the bug. The company stated to Maintenance Director J that it appeared as some kind of hard-shelled beetle bug. Maintenance Director J stated, They just sent me a contract to sign, and they didn't get to it. The pest solutions company sent another reminder recently to Maintenance Director J to fill out the contract before the company could come to spray potential bugs in the facility. Maintenance Director J stated they signed the contract and the company was at the facility last week and sprayed. Surveyor asked Maintenance Director J why spraying facility for potential bugs was not completed prior to last week. Maintenance Director J stated they were unsure and didn't know the facility needed to have the building sprayed on a regular basis. Surveyor requested to review pest controls invoices from prior visits to the facility.Surveyor reviewed third-party pest solutions service report order #2764753, dated 06/17/26, which states in part, .At today's service I sent [Maintenance Director J] a text because he was not in the office. [Maintenance Director J] stated he was in a meeting. I asked him if he reached out for the ant spray and he has not yet. I can't do the spray until I get a contract to do so. I walked the interior and exterior perimeter inspecting the foundation for any pest related concerns. No concerns to note. I checked all bait stations for any rodent activity. Light rodent activity detected. I did not need to replace the bait station at this time.Surveyor reviewed a different third-party service with report order #394184, dated 07/24/26, which states in part, .Inspected selected areas. I inspected the interior and exterior perimeter inspecting the basement break room, the upstairs break room, and all of the main hallways on the main floor for any insect and rodent activity. Inspected and treated selected areas. I applied to a liquid spot application of Demand CS [professional liquid insecticide] to the [NAME] hallway, as well as downstairs basement for any beetle activity. Please give the application 2-4 hours of dry time. Do not tamper with treated areas.On 08/03/26 at 3:45 PM, Surveyor interviewed Maintenance Director J and asked if after the company came and sprayed the facility, how were they assessing the treated areas and cleaning the dead bugs and spider webs in the affected areas Maintenance Director J stated housekeeping should be following the task list and the high traffic areas, lounges, and the hallways. If task list is followed the areas would be free from dead bugs and spiders.

Based on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 7 of 7 residents (R) reviewed (R2, R5, R6, R7, R11, R17, and R18). -Medication carts on [NAME] and [NAME] hall had 13 medication pens opened, unlabeled, unidentified, unknown expiration date, and/or medication stored in wrong resident's compartment. Findings include: Facility policy titled, Medication Labeling and Storage, dated 08/01/25 states in part: .2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated, or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medication Labeling: 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. Medication label includes, at a minimum: a. medication name; b. prescribed dose; c. strength; d. expiration date, when applicable; e. residents' name; f. route of administration; and g. appropriate instructions and precautions. 8. If medication containers are missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. 10. Only the dispensing pharmacy may label or alter the label on a medication container or package.Facility policy titled, Administering and Documentation of Medication Administration, dated 12/09/25 states in part: .Steps in the Procedure: 6. Check the label on the medication and confirm the medication name and dose with the MAR. 7. Check the expiration date on the medication. Return any expired medications to pharmacy.Facility policy titled, Medication Administration Subcutaneous Insulin, dated 01/23 states in part: .Subcutaneous Insulin. 5. Obtain insulin. Check expiration date. 6. Date vial or device after first use.On 08/04/26 at 7:20 AM, Surveyor observed Registered Nurse (RN) O prepping R5's morning medications. Surveyor observed RN O grab a clear zipper bag which had 5 insulin pens inside. Surveyor observed one used Lantus pen, an Ozempic pen, and a Novolog pen with no label for identifying if it was R5's and no labels stating pen open or expiration date. Surveyor observed R7's Humalog pen was labeled thoroughly but had no cap on it leaving the tip exposed to potential contamination in R5's zipper bag. Surveyor also observed a Toujeo Max Solostar pen unlabeled with no resident identifier, and no open and expiration date in R5's zipper bag.On 08/04/26 at 7:23 AM, Surveyor interviewed RN O and asked how insulin pens are stored for each resident. RN O stated all medication carts hold each individual resident's insulin pens in a little colored zipper bag. One pen per medication is stored in the zipper bag and extras are stored in the fridge. Surveyor asked whose Toujeo Max Solostar pen was located in R5's zipper bag since it was missing its label. RN O stated R5 does not take Toujeo and it is R7's pen. Surveyor asked why there were so many pens unlabeled with no open and expiration dates or resident identifying information on them. RN O stated they are unsure why pens are not labeled. Surveyor observed R11 had a zipper bag with a Novolog pen unlabeled with no open or expiration dates and resident identifying information. Surveyor observed R7's zipper bag to have an extra Toujeo Max Solostar pen, which has not been used but not it was not refrigerated until use. Surveyor asked RN O why R7's extra insulin pen was not being stored in fridge at this time since R7 has another insulin pen in the medication cart. RN O reported to Surveyor RN O is unsure as storing a potential unopened insulin pen should be kept in fridge until further use. Surveyor also observed R2's Lantus pen labeled correctly but stored in R7's zipper bag. Surveyor asked RN O why all the insulin pens were in different resident's zipper bags versus in the correct zipper bag. RN O stated they were unsure. Surveyor asked RN O who oversees medication cart audits. RN O stated DON B should be the one responsible or maybe pharmacy comes monthly to review medication cart. RN O stated they do not know who is in charge of medication cart audits.On 08/04/26 at 8:31 AM, Surveyor observed Licensed Practical Nurse (LPN) H prepping R6's Novolog short acting insulin pen. LPN H sanitized tip of R6's insulin pen, primed 2 units, and drew up 12 units. Surveyor stopped LPN H and asked if they checked the label on R6's Novolog pen. LPN H quickly stated, Oh no, I did not know that. I will not administer. LPN H notified RN G to grab a new insulin pen for R6. Surveyor asked LPN H to review other residents' zipper bags with medication pens stored in them. LPN H pulled R6's zipper bag again and Surveyor observed Ozempic and Novolog pen had no resident identifying information and open nor expiration date label. Surveyor observed LPN H pulling R17's Liraglutide pen from R17's zipper bag. Surveyor observed no open or expiration date label on R17's medication pen. LPN H stated R17 needs the Liraglutide injection this morning and will need to have RN G help find another pen since LPN H does not know the exact expiration date of the pen. Surveyor observed R18's zipper bag. R18 had an expired Lantus pen in it dated 06/07/26. Surveyor asked LPN H why R18 still had an expired pen in their zipper bag. LPN H stated they are unsure as R18 just got back from hospital on [DATE].On 08/04/26 at 9:47 AM, Surveyor asked Director of Nursing (DON) B if DON B was aware R7's medication pen was in R5's zipper bag and R2's medication pen was in R7's zipper bag. DON B stated they were not aware that medication pens were not in the proper zipper bags. Surveyor asked DON B who completes medication cart audits and how often the audits were completed. DON B stated they have not been able to start medication cart audits since DON B started in the position at the facility. DON B stated there are no medication cart reports available.On 08/04/26 at 3:24 PM, Surveyor interviewed DON B and informed them of LPN H prepping an unlabeled insulin pen for administration to R6. Surveyor asked DON B what the expectation and process is for insulin pens and what should staff do if they find an unlabeled medication pen. DON B stated that if the pen has been opened and it is an unknown expiration date, the pen needs to be discarded, and a new one assigned to residents. If the opened medication pen does not have a correct resident identifier label, the pen will need to be discarded to prevent the wrong resident's medication being administered to the wrong resident. DON B stated the expectation is LPN H should review R6's insulin pen for open date and expiration label and R6's identifying information on pen. DON B's expectation is if there is not an open date label on the insulin pen, then it is unknown when the expiration date would be, and DON B would expect LPN H to dispose of the insulin pen and get another one. DON B stated this applies to all medication pens administered to residents. Surveyor asked DON B what the expectation is for expired medications in the medication cart. DON B expired medications should be discarded or returned to pharmacy. Surveyor informed DON B of an expired Lantus pen in R18's zipper bag with a date of 06/07/25.

Based on observation, interview, and record review, the facility did not ensure medication error rates are not 5% or greater. Surveyor observed 4 errors out of 20 opportunities for an error rate of 20% during medication administration affecting 3 of 4 residents (R) reviewed (R5, R6, and R17).-Registered Nurse (RN) O did not prime R5's insulin pen prior to administration.-RN O administered the wrong dose of Bio freeze gel medication to R5.-Licensed Practical Nurse (LPN) H was attempting to administer insulin to R6 without an open or expiration date.-LPN H administered Midodrine to R17 without following physician orders to check blood pressure prior to administering the medication.This is evidenced by:The facility policy titled, Administering and Documentation of Medication Administration, dated 12/09/25 states in part: .Steps in the Procedure: 6. Check the label on the medication and confirm the medication name and dose with the MAR. 7. Check the expiration date on the medication. Return any expired medications to pharmacy. 13. Perform any pre-administration assessments.Facility policy titled, Medication Administration Subcutaneous Insulin, dated 01/23 states in part: .Subcutaneous Insulin. 5. Obtain insulin. Check expiration date. 6. Date vial or device after first use. 9. Prepare injection: b. Prepare syringe/pen and safety needle. (See pen example). Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly and removing air bubbles. A. Select the dose of 2 units by turning the dosage selector. After completing the safety check, check that the window shows 0 before setting medication order dose. You may have to perform the safety test several times before insulin is seen. If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them before administering insulin. Example 1R5's physician orders state:-Humalog Kwik/pen subcutaneous 100 units/ml, inject 7 units subcutaneously three times a day, started on 05/01/26.On 08/04/26 at 7:20 AM, Surveyor observed Registered Nurse (RN) O prepping R5's morning medications. Surveyor observed RN O prep R5's Humalog short acting insulin pen. RN O sanitized top, applied needle, and drew 7 units of insulin. RN O entered R5's room. Surveyor asked RN O if they primed R5's insulin with 2 units and discarded first before drawing 7 units. RN O stated they only draw up 2 units in R5's pen when it is brand new. RN O proceeded and administered R5's short acting insulin into R5's abdomen. On 08/04/26 at 7:26AM, Surveyor asked RN O if they knew that the pain-relieving bottle was labeled 5% not 4% as ordered for R5. RN O looked at pump bottle and stated, Oh I did not know it was a different percentage. I'll have to let my boss know.On 08/04/26 at 9:47 AM, Surveyor interviewed DON B and asked DON B for the process for preparing an insulin pen for administration. DON B stated all nursing staff are to review physician orders, assess the pen being used, verify correct identifying information such as resident name, date of birth , dosage/concentration, and then prep the insulin pen. Surveyor how the insulin pen is prepped. DON B stated the insulin pen is prepped by sanitizing the tip once the cap is removed, place a needle on the pen, then prime with 2 units and discard the 2 units to remove air bubbles. DON B stated then staff draws up the correct dose of units to be given. Example 2R5's physician orders state: -Bio freeze cool the pain external gel 4% (Menthol topical analgesic), Apply to shoulders/cervical topical two times a day, apply per label instructions/affected areas, started on 12/24/25.On 08/04/26 at 7:20 AM, Surveyor observed Registered Nurse (RN) O prepping R5's morning medications. Surveyor observed RN O grabbing a tall pump bottle that was labeled pain relieving gel 5% menthol and pumped a couple of pumps into a medicine cup.RN O administered pain relieving gel to R5's left shoulder and then exited R5's room.On 08/04/26 at 9:47 AM, Surveyor interviewed DON B and asked if they knew about R5's pain gel strength was ordered at 4% and staff have been giving R5 a 5% dose. DON B stated they were unaware there was a one percent difference on the bottle. DON B stated they would investigate R5's medications orders but RN O should have followed the physician order.Example 3R6's physician order states in part,- Novolog flex pen 100units/ml, inject 12 units subcutaneously with meals for Diabetes. Give with sliding scale and hold if BG is less than a 100, started on 06/02/26.On 08/04/26 at 8:31 AM, Surveyor observed LPN H prepping R6's Novolog short acting insulin pen. LPN H sanitized tip of R6's insulin pen, primed 2 units, and then drew up 12 units. Surveyor stopped LPN H and asked if they checked label on R6's Novolog pen as Surveyor observed R6's pen did not have an open date label. LPN H quickly stated, Oh no, I did not know that. I will not administer. LPN H quickly notified RN G to get a new insulin pen for R6.On 08/04/26 at 9:47 AM, Surveyor interviewed DON B and informed them of the observation of LPN H prepping R6's insulin pen for administration, and Surveyor stopping LPN H from administering an unlabeled insulin pen. Surveyor asked DON B to provide expectations and process of administering insulin pens to residents. DON B reported expectation is LPN H review R6's insulin pen for open date label and R6's identifying information on pen. DON B's expectation if there is not an open date label on the insulin pen, then it is unknown when the expiration date would be, and DON B would expect LPN H to dispose of the insulin pen and get another one. Example 4-LPN H administered Midodrine to R17 without following physician orders to check blood pressure prior to administering the medication.R17 physician order states:-Midodrine HCL oral tablet 10 mg. Give 10mg by mouth three times a day for hypotension. Hold if systolic blood pressure is greater than 140. Started on 06/30/25.On 08/04/26 at 8:22 AM, Surveyor observed LPN H prepping R17's medications. LPN H entered R17's room and administered Midodrine.On 08/04/26 at 8:57 AM, Surveyor interviewed LPN H and asked if they checked R17's blood pressure prior to administering R17's Midodrine. LPN H stated, I am sorry, I did not. I'll go check now. LPN H stated they should have taken R17's blood pressure prior to administering Midodrine.On 08/04/26 at 3:24 PM, Surveyor interviewed DON B about what the expectation is when administering Midodrine. DON B stated the blood pressure should be checked per physician order prior to administration. Surveyor informed DON B of LPN H not following physician order.

Based on observation and interview, the facility did not provide a safe, sanitary, and comfortable environment for 2 of 16 residents (R). (R16 and R13)-R16's and R13's bathroom had foul urine odor, urine stains, and free-standing water around the toilet. R16 reported not being able to use the bathroom due to the function and cleanliness of the bathroom. Findings include:On 08/03/26 at 1:41 PM, Surveyor interviewed R16 and asked if they had any concerns with the environment pertaining to their room. R16 stated they are concerned with their toilet not working and how the bathroom is filthy. Surveyor observed R16's bathroom to have an odor of urine and observed urine stains all over R16's bathroom floor. R16 stated they do not use the bathroom anymore because R16 must share with R13 and it is disgusting. Surveyor asked where R16 uses the bathroom. R16 stated staff have given R16 their own bathroom down the hall in an unoccupied room. R16 stated the toilet in R16's and R13's bathroom has not been flushing correctly and always leaks all over the floor. Surveyor observed a blackish grey stain with free standing liquid all around the base of the toilet. Surveyor asked R16 how long the bathroom has been in this condition. R16 stated the bathroom has been gross and not functional with the constant leaking for a month or so. On 08/03/26 at 3:34 PM, Surveyor interviewed Maintenance Director J and asked if they were aware of R16's and R13's bathroom toilet not functioning properly and leaking around the base. Maintenance Director J stated they just heard about the toilet today and fixed the toilet right away by caulking around the base of toilet. Surveyor asked how Maintenance Director J knows when repairs are needed in the facility. Maintenance Director J stated staff are to place a work ticket in through the facility work ticket software and Maintenance Director J addresses right away. Surveyor asked Maintenance Director J how long it takes to complete a work order. Maintenance Director J stated they fix issues immediately when the work orders come through. Surveyor requested to review work tickets for the last 6 months.On 08/03/26 at 3:47 PM, Surveyor entered R16's room and observed bathroom cleaned with new caulking around the base of toilet. On 08/04/26 at 8:12 AM, Surveyor received old work ticket orders for the last 6 months.Surveyor reviewed work orders:-On 05/03/26, work order #265, R16's and R13's bathroom toilet not flushing.-On 05/17/26, work order #282, R16's and R13's bathroom toilet isn't working. On 08/04/26 at 8:59 AM, Surveyor interviewed Maintenance Director J and asked if they knew of issues with R16's and R13's toilet. Maintenance Director J stated they did not know what was going on with R16's and R13's bathroom, and they thought the work order number 265 and 282 were related to another issue with R16's and R13's toilet but they are unsure. Maintenance Director J stated R16's and R13's toilet is fixed now.

Based on observation, interview and record review, the facility did not ensure resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 11 residents (R) reviewed (R5). R5 was left unattended while connected to mechanical lift equipment and no call light was in reach.Findings include: R5 was admitted to the facility on [DATE], with diagnoses including, in part, congestive heart failure (CHF), acute and chronic respiratory failure with hypoxia, and hypertension.R5's Minimum Data Set (MDS) assessment, dated 06/29/26, indicated R5 had Brief Interview of Mental Status (BIMS) score of 15/15 indicating R5 had intact cognition.R5's Activities of Daily Living (ADL) related to decreased mobility, care plan states:-Toileting assist of 2.-Transfer assist of 2 with EZ-Stand.R5's fall care plan states:-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 08/04/26 at 11:22 AM, Surveyor observed R5 sitting in wheelchair connected to an EZ-Stand mechanical lift. R5 was screaming out loud, This is ridiculous! They leave me in here for far too long while they go get help to transfer me all the time. I am sick of it. Surveyor did not observe R5's call light in place while R5 was left alone connected to the EZ-Stand mechanical lift. Surveyor waited with R5 until Certified Nursing Assistant (CNA) returned.On 08/04/26 at 11:26 AM, Surveyor observed CNA D and CNA I enter R5's room and began transferring R5 to bedside commode with EZ-Stand.On 08/04/26 at 11:28 AM, Surveyor interviewed CNA D and CNA I and asked why R5 was left hooked on the EZ-Stand mechanical lift and did not have a call light in place to call for assistance if needed. CNA D stated, Well, I was coming back, but ok. Surveyor asked CNA D if it is normal to leave R5 alone in a wheelchair while hooked to a mechanical lift without a call light in reach. CNA D stated they probably should not have left R5 alone and connected to a mechanical lift.On 08/04/26 at 11:31 AM, Surveyor interviewed Registered Nurse (RN) O and asked if CNA D should leave a resident unattended while hooked up to a mechanical lift and has no call light within reach. RN O stated CNA D should not leave any resident hooked on a mechanical lift alone. RN O stated CNA D should have unhooked R5 from then mechanical lift and R5 should have been given the call light while CNA D searched for assistance. On 08/04/26 at 3:24 PM, Surveyor interviewed Director of Nursing (DON) B and informed DON B of CNA D leaving R5 unattended while hooked to a mechanical lift and no call light in reach. DON B stated all staff are not to leave residents hooked on a mechanical lift alone in rooms. DON B stated R5 should have been disconnected, and a call light should have been given to R5 until CNA D returned.

Based on observations, interview, and record review, the facility did not provide care and treatment in accordance with professional standards of practice to maintain a resident's highest practicable level of physical wellbeing for 1 of 11 residents (R4) reviewed for non-pressure wound care out of total sample of 20 residents. Certified Nurse Assistant (CNA) E left a heavily blood-tinged colored soiled pillow under resident (R) R4's right lower extremity. Findings include:R4 was re-admitted to the facility on [DATE] with diagnoses including, in part, displaced fracture of lower end of right humerus, non-pressure chronic ulcer of right lower leg, drug-induced polyneuropathy, reduced mobility, lymphedema, multiple myeloma, and thrombocytopenia.R4's Minimum Data Set (MDS) assessment, dated 06/15/26, identified R4 had Brief Interview of Mental Status (BIMS) score of 14/15 indicating R4 had intact cognition. R4's Activities of Daily Living (ADL) related to decreased mobility, care plan state in part:-Toileting assist of 2. -Transfer assist of 2 with Hoyer. R4's physician orders, state in part:-Wound Care: right posterior lower leg: (offer pain medication 30 min prior to dressing change. May use saline to moisten dressings prior to removal.) Cleanse wound with saline. Dakins 0.125% gauze soak 5-10 minutes. Pat dry. Place calcium alginate into wound and cover with abdominal pad. Secure with rolled gauze. Apply ACE wrap from toes to just below knee. Change every other day and as needed. Started on 08/01/26.Observations/InterviewsOn 08/04/26 at 11:17 AM, Surveyor walked by R4's closed door. Surveyor knocked and entered. CNA E reported to Surveyor CNA E was performing cares for R4 and would be out shortly. Surveyor observed CNA E rolling R4 in bed to the left side of R4's bed. Surveyor exited R4's room and waited for CNA E to exit. On 08/04/26 at 11:23 AM, Surveyor observed CNA E exit R4's room. Surveyor asked CNA E what R4 was doing next. CNA E reported eventually nurse will complete wound dressing change while R4 is lying down in bed. On 08/04/26 at 11:57 AM, Surveyor entered R4's room with Registered Nurse (RN) G and Licensed Practical Nurse (LPN) H to observe wound dressing change. Surveyor observed LPN H uncovered R4 from blankets. LPN H removed a pillow from underneath R4's right lower extremity. Surveyor observed a heavily soiled blood tinged/brown colored discharge on 3/4ths of the pillowcase. Surveyor observed R4's ace wrap was mostly dry with a small spot the size of a small orange on R4's ace wrap. LPN H asked RN G if the soaked pillow was normal for R4. RN G reported to LPN H that sometimes R4's wound will drain some, but the soaked pillow should not be under R4's leg like it was found. Surveyor asked RN G how long the soaked pillow had been under R4. Immediately R4 stated to RN G and Surveyor, I tried telling [CNA E] earlier this morning about the soaked pillowcase. [CNA] E told me that it was fine and nurses would be changing dressing later today. Surveyor asked R4 how long R4's leg has been soaked and the pillowcase the way it is found. R4 reported to Surveyor, staff changed R4's dressing the other day and R4 has had same ace wrap on since the other day. R4 reported R4 observed R4's leg draining yesterday on 08/03/26. Surveyor asked RN G if leaving a soiled pillow under R4's right vascular wound was a normal process for cares. RN G reported to Surveyor, CNA E should have never placed the soiled pillow once discovered back under R4's leg. RN G reported to Surveyor it is not good practice as it can introduce possibility of infection and deter wound healing. Surveyor observed RN G assessing R4's leg after unwrapping ace wrap and dressing. RN G stated, This dressing is really adhered to [R4's] leg and is going to need to be soaked. [R4] has an order to change ace dressing as needed as well between scheduled changes. I am unsure why this was not done prior to now if ace wrap had been soaked prior to my shift. On 08/04/26 at 12:34 PM, Surveyor interviewed CNA E and asked why R4's pillow was placed back under R4 after CNA E observed R4's pillow to be saturated with blood and discharge from R4's leg wound. CNA E stated to Surveyor, I figured the nurses were going into [R4's] room sometime today so they could see the discharge found on pillow. Surveyor asked CNA E how long pillowcase was saturated. CNA E reported to Surveyor CNA E saw it earlier this morning but unsure what time. On 08/04/26 at 3:24 PM, Surveyor interviewed Director of Nursing (DON) B and reported Surveyor's observation of R4's pillow under R4's right lower extremity completely saturated with blood-tinged drainage. Surveyor reported to DON B, CNA E reported CNA E did that on purpose figuring nurse would go in sometime today. Surveyor asked DON B for expectation for wound management and R4's saturated pillowcase. DON B reported to Surveyor, CNA E should have changed the saturated pillowcase, and taken pillowcase to RN G to report R4's drainage right away.

Based on observation, interview and record review, the facility failed to check blood glucose levels prior to residents eating their meal per physician orders for 1 of 3 residents (R12) reviewed for blood glucose monitoring.Findings include: Review of facility's policy titled Obtaining a Fingerstick Glucose Level dated 10/2011 states in part: .1. Verify that there is a physician's order for this procedure . Example 1R12's physician orders state in part, -Blood Glucose check before meals three times a day, starting on 04/11/26. On 08/04/26 at 12:58 PM, Surveyor observed R12's lunch tray in front of R12 at the dining room table. Surveyor observed R12 had eaten all their food. Registered Nurse (RN) G gathered R12's BG with result of 168. RN G reported to Surveyor R12 does not receive any insulin at this time.R12 did not receive BG prior to meals per MD order. On 08/04/26 at 3:24 PM, Surveyor interviewed Director of Nursing (DON) B and reported an observation of RN G performing BG checks after lunch meal for R12. Surveyor asked DON B's expectation of RN G performing BG checks. DON B stated RN G should have checked R12's blood glucose prior to R12 eating.

Based on record review and interviews, the facility administration did not ensure resources or practice to effectively and securely manage resident finances were in place to ensure the integrity of resident accounts and to maintain the highest practicable psychosocial well-being of each resident. This had the potential to affect any resident utilizing the facility's billing office(s) or third-party billing company.Administration did not have an effective tracking system of payments coming into the facility by residents and/or representatives. Administration did not hold the Business Office Manager, (BOM)-D, and/or third-party billing company accountable to safe, secure, and accurate handling of resident finances. Administration did not have practices in place to ensure insurances payments (i.e. Social Security Income/SSI) and/or withdrawals for care/room and board ended when a resident no longer resided at the facility. Nor did the facility have practices to ensure SSI money was not utilized when a MCO was also in place for payment of care and room/board. Administration did not follow regulation or policy on reporting and investigating suspected misappropriation and/or exploitation of residents' finances nor determine the extent of the matter nor protect residents from potential further misappropriation. Administration did not provide education and/or appropriate tools or equipment to carry out transfers of checks coming to the facility intended for resident care/room and board fees.Administration did not implement policies and procedures for accounts payable/account receivables.The facility's failure to implement appropriate practices and policies related to resident finances put residents at risk of misappropriation and exploitation of funds which created a finding of immediate jeopardy that began on 10/08/25. Surveyor notified NHA-A of the immediate jeopardy on 10/31/25 at 1:15 PM. The immediate jeopardy was removed on 11/3/25; however, the deficient practice continues at a scope/severity level E (potential for more than minimal harm/pattern) as the facility continues to implement their action plan.Findings:1. On 10/30/25, Surveyor interviewed NHA-A who had concerns of misappropriation of residents' funds after finding out about a bank account in the facility's name which BOM-D had a debit card and checkbook for, but which NHA-A did not know existed. Other management staff were also not aware BOM-D held such an account. NHA-A noted cash withdrawals, money orders, grocery and department store purchases, gas station purchases, restaurant purchases, and hardware store purchases, as well as other spending. Surveyor viewed facility provided statements from July, August, and September confirming these charges and cash/money withdrawals on the account. NHA-A indicated there not being an effective way to determine what these charges were made or for whom they may have been made for or if the funds were being misappropriated or mishandled. NHA-A nor other facility managers were aware the account existed. Surveyor reviewed a copy of a check from R1 in the amount of $2,040 dated 6/13/25 with a stamped date of 8/7/25, which correlated with a deposit noted on August's bank statement for the account BOM-D held in the facility's name. The check was written and deposited after the resident discharged from the facility (4/27/25); therefore, would not be intended for resident's personal spending.On 10/30/25, NHA-A also shared concerns related to known issues with the third-party billing company. NHA-A indicated Owner-G was aware of issues with the facility's third-party billing company. Residents noted during interviews with NHA-A were R1, R2, R3, R4, and R8. On 10/30/25, Surveyor interviewed R1's family member (FM)-H who shared concerns about inaccurate statements, the way which BOM-D would text or call with balances needing to be paid, as well as concerns of lack of receipt for payments. FM-H indicated BOM-D suggested FM-H pay extra and would be paid back; however, FM-H instead received a statement on 10/27/25 for over $7,000. Also, statements were missing entries for payments made. FM-H expressed fears that collections would come after FM-H due to the inaccuracy of resident funds management at the facility. Despite concerns, no changes were made by administration to correct the issues. On 5/31/25 at 12 PM, Surveyor interviewed Director of Operations (DOO)-F who indicated you (Surveyor) got firsthand how difficult the third-party biller was to communicate with (referring to a call DOO-F initiated on 10/30/25). DOO-F added, I would expect if someone would have been diverting funds, there would have been an alert that a resident was not paying for the last 2, 3, 4 months and NHA would have gotten a notification or alert. When discussing potential for misappropriation, DOO-F indicated some of those safeguards were not there. DOO-F stated, we will now be putting things in place to make that harder to do. The receivership occurred, constant changeover of management and new ownership; BOM-D had that opportunity with all those holes.2. On 10/30/25, Surveyor interviewed R2's family member, (FM)-J, who expressed concerns related to R2 being evicted from the Assisted Living facility R2 was currently residing at. FM-J stated, where is the money? Can't pay the Assisted Living and they are going to kick R2 out. FM-J further explained the MCO R2 was enrolled with was not being paid as they should have been. On 10/30 and 10/31/25, Surveyor interviewed MCO Finance Manager (MCO)-K who confirmed not receiving payment which typically would come in the form of a member's Social Security (SS) check. MCO-K indicated this put R2 at risk for losing benefits. On 10/30/25, NHA-A provided Surveyor with a ledger which showed R2's SS was being deposited to the Resident Fund Management System (RFMS) system and then withdrawn for care costs via auto withdrawal through 9/17/25. R2 discharged from the facility on 8/2/25. NHA-A indicated that R2's October check came to the facility as well and was then sent back. MCO-K indicated BOM-D was listed as the authorized user on R2's account and therefore, MCO was not able to change anything without police involvement as R2 cannot get to the SS office due to health inabilities. MCO-K also indicated that the MCO was paying for R2's care costs since May 2025, including care at the facility. MCO-K indicated they have never received payment to the MCO since R2 has enrolled on 5/1/25. R2 admitted to the facility on [DATE] and discharged on 8/5/25.3. On 10/30/25, Surveyor interviewed NHA-A who indicated having notified DOO-F and Owner-G of concerns of potential misappropriation. NHA-A provided Surveyor with the email which contained the following information:10/8/25 7:21 PM From: NHA-A To: DOO-F and Owner-G.Today, I opened a bank statement with the company's name on showing large withdrawals. This was the first time that I have ever seen this statement.I called the bank and spoke to (employee) who stated that the withdrawals were all done via a debit card and the debit card was issued to BOM-D. discussed with bank [NAME] Present (VP)-I. VP-I looked at accounts. While in our 2 pm meeting, I received a call from VP-I.VP-I stated that BOM-D came to close out the account. With my follow up with VP-I, did say from reviewing our account, VP-I fully believes there is fraud that is occurring. From looking briefly at the deposits, I am wondering if some of those deposits are maybe resident deposits, that BOM-D has been blaming (third-party billing company) for not making.Other emails provided by NHA-A indicated:10/13/25 5:16 PM From: NHA-A To: DOO-F Subject (BOM-D's first name) ExcellAttached is an excel spreadsheet breakdown . We have deposits, bank statements and withdrawals. (BOM-D) has signed for everything.10/14/25 10:40 AM From: NHA-A To: DOO-F Subject (BOM-D's first name) [NAME].(BOM-D) has withdrawn money for money orders and cash that were never for the company. (BOM-D) is trying to blame third-party billing company for R1's $2,400 deposit not being put in R1's account. Third-part billing company never received the check as BOM-D put it in the small business account. SW-E also knows another resident who had over $2,000 in Resident Fund Management System (RFMS) (a system used to manage residents' funds and payments) and now has no money.typically only purchases soda. I have not had the opportunity to dig more into the past RFMS. SW-E had no idea this account ever existed, or that there were checks, or a debit card.I have never seen a checkbook and even SW-E and I went through BOM-D's office and we did not see one.DOO-F advised NHA-A to not submit a facility-initiated report to the State Agency (SA) nor police. In addition, a thorough investigation was not conducted; therefore, the extent of the issues was not determined, nor was a root cause of the financial issues completed. Additionally, information was not disclosed transparently to residents and/or representatives as per interview with NHA-A on 10/31/25.4. On 10/31/25 at 12:39 PM, Surveyor interviewed BOM-D who indicated not understanding how to use the facility's RFMS. On 10/31/25 at 10:05 AM, Surveyor interviewed NHA-A who indicated that it is NHA-A's understanding there should be a check scanner in the facility to scan incoming funds from residents/representatives; however, NHA-A was not aware of one being provided by upper Administration/Owner-G.5. On 10/30/25, Surveyor requested policies on accounts payable and accounts receivable. None were provided. On 10/31/25, Surveyor sent an email to NHA-A at 2:13 PM again requesting policies; it appeared the email forwarded to those in superior positions to NHA-A. No policies were provided. On 11/3/25, Surveyor notified NHA-C of the request for policies. NHA-C was the new administrator effective 10/31/25. NHA-C provided Surveyor with policies on 11/3/25. The policies had an effective and revision date of 11/2/25. Policies prior to the 11/2/25 implementation date were not provided.The facility's failure to implement appropriate practices and policies related to resident finances, putting residents at risk for misappropriation and exploitation of funds, created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 11/3/25; however, the deficient practice continues at a scope/severity of level E (potential for more than minimal harm/pattern) as the facility continues to implement the follow action plan:1.The compliance consultant will provide the NHA, DON, new BOM and members of the governing body training about the intent of F835 and their responsibility to operate and manage the facility efficiently and effectively to ensure that the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The training will also include review of their responsibility to prevent abuse, including misappropriation of resident property and exploitation, identifying, investigating and protecting residents from allegations of abuse and exploitation that has the potential to cause serious injury, harm, impairment, or death. To identify any negative outcome, the DON/ SSD (Social Service Director)/Nurses will complete assessment of all residents. The attending physician/NP (nurse practitioner) of the resident will be notified of any negative findings.2. On 10/31/25, the NHA and members of the governing body (CEO - chief executive officer, RDO, [NAME] President of Clinical Services), NHA and Regional Director of Clinical Services discussed the alleged deficiency and the corrective actions which are described in this plan of removal. The Administrator also notified the Medical Director of the alleged deficiency and immediate actions described in this plan of removal.3. To prevent the recurrence of the alleged deficiency, safeguard and track resident financials to include accounts payable and accounts receivables, an updated process was implemented. The NHA/corporate regional representative will provide training to the new BOM about the new process on or before 11/3/25. NHA to review and initial/sign off on all new accounts.4. Deposit process was reviewed and updated to include two signers to accept checks and provide receipt with signatures. Both signers then log receipt of check on the Facility Check Receipt Log. Log is then reviewed weekly by facility NHA.5. Resident fund requests was reviewed and updated: BOM makes withdrawal from resident's RFMS account and puts the money into the facility's RFMS Petty Cash account. BOM provides resident with requested money at the facility out of the RFMS Petty Cash box RFMS Petty Cash box is counted by the NHA and BOM weekly to ensure accuracy. Once RFMS Petty Cash box reaches a certain threshold (set by the NHA based on facility needs), a replenishment check is requested. RFMS Petty Cash box is counted. Receipts, G/L log and count are sent to third-party billing office. Replenishment check is issued to facility. Replenishment check is then cashed at local bank. Funds are counted at facility by two employees. Funds are then placed back into the RFMS Petty Cash box.6. The policies and procedures related to administration of the facility will be reviewed by the NHA, DON, Medical Director and a representative of the governing body. The compliance consultant will provide the NHA, DON and members of the governing body training about administration of the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. It will be emphasized that the NHA and DON are accountable for all the programs and services in the facility to meet the needs of the residents who reside in the facility. The Administrator and DON are accountable for planning, coordinating and managing all services, including protection of residents from misappropriation of property and exploitation, meeting the reporting and thorough investigation requirements of any allegation related to misappropriation of resident property and exploitation, and are responsible for the overall direction, coordination and evaluation of all care and services provided to the residents in the facility.7. The NHA/DON will provide training to the department heads (Activities, SSD, BOM - business office manager, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) about the intent of F835 and their responsibility to operate and manage the facility efficiently and effectively to ensure that the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The training will also include review of their responsibility to prevent abuse, including misappropriation of resident property and exploitation, identifying, investigating and protecting residents from allegations of abuse and exploitation that has the potential to cause serious injury, harm, impairment, or death.

Based on record review and interview, the facility did not ensure residents were free of misappropriation and/or exploitation. The facility's failures of not thoroughly investigating and not reporting to the State Agency (SA) or local authorities when suspected misappropriation was first discovered on 10/08/25 left the residents at continued risk of misappropriation, exploitation, and mishandling of resident funds. Five residents (R) R1, R2 R3, R4, and R8 were affected. All residents who made payments at the facility were at risk.R1's funds were misappropriated when a check in the amount of $2,040, which was meant for R1's care/room charges, was deposited into a bank account only Business Office Manager (BOM)-D was aware of and had access to withdraw funds from. R2's family member (FM)-J had contacted the facility about where R2's money was going. R2 discharged on 8/5/25 to an Assisted Living (AL) facility and FM-J or R2 still cannot get answers as to where R2's funds are. R2 is at risk of being kicked out of current AL facility per FM-J. On 10/10/25, Nursing Home Administrator (NHA)-A noted that R3's personal checkbook had 13 checks written from it from 8/12/24 to 8/28/25. NHA-A had concerns as to where the funds were. NHA-A indicated being suspicious that the signature on some of R3's personal checks were not that of R3's handwriting.Social Worker (SW)-E had concerns related to R4's funds. SW-E indicated R4 had a lot of money and no family. NHA-A indicated R4 now has a negative balance in R4's account and the facility was rep payee for R4. Both SW-E and NHA-A had concerns that R4's money may have been misappropriated.SW-E and NHA-A shared concerns that R8 had funds in the amount of approximately $2,000 and only purchased soda and is now without funds in a short amount of time. The facility was rep payee for R8. An AFLAC insurance check was deposited into a bank account only Business Office Manager (BOM)-D was aware of and had access to withdraw funds from. In addition, residents' family members expressed concerns about resident funds that were not accounted for, and the facility did not take action to thoroughly investigate the concerns. The facility's failure to respond to suspected misappropriation created a finding of immediate jeopardy that began on 10/8/25. Surveyor notified NHA-A of the immediate jeopardy on 10/31/25 at 1:15 PM. The immediate jeopardy was removed on 11/3/25, however, the deficient practice continues at a scope/severity level E (potential for more than minimal harm/pattern) as the facility continues to implement their action plan.On 10/30/25, Surveyor reviewed a facility-provided policy titled Resident Right to Freedom from Abuse, Neglect and Exploitation which had a consulting company's trademark date of 2025 and stated in part:Policy: The Facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility.Procedure: IV. When the facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility will increase enforcement action, including but not limited to: A. Taking steps to prevent further potential abuse. B. Reporting the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. C. Conducting a thorough investigation. D. Taking appropriate corrective action. V. The facility will develop written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program to allow the QAA Committee to determine: A. If a thorough investigation is conducted. B. Whether the resident is protected. C. Whether an analysis was conducted as to why the situation occurred. D. Risk factors . E. Whether there is further need for systemic action such as: e. Tracking patterns of similar occurrences. IX: The facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property. XII: The Facility will ensure compliance with the Elder Justice Act pursuant to the Facility's Elder Justice Act Policy and Procedure. XIII. Response: Have evidence that all alleged violations are thoroughly investigated. c. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.On 10/30/25, Surveyor requested policies from NHA-A related to accounts receivables and/or resident funds; no policies were provided. On 10/31/25, Surveyor emailed NHA-A requesting these policies again, no policies were provided. On a final request on 11/3/25, NHA-C provided polices which indicated an effective date of 11/2/25.On 10/30/25 at 8:45 AM, Surveyor interviewed NHA-A, who indicated having opened a bank statement on 10/8/25 which was in the facility name but NHA-A did not know existed. The statement was for the month of September 2025. NHA-A contacted the bank where the account was located and learned that Business Office Manager (BOM)-D was the authorized user of the account. BOM-D had a debit card for this account as well as a checkbook. NHA-A indicated BOM-D had been on Family Medical Leave (FMLA) at the time the statement came to the facility. NHA-A indicated BOM-D would stop in at work and go to BOM-D's work area despite being off of work and that prior to being on leave, BOM-D was on restricted hours but would not leave the facility within the hours of restriction. In hindsight, NHA-A wondered if BOM-D had been ensuring BOM-D received these statements from the facility mail.NHA-A expressed further concern about the account because the September statement included a cash withdrawal in the amount of $875 on 9/2 and a money order/cash back entry was noted in the amount of $678 on 9/6. On 10/1, there was a cash withdrawal of $150.00. There were also two gas station charges. There was one deposit in the amount of $100.00; however, NHA-A did not know where the deposits would be coming from as the facility was not funding this account with company funds. It was NHA-A's belief that BOM-D opened this account under the facility name. NHA-A went to the bank to look into this matter and bank employees involved [NAME] President (VP)-I. VP-I had concerns of fraudulent activity, however, could not share much information with NHA-A as NHA-A was not listed on the account.Because SW-E was on the facility's two other known bank accounts for resident council funds, NHA-A asked SW-E if was aware of this account with a debit card. SW-E was not. NHA-A asked SW-E to go to the bank to obtain statements of accounts.On that same day, BOM-D stopped into the facility at which time SW-E questioned BOM-D if BOM-D was aware of a debit card. BOM-D indicated, I don't know, maybe, but I don't have it. BOM-D left the facility shortly after. SW-E was wrapping up something and then proceeded to the bank as NHA-A requested.Soon after BOM-D left the facility, bank VP-I contacted NHA-A and informed NHA-A that BOM-D had just been at the bank and closed the account and that SW-E had also came to the facility to collect statements and they just missed each other.After obtaining bank statements for July and August from the bank, NHA-A became increasingly concerned due to charges at restaurants, some in the amounts in excess of $77, and store purchases as well as gas station purchases. On 8/7/25, there was a check deposit for $2,040 and $100, with two cash withdrawals on the same day of $100 and $600. On 8/8/25, a debit card withdrawal of $100. On 8/9/25, another debit card withdrawal of $89.01 and on 8/14/25, a cash withdrawal of 55.00. July's statement had gas station, store and restaurant charges as well as a money order along with deposits that were unknown by NHA-A where they came from. NHA-A suspected deposits may be from checks made out by residents or their representatives meant for resident care/room and board. NHA-A notified Owner-G and Director of Operations (DOO)-F of the concerns via email on 10/8/25. NHA-A provided Surveyor with the email which contained the following information:10/8/25 7:21 PM From: NHA-A To: DOO-F and Owner-G.Today, I opened a bank statement with the company's name on showing large withdrawals. This was the first time that I have ever seen this statement.I called the bank and spoke to (employee) who stated that the withdrawals were all done via a debit card and the debit card was issued to BOM-D. discussed with bank [NAME] Present (VP)-I. VP-I looked at accounts. While in our 2 pm meeting, I received a call from VP-I.VP-I stated that BOM-D came to close out the account. With my follow up with VP-I, did say from reviewing our account, VP-I fully believes there is fraud that is occurring. From looking briefly at the deposits, I am wondering if some of those deposits are maybe resident deposits, that BOM-D has been blaming (third-party billing company) for not making.Other emails provided by NHA-A indicated:10/13/25 5:16 PM From: NHA-A To: DOO-F Subject (BOM-D's first name) ExcellAttached is an excel spreadsheet breakdown . We have deposits, bank statements and withdrawals. (BOM-D) has signed for everything.10/14/25 10:40 AM From: NHA-A To: DOO-F Subject (BOM-D's first name) [NAME].(BOM-D) has withdrawn money for money orders and cash that were never for the company. (BOM-D) is trying to blame third-party billing company for R1's $2,400 deposit not being put in R1's account. Third-part billing company never received the check as BOM-D put it in the small business account. SW-E also knows another resident who had over $2,000 in Resident Fund Management System (RFMS) (a system used to manage residents' funds and payments) and now has no money.typically only purchases soda. I have not had the opportunity to dig more into the past RFMS. SW-E had no idea this account ever existed, or that there were checks, or a debit card.I have never seen a checkbook and even SW-E and I went through BOM-D's office and we did not see one.On 10/30/25, Surveyor reviewed a discipline provided by NHA-A for BOM-D dated 10/22/25 ending employment which was signed by NHA-A and DOO-F. NHA-A explained the three had met. DOO-F gave BOM-D the option of resigning or police would be called; BOM-D resigned.On 10/30/25, Surveyor reviewed medical records for R1, R2, R3, R4, and R8 noting the following:R1 was admitted to the facility 1/14/25 and discharged [DATE]. Face sheet indicated yes to rep payee and was responsible for self. R1 had diagnoses of Crohn's disease and cellulitis. A Brief Interview for Mental Status (BIMS) completed 4/23/25 indicated a score of 15 (intact cognition). On 10/30/25 at 9:15, Surveyor interviewed NHA-A. NHA-A indicated R1 kept getting bills for stay even though family had paid. There was around $2,000 that was taken by BOM-D. NHA-A confirmed that the concern had not been shared with R1's family. NHA-A stated SW-E knows.Surveyor reviewed documentation which included an August 2025 bank statement from the account BOM-D utilized which had a deposit in the amount of $2,140 on 8/7/25. Surveyor reviewed a cashier's check dated 6/13/25 with a stamp of 8/7 on it which was from R1's family member (FM)-H in the amount of $2,040. Surveyor also noted a deposit slip which showed a deposit in the amount of $2,040 and another check for $100.00 which were both deposited on 8/7. Surveyor noted R1 had discharged from the facility 4/27/25. The same bank statement showed cash withdrawals, purchases to restaurants (including amounts in excess of $77), purchases to grocery store ($219.06) and Home Depot ($70.64) in addition to multiple other purchases.On 10/30/25 at 10:59 AM, Surveyor interviewed R1's family (FM)-H who indicating having issues with the facility related to health and finance issues. FM-H indicated, they (facility) are using a billing entity and BOM-D is collecting payments. We were paying over $10,000 a month, but we kept getting bills. In fact, just this Monday (10/27), I received a bill saying I owe over $7,000 but payments were already made. I have called and called. I am also paying another nursing home. I have overpaid. I finally had BOM-D put something in writing saying I paid. I asked BOM-D to put it on letterhead, but BOM-D put it on a plain piece of paper instead and just typed the facility name on top. I paid for 90 plus days and statements only show I paid two times. I would call BOM-D and BOM-D would tell me it is resolved. It wasn't though, I don't understand. I have called Directors on the phone and left messages and do not get a return call. I am afraid I am going to go to collections due to this. I came in monthly with a payment. BOM-D would call me or text me what I owed, then would offer to meet me on BOM-D's days off, even offered that I come to BOM-D's house to drop off payments and also offered to meet me on a Saturday or Sunday to make a payment or end of the day after normal shift of 4:30 PM. At the beginning of June I even presented one extra check which BOM-D said I would get paid back for. I wanted it resolved, so I paid it (June amount), I was trying to pay so R1 could get Medicaid; I wanted to be sure R1 would have care at the new nursing home. FM-H confirmed R1 had already discharged , stating, I was paying another nursing home then also. BOM-D told me I was golden. I told BOM-D I continue to get bills and nothing shows I paid. Every month from February to April 23rd, shows I paid nothing. I was trying to spend down for R1 to be eligible for Medicaid. BOM-D also said that the statement showed charges, but they were probably meant to be payments and BOM-D would take care of it, but never did. FM-H added that ever since February, BOM-H was to file for Medicaid for R1; however, FM-H heard nothing for months and then something saying R1 was not approved. After R1 left the facility, FM-H worked on getting R1 Medicaid and learned BOM-H gave an inaccurate social security number when applying originally. FM-H indicated having proof of what was paid in R1's bank statements as a means to get Medicaid for R1, stating, it was an absolute mess. BOM-D did not always give me copies of receipt of payment. It was always BOM-D who I paid. I made out all the checks to the facility name and thought, how could BOM-D be taking the money, right? It was messed up! I was paying $10,500 for minimal care. I first became concerned about where the money was going when I asked for the statement on letterhead. It was awful between the care and the funding, I felt something was off. I am scared, I don't have $7,000 to pay this new bill.On 10/30/25 at 11:55 PM, Surveyor interviewed DOO-F who denied knowing of anything about resident finances, misappropriation, issues with accounts receivables or anything with money at all. When asked who had access to money, DOO-F indicated NHA-A. When asked who would have had access to money prior to NHA-A's employment, DOO-F noted BOM-D and added, I don't know BOM-D, only a couple interactions. Surveyor again asked if DOO-F was aware of any money concerns and DOO-F answered, No. Surveyor requested financial statements for R1, R2, R3, R4, R5 and R6 from DOO-F dating back to January 2024.2. R2 was admitted to the facility on [DATE] and discharged [DATE]. Face sheet indicated R2 was responsible for self at that time and that Managed Care Organization (MCO) received the bill. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and diabetes. BIMS completed on 6/10/25 scored 15 indicating intact cognition.On 10/30/25 at 12:30 PM, Surveyor interviewed SW-E who indicated R2's family member, FM-J had called the facility concerned about where R2's check was, indicating MCO has not been paid since May for R2's care.On 10/30/25 at 1:29 PM, Surveyor interviewed FM-J who indicated having concerns with the facility and how R2's finances are being handled. FM-J stated, I am not sure what is being paid for or not or where the money is going. FM-J indicated this to still be an issue despite R2 having been discharged from the facility on 8/5/25. FM-J explained that R2 is now residing in an AL and R2's bills are not being paid for, R2's SSI check is not coming to R2. FM-J indicated having contacted SW-E about the concerns. FM-J indicated things are not lining up and cannot get answers for R2. We just do not know where the money is. We cannot pay for the AL and they are going to kick R2 out. R2 is worried. R2's Managed Care Organization (MCO) is indicating the money has to be going somewhere. We do not know where it is, just that it is in a bank account somewhere. R2 does not have a bank account, cannot drive or go anywhere so R2 cannot sign to have money moved and I did not open an account for R2 anywhere. When R2 went to Waterfall (prior name of facility), they had R2 sign over checks to them; then MCO started and said they would handle costs but they also have not gotten money. R2 is worried because R2 has been told R2 will be getting kicked out and the bills keep piling up.On 10/30/25, Surveyor reviewed R2's RFMS statement provided by NHA-A. The statement showed monthly deposits labeled SSA Tres along with monthly entries labeled care cost auto wdl (withdrawal) from August 2024 to October 2025. Surveyor reviewed R2's medical record which indicated Stop Billing on 8/5/25 at which time R2 discharged from the facility. NHA-A confirmed care payments were auto withdrawn past the date of R2 residing in the facility. NHA-A indicated R2's October SSI check also came to the facility, but NHA-A sent it back. NHA-A confirmed the statement showed no credits had been made to R2 for monies withdrawn after R2 left the facility nor from MCO funds.On 10/30/25 at 2:30 PM, Surveyor interviewed MCO Finance Manager, MCO-K, who indicated not having heard where R2's SSI checks are going. R2 would have to open own account because they (MCO) are not rep payee for R2. MCO-K indicated having gotten no payment since R2 enrolled in MCO on 5/1/25. MCO-K indicated since that date, the SNF (skilled nursing facility/nursing home) should not have pulled any money because we (MCO) have paid the facility since May. They (SNF) should not be withdrawing care costs. Surveyor asked if MCO is auto withdrawing money from an account. MCO-K indicated we would only be able to withdraw from an enrollee's own personal account with approval, we cannot withdraw from another facility account. We paid for R2's care since 5/1/25, they (SNF) should not be withdrawing funds. MCO-K indicated there has now been 5 months of patient liability not paid to the MCO, putting R2 at risk for disenrollment.On 10/30/25 at 12:30 PM, Surveyor interviewed NHA-A and DOO-F, both indicated not having completed a thorough investigation into financial concerns. DOO-F again denied being aware of financial concerns.On 10/31 at 12:47 PM, MCO-K contacted Surveyor related to R2, and started learning that BOM-D was the authorized rep for Social Security (SS) for R2. R2 is bedridden but SS office said R2 needs to come to their office to straighten this out. MCO-K was concerned as to what could be done, indicating possibly could get R2 a rep payee; however, this may not help with getting past funds back. Discussed having police assist as well as they had to do that one other case in the past. MCO-K indicated the facility has not yet contacted them about this matter. MCO-K was not aware BOM-D, as R2's authorized rep for SSI, was no longer working the facility. MCO-K indicated now that they know R2 was not holding or using the patient liability, they would continue to work with R2 and FM-J to get the funds back and keep R2 enrolled so R2 can continue to reside at the AL.On 10/30/25 at 1:03 PM, Surveyor interviewed Owner-G who indicated not being aware of any financial concerns that Owner-G could recall. Owner-G stated was also not aware of any issues with resident payments not being applied to statements, stating, I don't believe so, I do not recall. When asked if knew of any money concerns in general, stated, I don't recall, I would have to ask DOO-F. When asked if there were any conversations about paying residents back, Owner-G responded, I do not remember a specific case.3. R3 was admitted to the facility on [DATE] and remains in the facility. Diagnoses include dementia, anxiety, and depression. BIMS score of 6, indicating severe impairment. R3's healthcare Power of Attorney was activated 4/3/24 and R3 had no financial representative.On 10/30/25 at 8:45 AM, Surveyor interviewed NHA-A who indicated having concerns for R3's funds due to there being multiple checks written from R3's checkbook that have not been accounted for. NHA-A added R3 is having issues getting Medicaid because of this mess.On 10/30/25, Surveyor reviewed R3's medical record which the face sheet indicated R3 is own person, resident's BIMs indicated severe impairment since 8/7/24, with the most recent BIMs of 6 on 8/5/25. (Score of 0-7 = Severe cognitive impairment.) An incapacitation form signed by two physicians was located in the medical record dated 4/3/24. Surveyor noted that three checks were scanned into the finance area of the record. Surveyor requested a copy of these checks. On 10/30/25 at 4 PM, NHA-A provided Surveyor copies of the three checks that were scanned into R3's medical record. Surveyor asked if anything seemed unusual about the checks and NHA-A indicated, Yes, the signature is not R3's handwriting and said NHA-A had noticed that prior to 10/30/25 survey. Surveyor confirmed signatures appeared to be a different style of penmanship.On 10/30/25 at 2:02 PM, Surveyor interviewed R3's Power of Attorney for Healthcare (POAHC) who indicated not being responsible for billing/finances for R3 but was sent a few bills, talked to someone in the office at the facility (not sure who) and they said it would be taken care of but then the second bill was sent a little over a month ago and so I just ignored it, I did not pay it.On 10/30/25, NHA-A provided Surveyor a list of check numbers with dollar amounts which was sent to third-party billing company on 10/10/25. NHA-A indicated the billing company informed NHA-A they had not received the checks on the list. NHA-A confirmed R3 or R3's representative had not been informed of concerns. NHA-A indicated not having time to investigate further. 4. R4 was admitted to the facility 3/3/25 and remains in the facility. Diagnoses include quadriplegia, depression, anxiety, and chronic pain. Face sheet indicates responsible for self, no rep payee; however, on 11/3/25 NHA-C indicated facility was rep payee for R4. R4's BIMS was 13 on 10/2/25.On 10/30/25 at 9:50 AM, Surveyor interviewed SW-E who indicated R4 once had a lot of money, has no family and now has no funds. SW-E had concerns of misappropriation of funds. SW-E said, I would have called the police right away; corporate said they would handle it, but they did not.On 10/30/25 at 12:15 PM, Surveyor interviewed R4, who could only answer yes or no questions. R4 was unaware of financial issues.5. R8 was admitted to the facility on [DATE] and remains in the facility. R8 has diagnoses of major depressive disorder and adult failure to thrive. The face sheet indicated R8's nephew is responsible for billing and also indicates facility is representative payee.On 10/30/25 at 9:50 AM, Surveyor interviewed SW-E who indicated having concerns that R8 had approximately $2,000, only buys soda and now R8's funds are low; SW-E indicated that SW-E was concerned misappropriation was occurring.6. On 10/30/25, Surveyor reviewed July bank statement for the account only BOM-D was aware of and had access to. A deposit in the amount of $1,182.56 was noted to be entered on 7/23/25. NHA-A provided Surveyor with a copy of an AFLAC insurance check dated 6/6/25 with a stamped date of 7/23/25 (deposit date) in the amount of $1,182.56. The check was made out to the facility. NHA-A was not able to indicate which resident the check was intended for. On 10/30/25 at 2:57 PM, DOO-F presented to the Surveyor along with NHA-A and a cell phone which was on speaker mode. DOO-F explained the third-party billing company was on the phone and we were speaking with billing employee (BE)-M. DOO-F told Surveyor to explain what it was Surveyor had requested earlier in the day. Surveyor requested the billing statements for R1, R2, R3, R4, R5 and R6. BE-M seemed confused asking what exactly was needed. Surveyor explained again and asked for a date range of those statements. BE-M indicated could go back as far as January 2025.On 10/30/25 at 4 PM, NHA-A indicated to Surveyor that NHA-A contacted the police and will be filing a self-report related to misappropriation of funds to the SA.On 10/30/25 after 4 PM, a police officer presented and discussed the situation with NHA-A and DOO-F as well as Surveyor. NHA-A indicated to officer that bank indicated at least $5,000 was in question. Officer asked if BOM-D's email had been cancelled, and NHA-A indicated not being certain but would take care of that. NHA-A indicated to officer that approximately $300 was taken from the account BOM-D closed.On 10/31/25 at 10:05 AM, NHA-A contacted Surveyor via phone indicating that Owner-G's sister left a voicemail on 10/29 indicating that another resident's (R13) family is questioning billing statement because it had doubled the normal price despite having fully paid through September. Also, R12 is again questioning R12's statement amounts, SW-E had reminded NHA-A that R12 had concerns in the past. NHA-A indicated concerns that those payments may have been directed to the account BOM-D was utilizing. On 10/31/25 at 12:39 PM, Surveyor interviewed BOM-D who confirmed meeting with NHA-A and DOO-F on 10/22/25. BOM-D indicated I was told I needed to resign, that was pretty much my only option. BOM-D confirmed having a debit card for a business account that BOM-D was the authorized user of and confirmed closing the account. BOM-D had inconsistent answers in terms of how the money was spent and how the account came to be and would divert to other topics of conversation during interview.The facility's failure to respond to suspected misappropriation created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 11/3/25, however, the deficient practice continues at a scope/severity of level E (potential for more than minimal harm/pattern) as the facility continues to implement the follow action plan:1. The NHA and member of a governing body conducted an audit of past residents' funds. Credits will be made to families who are owed. The NHA and member of the governing body reviewed the petty cash policy reviewed and implemented on 11/1/25.2. The Director of Nursing (DON), Social Service Director (SSD) and Minimum Data Set (MDS) nurse)/care plan nurse will review clinical documents to identify any negative outcome that may have resulted from the alleged deficiency. The following document were reviewed: NAR report, 24-hour summary, order report listing, incident report portal, transfer/discharge log, concern log and resident council minutes.3. The DON/ SSD/Nurses will complete assessment of all residents to identify any negative psychosocial outcomes or worsening of overall condition that may have resulted from the alleged deficiency. The attending physician/Nurse Practitioner (NP) of the resident will be notified of any negative findings.4. The NHA/SSD/DON will conduct interviews of interviewable residents to identify if they have any concern related to mishandling, misused and/or misappropriation of their funds. Any identified concern will be reported to the state agency and law enforcement, and investigation will be conducted. For residents who are not able to participate in the interviews, the NHA/SSD/DON will interview the resident representatives.5. The corporate BOM will also audit all residents' status of benefits (Medicaid and Managed Care) to identify any concern. An investigation will be conducted if any concern is identified. Any identified misappropriation of residents' funds and exploitation will be reported to the NHA, state agency and law enforcement.

Based on record review and interview, the facility did not report suspected misappropriation and/or exploitation of resident funds to the State Agency (SA) or to local authorities immediately upon discovery. The facility's failure to report the allegations affected 5 residents (R) of 8 residents (R1, R2, R3, R4, and R8) reviewed and had the potential to affect other residents who had financial accounts or made payments at the facility.Nursing Home Administrator (NHA)-A identified concerns related to misappropriation and/or exploitation on 10/8/25 after reviewing a bank statement of an account under the facility name that NHA-A was not aware existed. The statement showed a cash withdrawal and a money order. The bank informed NHA-A that Business Office Manager (BOM)-D had a checkbook and debit card for this account. NHA-A believed BOM-D opened this account. NHA-A reported the concerns to Director of Operations (DOO)-F and Owner-G. DOO-F instructed not to report these concerns to the SA nor police department.NHA-A suspected that deposits of money to the above-noted bank account may have been from payments provided to BOM-G for residents' monthly room and care fees instead of being entered into the facility Resident Fund Management System (RFMS) (a software system connected to financial accounts for residents which provides direct deposits and direct debits with automatic care costs payments), including R1's payments. This was not reported to the SA nor police department.Social Worker (SW)-E indicated R2's family had expressed concerns about where R2's Social Security check was and they were planning to file a complaint as they did not know where R2's funds were going.On 10/10/25, NHA-A noted that R3's personal checkbook had 13 checks written from it from 8/12/24 to 8/28/25. NHA-A had concerns as to where the funds were. NHA-A indicated being suspicious that the signature on some of R3's personal checks were not that of R3's handwriting. This was not reported to the SA or police department.Social Worker-E had concerns related to R4's funds. SW-E indicated R4 had a lot of money and no family. NHA-A indicated R4 now has a negative balance in R4's account and the facility was rep payee for R4. Both SW-E and NHA-A had concerns that R4's money may have been misappropriated. This was not reported to the SA or police department.SW-E and NHA-A shared concerns that R8 had funds in the amount of approximately $2,000 and only purchases soda and is now without funds in a short amount of time. This was not reported to the SA nor police department.An insurance check from AFLAC was deposited into the bank account only BOM-D was aware of and had access to. NHA-A was not able to indicate which resident this check was intended for. This was not reported to the state agency nor police department. The facility's failure to report the suspected resident misappropriation and/or exploitation created a finding of immediate jeopardy that began on 10/08/25. Surveyor notified NHA-A of the immediate jeopardy on 10/31/25 at 1:15 PM. The immediate jeopardy was removed on 11/3/25, however, the deficient practice continues at a scope/severity level E (potential for more than minimal harm/pattern) as the facility continues to implement their action plan.Findings:On 10/30/25, Surveyor reviewed a facility-provided policy titled Resident Right to Freedom from Abuse, Neglect and Exploitation which had a consulting company's trademark date of 2025 and stated in part:Policy: The Facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility.Procedure: XII: The Facility will ensure compliance with the Elder Justice Act pursuant to the Facility's Elder Justice Act Policy and Procedure. XII: A a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported in the proper time frame pursuant to this policy.On 10/30/25 at 8:45 AM, Surveyor interviewed NHA-A who indicated there have been concerns with residents' statements not reflecting payments made. NHA-A indicated that BOM-D was collecting resident care/room and board payments at the facility. NHA-A believed BOM-D opened up a small business account at a local bank under the name of the facility and put resident funds meant for payment of care/room and board into this account and then utilized the money personally. BOM-D is no longer employed at the facility as of 10/22/25.NHA-A further explained that on 10/8/25, while BOM-D was off work for a medical leave, a bank statement for the month of September 2025 came in the mail to the facility. NHA-A opened it and was not familiar with this account at a local bank. NHA-A noted cash withdrawal and a money order in large amounts on the statement. NHA-A spoke with bank employees who indicated the account had a debit card and checkbook assigned to BOM-D. Bank Executive [NAME] President (VP)-I was pulled into the situation, reviewed the charges, and indicated to NHA-A that VP-I believed there to be fraud occurring.On 10/8/25, NHA-A notified facility Owner-G and Regional Directors, including Director of Operations (DOO)-F of the concerns via an email. NHA-A indicated after discussing with DOO-F, NHA-A was ultimately directed that if BOM-D resigned on own that they would consider this to be stealing from the facility and any residents affected, Owner-G would pay back their money. NHA-A was instructed not to report this to the SA or police department. NHA-A confirmed BOM-D resigned following a disciplinary meeting with NHA-A and DOO-F on 10/22/25.NHA-A provided Surveyor with an email that was sent by NHA-A to facility owner-F and DOOs, including DOO-F. The email was dated 10/8/25 and contained the following information: .Today I opened a bank statement with the company's name on showing large withdrawals. This was the first time that I have ever seen this statement. I spoke to staff at the bank who stated that the withdrawals were all done via a debit card and the debit card was issued to BOM-D. then spoke with bank Executive VP-I, who looked at the account. with follow up call with VP-I, VP-I did say from reviewing the account VP-I fully believes there is fraud that is occurring. From looking briefly at the deposits, I am wondering if some of those deposits are maybe resident deposits, that (BOM-D) has been blaming the facility's third party billing company for not making. NHA-A further indicated that on 10/8/25, NHA-A inquired with SW-E if SW-E was aware of a bank account held by the facility which had a debit card attached to it for which SW-E was not aware of. NHA-A informed Surveyor that on 10/8/25, after SW-E questioned BOM-D about having a debit card, BOM-D went to the local bank and closed the account. NHA-A indicated knowing this because the bank contacted NHA-A via phone to notify NHA-A of this.On 10/30/25 at 9 AM, Surveyor reviewed a September bank statement which NHA-A indicated was the one that was of initial concern to NHA-A. The statement was from a local bank, contained the facility's address and recent name and included three purchases on 9/2/25 at two separate gas stations for $16.29, $10.00, and $12.24, a withdrawal on 9/2/25 of $875.00 and on 9/6/25 a money order/cash back transaction of $678.00. On 10/30/25 at 9:50 AM, Surveyor interviewed SW-E who confirmed being informed that BOM-D had a bank account in the facility's name by NHA-A. SW-E asked BOM-D about it on 10/08/25 at which point BOM-D indicated not knowing if there was a debit card for the facility accounts and that BOM-D didn't have it if there was one.SW-E indicated having concerns that R8 had approximately $2,000, only buys soda, and now funds are low; that R4 had a lot of money, has no family, and now has no funds. SW-E indicated running into R1's family in a local store and they had concerns regarding where payments had gone. Also, R2's family was upset as they were unable to locate where R2's Social Security income was going since residing at the facility. SW-E indicated that SW-E believed misappropriation was occurring and reported being upset about the thought of this, not sleeping at night. SW-E indicated, I would have called police right away if it were up to me. On 10/30/25, Surveyor reviewed July bank statement for the account only BOM-D was aware of and had access to. A deposit in the amount of $1,182.56 was noted to be entered on 7/23/25. NHA-A provided Surveyor with a copy of an AFLAC insurance check dated 6/6/25 with a stamped date of 7/23/25 (deposit date) in the amount of $1,182.56. The check was made out to the facility. NHA-A was not able to indicate which resident the check was intended for. On 10/30/25, Surveyor reviewed medical records for R1, R3, R4, and R8 noting the following:R1 was admitted to the facility 1/14/25 and discharged [DATE]. Face sheet indicates yes to rep payee and R1 was responsible for self. R1 had diagnoses of Crohn's disease and cellulitis. A Brief Interview for Mental Status (BIMS) completed 4/23/25 indicated a score of 15/15 indicating intact cognition.On 10/30/25 at 10:59 AM, Surveyor interviewed R1's family member (FM)-H. FM-H indicated having concerns while R1 resided at the facility with both care and financials. FM-H explained that FM-H kept getting bills for R1's stay despite having paid multiple cashier checks to the facility through BOM-D. FM-H indicated, we paid self pay for R1's stay at the facility and were spending down R1's money as they knew R1 would be long-term. We were paying over $10,000 a month, but we kept getting bills that did not reflect payments. In fact, just this Monday, 10/27, I received a bill saying we owe $7,000, but payments were made already. R1 has been at another facility since May as I would not bring R1 back there after a hospitalization. I have called and called trying to get this taken care of and I was having to pay another facility. I had actually overpaid (to Amethyst). I would call BOM-D and was told it was taken care of, but it was not. I eventually had BOM-D put it in writing that I had paid the checks to the facility and was paid up, requesting it to be on letterhead. BOM-D typed something up, but it was not on letterhead, it was on plain paper and I said that was ridiculous. BOM-D only typed the facility name on top of the paper and said to contact BOM-D. The most recent bill says I only made two payments. Over the stay, I would call BOM-D and would say it's resolved but it wasn't, would make excuses like they must have entered my payment as a debit on accident and that BOM-D would take care of it, but never did. I had called Directors on the phone and left messages but no return. I am afraid I am going to go to collections. I did cashier checks so that I had a paper trail. I found it odd that BOM-D would offer to meet me on BOM-D's days off and even offered I come to BOM-D's house to drop off payment, also offered to meet me on Saturday or Sunday to bring payment or end of the day after BOM-D had left work already. I came in monthly with payment, last time was beginning of June and presented one extra check for partial payment; it was approximately $1,200 to $1,400. BOM-D said I would be paid back for that. I wanted to have the billing issues resolved because I had a new nursing home to pay for now. BOM-D would say I am golden (paid up). I told BOM-D that I continued to get bills and nothing changed. Every month from 2/10 to 4/23, it would say nothing was paid and nothing after. I'd pay more and more. We were trying to spend down so R1 would have care; we tried to stay ahead so we could get R1 taken care of (health wise). I would get text messages from BOM-D, and I thought, This is messed up, this is not right. I thought I am making the checks directly to the facility name, how could BOM-D be taking it, right? $10,500 a month and getting minimal care. I would hear no word from the corporate company, just text or call from BOM-D. At first, other than a text or call from BOM-D, there were no statements from an outside entity. Until 2-3 months later, I would get a bill and it showed charges vs credits. I started to really become concerned after BOM-D did that letter. R1 is now finally approved for Medicaid. That was a concern as well as BOM-D told me in February BOM-D had applied for R1; for months there was no contact from Medicaid and once I moved R1, found out BOM-D entered R1's information incorrectly (wrong SSN). I applied on own and was able to get Medicaid for R1. I was able to show proof of payments I had kept to get Medicaid. It was awful between the care and funding and kept feeling something was off. I am scared; I don't have an extra $7,000 to pay. Also, BOM-D did not always give me copies of my payments. It was always BOM-D I paid. It was a nightmare. I was thankful the new facility was so patient while I reapplied for Medicaid, and I was lucky the consortium helped me get Medicaid with this mess. On 10/30/25 at 11:55 AM, 12 PM, 12:30 PM, and 2:15 PM, Surveyor interviewed DOO-F, who denied on each occasion knowing anything about situations or issues with resident finances or issues with accounts payable/receivables or concerns with BOM-D. Surveyor asked DOO-F if in general DOO-F is aware of any financial issues and DOO-F again stated no. R3 was admitted to the facility 4/5/23 and remains in the facility. Diagnoses include dementia, anxiety, and depression. BIMS completed 8/5/25 indicated a score of 6/15, indicating severe cognitive impairment. R3's healthcare Power of Attorney (POAHC) was activated 4/3/24 and R3 had no financial representative.On 10/30/25 at 2:02 PM, Surveyor interviewed R3's Power of Attorney for Healthcare (POAHC) who verified not being responsible for billing/finances for R3 but was sent a few bills, talked to someone in the office at the facility (not sure who) and they said it would be taken care of but then the second bill was sent a little over a month ago and so I just ignored it, I did not pay it.Surveyor reviewed R3's medical record which the face sheet indicated R3 is own person on, resident's BIMS was that of severe impairment since 8/7/24, with the most recent BIMS of 6 on 8/5/25. (Score of 0-7 = Severe cognitive impairment.) An incapacitation form signed by two physicians was located in the medical record dated 4/3/24. Three checks were scanned into the record, each with R3's name signed but in different handwriting styles on each check.NHA-A provided Surveyor a list of check numbers with dollar amounts from R3's checkbook which was sent to the third-party billing company on 10/10/25. NHA-A indicated the third-party billing company informed NHA-A they had not received the checks. NHA-A indicated not having time to investigate further. On 10/30/35 at 1:03 PM, Surveyor interviewed Owner-G who indicated not recalling any concerns related to financials for residents. R2 was admitted to the facility on [DATE] and discharged [DATE]. Face sheet indicated R2 was responsible for self at that time and that Managed Care Organization (MCO) received the bill. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and diabetes. BIMS completed on 6/10/25 scored 15 indicating intact cognition. On 10/30/25 at 1:29 PM, Surveyor interviewed R2's family member (FM)-J who expressed concerns about where R2's money was going, indicating things are not lining up and cannot get any answers. Where is the money? Once R2 went to Waterfall (prior name of facility), they had R2 sign over checks to them and now MCO says they are not getting paid. R4 was admitted to the facility 3/3/25. Diagnoses include quadriplegia, depression, anxiety, and chronic pain. Face sheet indicates R4 responsible for self, no rep payee; however, on 11/3/25, NHA-C indicated facility was rep payee for R4.R8 was admitted to the facility on [DATE] and remains in the facility. R8 has diagnoses of major depressive disorder and adult failure to thrive. The face sheet indicated nephew is responsible for billing and also indicates facility is representative payee. On 10/30/25 at 2:15 PM, NHA-A indicated to Surveyor that on 10/13, NHA-A sent a list of deposits, banks statement, and withdrawals for the bank account in concern. The email indicated BOM-D has signed for everything listed. The email was addressed to Owner-D and DOO-F. NHA-A also provided Surveyor with an email dated 10/14/25 about BOM-D which included:. has withdrawn money for money orders and cash that were never for the company.trying to blame the third-party billing company for R1's $2,400 deposit not being put into R1's account. The third-party billing company never received the check as BOM-D put it in the small business account. SW-E also knows of another resident who had over $2,000 in RFMS and now has no money typically, only purchased soda. I have not had the opportunity to dig more into the past RFMS. SW-E had no idea that this account ever existed, or that there were checks or a debit card. I have never seen a checkbook and even SW-E and I went through BOM-D's office.On 10/30/25 at 2:25 PM, Surveyor interviewed DOO-F who again indicated having no knowledge of financial concerns or issues at the facility. DOO-F also indicated not knowing BOM-D, as had only a couple interactions.On 10/30/25 at 3:07 PM, Surveyor again asked DOO-F in the presence of NHA-A if DOO-F was aware of any financial concerns at the facility, DOO-F again initially denied and then asked NHA-A if NHA-A was aware of anything at which time NHA-A indicated, Yes, we talked about this. DOO-F initially indicated not knowing what NHA-A meant and then admitted to knowing something about a bank account.On 10/30/25 at 4 PM, NHA-A provided Surveyor copies of the three checks that were scanned into R3's medical record. Upon handing the checks to Surveyor, Surveyor asked if anything seemed unusual about the checks and NHA-A indicated, the signature is not R3's handwriting.On 10/30/25 at 4:20 PM, NHA-A informed Surveyor that NHA-A had now contacted the police department about these concerns and will be submitting a report to the SA.On 10/30 and 10/31, Surveyor requested policies for accounts receivables and accounts payable; none were provided. On 11/3/25, NHA-C provided policies with an effective date of 11/2/25. The failure to report suspicion of misappropriation and/or exploitation of residents' funds created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 11/3/25; however, the deficient practice continues at a scope/severity of level E (potential for more than minimal harm/pattern) as the facility continues to implement the following action plan:1. The DON/SSD (Social Service Director)/Nurses will complete assessment of all residents to identify any negative psychosocial outcomes or worsening of overall condition that may have resulted from the alleged deficiency. The attending physician/NP (nurse practitioner) of the resident will be notified of any negative findings.2. The NHA (Nursing Home Administrator)/SSD/DON will conduct interviews of interviewable residents to identify if they have any concern related to mishandling, misused and/or misappropriation of their funds. Any identified concern will be reported to the state agency and law enforcement, and investigation will be conducted. For residents who are not able to participate in the interviews, the NHA (Nursing Home Administrator)/SSD/DON will interview the resident representatives.3. The corporate business office manager will also audit all residents' status of benefits (Medicaid and Managed Care) to identify any concern. An investigation will be conducted if any concern is identified. Any identified misappropriation of residents' funds and exploitation will be reported to the NHA, state agency and law enforcement.4.The NHA/DON will provide training to the department heads (Activities, SSD, BOM - business office manager, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) related to the intent of F609, facility policy related to Abuse, Neglect, Exploitation and Misappropriation, focusing on the reporting requirements and responsibility of the staff to misappropriation of resident property, and exploitation to the state agency and police department. The DON/NHA/trained department head will provide training to all staff about reporting allegations of abuse, neglect and misappropriation to the Administrator/DON immediately. The staff members who are not available will receive their education prior to starting their shift upon return to work.

Based on record review and interview, the facility did not thoroughly investigate suspected misappropriation and/or exploitation of resident funds. The facility's failure to investigate the alleged misappropriation/exploitation affected 5 residents (R) of 8 residents (R1, R2, R3, R4, and R8) reviewed and had the potential to affect other residents who had financial accounts or made payments at the facility.Nursing Home Administrator (NHA)-A identified concerns related to misappropriation and/or exploitation on 10/8/25 after reviewing a bank statement of an account under the facility name that NHA-A was not aware existed. The statement showed a cash withdrawal and a money order. The bank informed NHA-A that Business Office Manager (BOM)-D had a checkbook and debit card for this account. NHA-A believed BOM-D opened this account and that it may have contained resident funds meant to be used for residents' care/room and board, including R1's payment. NHA-A reported the concerns to Director of Operations (DOO)-F and Owner-G. A thorough investigation into the concerns was not conducted.Social Worker (SW)-E indicated R2's family had expressed concerns about where R2's Social Security check was, and they were planning to file a complaint as they did not know where R2's funds were going. This was not thoroughly investigated.On 10/10/25, NHA-A noted that R3's personal checkbook had 13 checks written from it from 8/12/24 to 8/28/25. NHA-A had concerns as to where the funds were. NHA-A indicated being suspicious that the signature on some of R3's personal checks were not that of R3's handwriting. This was not thoroughly investigated. SW-E had concerns related to R4's funds. SW-E indicated R4 had a lot of money and no family. NHA-A indicated R4 now has a negative balance in R4's account and the facility was rep payee for R4. Both SW-E and NHA-A had concerns that R4's money may have been misappropriated. This was not thoroughly investigated.SW-E and NHA-A shared concerns that R8 had funds in the amount of approximately $2,000, R8 only purchases soda and is now without funds in a short amount of time. This was not thoroughly investigated.An insurance check from AFLAC was deposited into the bank account only BOM-D was aware of and had access to. NHA-A was not able to indicate which resident this check was intended for. This was not thoroughly investigated. On 10/30/25, Surveyor interviewed NHA-A who indicated having notified DOO-F and Owner-G of concerns of potential misappropriation; DOO-F advised NHA-A to not submit a facility-initiated report to the State Agency (SA) nor police.The facility's failure to thoroughly investigate suspected resident misappropriation and/or exploitation allowed the misappropriation/exploitation to continue, thus creating a finding of immediate jeopardy that began on 10/08/25. Surveyor notified NHA-A of the immediate jeopardy on 10/31/25 at 1:15 PM. The immediate jeopardy was removed on 11/3/25; however, the deficient practice continues at a scope/severity level E (potential for more than minimal harm/pattern) as the facility continues to implement their action plan.Findings:On 10/30/25, Surveyor reviewed a facility-provided policy titled Resident Right to Freedom from Abuse, Neglect and Exploitation which had a consulting company's trademark date of 2025 and stated in part:Policy: The Facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility.Procedure: V. The facility will develop written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI (Quality Assurance Performance Improvement) program to allow the QAA (Quality Assessment and Assurance) Committee to determine: A. If a thorough investigation is conducted. B. Whether the resident is protected. C. Whether an analysis was conducted as to why the situation occurred. D. Risk factors . E. Whether there is further need for systemic action. IX: The facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property. XII: The Facility will ensure compliance with the Elder Justice Act pursuant to the Facility's Elder Justice Act Policy and Procedure. XIII. Response: Have evidence that all alleged violations are thoroughly investigated. c. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.On 10/30/25, Surveyor reviewed medical records for R1, R2, R3, R4, and R8 noting the following:R1 was admitted to the facility 1/14/25 and discharged [DATE]. Face sheet indicated yes to rep payee and R1 was responsible for self. R1 had diagnoses of Crohn's disease and cellulitis. A Brief Interview for Mental Status (BIMS) completed 4/23/25 indicated a score of 15/15 indicating intact cognition.R2 was admitted to the facility on [DATE] and discharged [DATE]. Face sheet indicated R2 was responsible for self at the time and that Managed Care Organization (MCO) received the bill. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and diabetes. BIMS completed 6/10/25 was 15/15 indicating intact cognition.R3 was admitted to the facility 4/5/23 and remains in the facility. Diagnoses include dementia, anxiety, and depression. BIMS indicated a score of 6/15, indicating severe impairment. R3's healthcare power of attorney was activated 4/3/24 and R3 had no financial representative.R4 was admitted to the facility 3/3/25. Diagnoses include quadriplegia, depression, anxiety, and chronic pain. Face sheet indicates R4 responsible for self, no rep payee; however, on 11/3/25, NHA-A indicated facility was rep payee for R4.R8 was admitted to the facility on [DATE] and remains in the facility. R8 has diagnoses of major depressive disorder and adult failure to thrive. The face sheet indicated nephew is responsible for billing and also indicates facility is representative payee.On 10/30/25 at 8:45 AM, Surveyor interviewed NHA-A who indicated there have been concerns with residents' statements not reflecting payments made to the facility. NHA-A indicated that BOM-D was collecting resident care/room and board payments at the facility. NHA-A believed BOM-D opened up a small business account at a local bank under the name of the facility and put resident funds meant for payment of care/room and board into this account and then utilized the money personally. BOM-D is no longer employed at the facility as of 10/22/25.NHA-A further explained that on 10/8/25, while BOM-D was off work for a medical leave, a bank statement for the month of September 2025 came in the mail to the facility. NHA-A opened it and was not familiar with this account at a local bank. NHA-A noted cash withdrawal and a money order in large amounts on the statement. NHA-A spoke with bank employees who indicated the account had a debit card and checkbook assigned to BOM-D. Bank Executive [NAME] President (VP)-I was pulled into the situation, reviewed the charges and indicated to NHA-A that VP-I believed there to be fraud occurring.On 10/8/25, NHA-A notified facility Owner-G and Regional Directors, including Director of Operations (DOO)-F, of the concerns via an email. NHA-A stated after discussing with DOO-F, NHA-A was ultimately directed that if BOM-D resigned on own that they would consider this to be stealing from the facility and any residents affected, Owner-G would pay back their money. NHA-A confirmed BOM-D resigned following a disciplinary meeting with NHA-A and DOO-F on 10/22/25. NHA-A had some emails and bank statements regarding the concerns; however, stated NHA-A has not had time to fully investigate yet. NHA-A also indicated not being sure how many residents this involves.On 10/30/25 at 9 AM, Surveyor reviewed a September bank statement which NHA-A indicated was the one that was of initial concern to NHA-A. The statement was from a local bank, contained the facility's address and recent name and included three purchases on 9/2/25 at two separate gas stations for $16.29, $10.00 and $12.24, a withdrawal on 9/2/25 of $875.00 and on 9/6/25 a money order/cash back transaction of $678.00. On 10/30/25 at 9:50 AM, Surveyor interviewed SW-E who confirmed being informed by NHA-A that BOM-D had a bank account in the facility's name. SW-E asked BOM-D about it on 10/08/25 at which point BOM-D indicated not knowing if there was a debit card for the facility accounts and that BOM-D didn't have it if there was one. SW-E further explained that several family members/residents had concerns related to payments not being credited to their bills. SW-E indicated having concerns that R8 had approximately $2,000, only buys soda and now funds are low; that R4 had a lot of money, no family and now has no funds. SW-E indicated running into R1's family in a local store and they had concerns regarding where payments had gone and planned to file a complaint. Also, R2's family was upset due to not getting R2's social security check after staying at this facility. SW-E indicated that SW-E believed misappropriation was occurring.On 10/30/25 at 10:59 AM, Surveyor interviewed R1's family member (FM)-H. FM-H indicated having concerns while R1 resided at the facility with both care and financials. FM-H explained that FM-H kept getting bills for R1's stay despite having paid multiple cashier checks to the facility through BOM-D. FM-H felt something was not right with how the financials were being handled.On 10/30/25 at 11:35 AM, Surveyor interviewed NHA-A who confirmed being aware of R1's financial discrepancies and family's concerns as well as sharing NHA-A's own concerns with Owner-G and DOO-F.On 10/30/25 at 12:30 AM, Surveyor interviewed DOO-F who confirmed having no investigation related to resident financials.On 10/30/25 at 1:29 PM, Surveyor interviewed R2's family member (FM)-J who indicated having concerns with finances while R2 was at the facility and still now. FM-J stated, I am not sure what is being paid or not or where the money is going. FM-J indicated this is still not straightened out. FM-J also stated R2 is in an Assisted Living (AL) and the bills are not being paid and SSI checks are not coming. Things are not lining up and cannot get answers. Where is the money? We cannot pay the AL, and they are going to kick R2 out. R2 cannot drive or go anywhere, so she cannot sign, has no bank account, so we don't know where the SSI is, just that it's not in a bank account and the Managed Care Organization (MCO) cannot get it for care. Once R2 went to Waterfall (prior name of facility), they had R2 sign over checks to them and now MCO says they are not getting paid. R2 is worried because has been told getting kicked out and has bills piling up. On 10/30/25 at 11:55 AM, 12 PM, 12:30 PM and 2:15 PM, Surveyor interviewed DOO-F, who denied on each occasion knowing anything about situations or issues with resident finances or issues with accounts payable/receivables or concerns with BOM-D. When asked, DOO-F also indicated there had not been an investigation into financial concerns.On 10/30/25, Surveyor reviewed R3's medical record which the face sheet indicated R3 is own person on, resident's BIMS was that of severe impairment since 8/7/24, with the most recent BIMS of 6 on 8/5/25. (Score of 0-7 = Severe cognitive impairment.) An incapacitation form signed by two physicians was located in the medical record dated 4/3/24. Three checks were scanned into the record, each with R3's name signed but in different handwriting styles on each check.On 10/30/25 at 12:30 PM, Surveyor interviewed DOO-F who indicated not being aware of an investigation into resident finances and/or missing payments.On 10/30/25 at 2:02 PM, Surveyor interviewed R3's Power of Attorney for Healthcare (POAHC) who said they were sent a few bills, contacted someone in the office at the facility (not sure who) and they said it would be taken care of but then the second bill was sent a little over a month ago and so I just ignored it, I did not pay it. The facility had not contacted R3 to investigate concerns regarding R3's checks.NHA-A provided Surveyor a list of check numbers from R3's checkbook with dollar amounts which was sent to the facility's third-party billing company on 10/10/25. NHA-A indicated the third-party billing company informed NHA-A they had not received the checks. NHA-A indicated not having time to investigate further. On 10/30/25 at 2:15 PM, NHA-A indicated to Surveyor that on 10/13, NHA-A emailed Owner-D and DOO-F a list of deposits, banks statement and withdrawals for the bank account in concern. The email indicated BOM-D has signed for everything listed. NHA-A also provided Surveyor with an email dated 10/14/25 about BOM-D which included. has withdrawn money for money orders and cash that were never for the company. trying to blame third party biller for R1's $2,400 deposit not being put into R1's account. The third-party billing company never received the check as BOM-D put it in the small business account. SW-E also knows of another resident who had over $2,000 in the Resident Fund Management System (RFMS) and now has no money. Typically, only purchased soda. NHA-A indicated not having an opportunity to further investigate into the past RFMS. On 10/30/25 at 4 PM, NHA-A provided Surveyor copies of the three checks that were scanned into R3's medical record. Surveyor asked if anything seemed unusual about the checks and NHA-A indicated, the signature is not R3's handwriting. NHA-A indicated not having investigated this much further.On 10/30/25 at 9:50 AM, Surveyor interviewed SW-E who indicated R4 once had a lot of money, has no family and now has no funds. SW-E had concerns of misappropriation of funds. SW-E said, I would have called the police right away; corporate said they would handle it, but they did not. This was not thoroughly investigated.On 10/30/25 at 9:50 AM, Surveyor interviewed SW-E who indicated having concerns that R8 had approximately $2,000, only buys soda and now R8's funds are low; SW-E indicated that SW-E was concerned misappropriation was occurring. This was not thoroughly investigated.On 10/30/25, Surveyor reviewed July bank statement for the account only BOM-D was aware of and had access to. A deposit in the amount of $1,182.56 was noted to be entered on 7/23/25. NHA-A provided Surveyor with a copy of an AFLAC insurance check dated 6/6/25 with a stamped date of 7/23/25 (deposit date) in the amount of $1,182.56. The check was made out to the facility. NHA-A was not able to indicate which resident the check was intended for. On 10/30/25 at 4:20 PM, NHA-A informed Surveyor that NHA-A had now contacted the police department about these concerns and will be submitting a report to the State Agency and conducting an investigation.On 10/30/25, Surveyor interviewed NHA-A who indicated having notified DOO-F and Owner-G of concerns of potential misappropriation; DOO-F advised NHA-A to not submit a facility-initiated report to the State Agency (SA) nor police.On 10/30/25 at 9 AM, anonymous facility employee (AE)-L approached Surveyors with concerns for NHA-A. AE-L indicated that NHA-A wanted to report the misappropriation; however, those who supervisor NHA-A did not want it reported. AE-L indicated believing this matter should have been reported to the SA and police and an investigation completed. AE-L believed DOO-F planned to fire NHA-A over this matter. AE-L indicated NHA-A also having concerns of being fired if reported this situation to the SA and/or police.On 10/31/25 at 10:05 AM, Surveyor asked NHA-A if families/residents have been interviewed or updated of financial concerns since 10/30. NHA-A indicated being told by DOO-F to ask residents if they have money in an account and how that is going. Do they know how much was put in there? And to not to alert anyone; just get a sense of how things are going with them using RFMS.Cross reference F602.The failure to thoroughly investigate suspicion of misappropriation and/or exploitation of residents' funds created a reasonable likelihood for serious harm thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 11/3/25; however, the deficient practice continues at a scope/severity of level E (potential for more than minimal harm/pattern) as the facility continues to implement the follow action plan:The compliance consultant will provide the NHA, DON, new BOM and members of the governing body training about the intent of F610 and their responsibility to identify and investigate future allegations of misappropriation of residents' funds which has the potential to create a risk for residents to have financial stressors, hardships and/or potential loss of healthcare residency and funding.2. To identify residents who are like to be affected by the alleged deficiency, the following action items will be completed: The NHA (Nursing Home Administrator)/SSD/DON will conduct interviews of interviewable residents to identify if they have any concern related to mishandling, misused and/or misappropriation of their funds. Any identified concern will be reported to the state agency and law enforcement, and investigation will be conducted. For residents who are not able to participate in the interviews, the NHA (Nursing Home Administrator)/SSD/DON will interview the resident representatives.3. The corporate business office manager will also audit all residents' status of benefits (Medicaid and Managed Care) to identify any concern. An investigation will be conducted if any concern is identified. Any identified misappropriation of residents' funds and exploitation will be reported to the NHA, state agency and law enforcement.4. To identify any negative outcome, the DON/SSD (Social Service Director)/Nurses will complete assessment of all residents. The attending physician/NP (nurse practitioner) of the resident will be notified of any negative findings.5. The NHA will initiate the investigation while ensuring residents are protected from further misappropriation of property and exploitation.6. The Compliance consultant will provide training to the RDO (Regional Director of Operations), NHA, DON, and members of the governing body, related to the intent of F610, facility policy related investigation of allegations of Misappropriation of Resident Property and Exploitation and responsibility of the staff to assure thorough investigation and to implement measures to prevent further mishandling of finances and/or exploitation and to safeguard residents' finances.7. The NHA/DON will provide training to the department heads (Activities, SSD, BOM - business office manager, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) related to the intent of F610, facility policy related investigation of allegations of Misappropriation of Resident Property and Exploitation and responsibility of the staff to assure thorough investigation and to implement measures to prevent further mishandling of finances and/or exploitation and to safeguard residents' finances.8. The NHA/DON/trained department head will provide the staff with training about their responsibility to participate/cooperate with the administration when conducting an investigation. Staff who are not available will receive their education prior to starting their shift upon return to work

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 13 employees reviewed.The facility did not ensure their abuse policy was implemented when one employee's Background Information Disclosure (BID), Department of Justice Response (DOJ), and Government Findings report was not obtained before employee started working at facility, Registered Nurse (RN) H.This is evidenced by:Facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with a revised date of 04/2021, states in part: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 4. Conduct employee background checks and no knowingly employ or otherwise engage an individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.On 11/05/25, Surveyor reviewed 12 random staff Caregiver Background Check and Misconduct Reporting Compliance Check. RN H was hired on 08/22/23. Surveyor found no BID, Department of Justice (DOJ), or Government Findings report completed for RN H.On 11/05/25 at 1:10 PM, Surveyor interviewed Executive Director Assistant ([NAME]) I regarding completion of employees' BID, DOJ, and Government Findings report. [NAME] I stated that it was recently discovered that many personnel files were missing items and sweep was being done to determine which personnel files were missing items. Surveyor asked [NAME] I if any personnel files had been updated with the necessary paperwork yet. [NAME] I stated no and that currently it is just a list. Surveyor asked [NAME] I to provide a list of employees identified needing BID, DOJ, and Government Findings report. No additional documentation was provided to Surveyor by exit.On 11/05/25 at 1:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding lack of RN H's BID, DOJ, and Government Findings report. NHA A stated apologies having just recently taking over at facility. NHA A stated that a sweep was being done and those without a background check will be removed from the schedule until their background check is completed.

Based on interview and record review, the facility did not ensure required infection control training was completed for 2 out of 2 staff in Housekeeping (HSK). (HSK E and HSK D). This has the potential to affect all 33 residents.Housekeeping staff HSK E and HSK D were not provided the required infection control training since being hired. Findings include:Per State Operations Manual, appendix PP, 483.95 Infection control, states in part, .All facilities must develop, implement and permanently maintain an effective training program for all staff, which includes, training on the standards, policies, and procedures for the infection prevention and control program as described at S483.80(a)(2), that is appropriate and effective, and as determined by staff need. For the purposes of this training requirement, staff includes all facility staff (direct and indirect care functions), contracted staff, and volunteers (training topics as appropriate to role).Changes to the facility's resident population, community infection risk, national standards, staff turnover, the facility's physical environment, or facility assessment may necessitate ongoing revisions to the facility's training program for infection prevention and control.All training should support current scope and standards of practice through curricula which detail learning objectives, performance standards, evaluation criteria, and addresses potential risks to residents, staff, and volunteers if procedures are not followed. There should be a process in place to track staff participation in and understanding of the required training.On 09/24/25 at 10:00 AM, Surveyor interviewed HSK E, who stated she did not receive any training on infection control since she was hired on 01/29/25. On 09/24/25 at 10:25 AM, Surveyor interviewed HSK D, who stated she did not receive any training on infection control since she was hired on 08/21/25.On 09/24/25 at 11:00 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding housekeeping staff infection control education. NHA A stated the facility currently does not have a policy for infection control training completed nor have they provided infection control training to HSK E and HSK D. NHA A stated the expectation would be that staff receive the required training on infection control, and the facility did not provide required training.

Based on interview and record review, the facility did not provide care and treatment consistent with professional standards of practice, for 1 of 3 sampled residents (R2). The facility did not complete comprehensive assessments after R2 was re-admitted to the facility, following a hospitalization, and removal of an indwelling catheter. According to the Wisconsin Nurse Practice Act, N6.03(1), A RN (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness, or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a). Assessment. Assessment is the systemic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b). Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nurse acts delegated to LPNs (Licensed Practical Nurse) or less skilled assistants. (c). Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward a goal or achievement which may lead to modification of the nursing diagnosis. The nurse conducting an assessment after removal of an indwelling catheter should evaluate the resident's ability to void and monitor for complications. R2 was admitted to the facility on [DATE], after hospitalization for a bladder stone causing a laceration to his bladder. Diagnoses included blood loss anemia requiring transfusion. R2 was admitted to the facility with an indwelling foley catheter. On 08/26/25, R2 was sent to the emergency room (ER) for blood in urine and clotted foley catheter. Catheter was replaced and irrigated. R2 returned to the facility on [DATE]. On 08/28/25, R2 was transferred to the ER for worsening blood in his urine, blood leaking around catheter, and spasms to penis. R2 was admitted to the hospital when bleeding continued after five hours of catheter irrigation, and urinalysis came back positive for urinary tract infection (UTI). On 09/11/25, R2 was re-admitted to the facility. R2's progress notes revealed R2's bladder stent and foley catheter were removed during hospitalization. R2 was to void using urinal. Surveyor reviewed R2's record and noted there was no documentation from 09/12/25-09/13/25. On 09/23/25 at 11:07 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked DON B to describe the process for documenting when a resident re-admits from the hospital. DON B stated documentation would be based on the resident's status change. Surveyor asked DON B if a resident transferred from the facility to the hospital with an indwelling catheter and then re-admitted to the facility without an indwelling catheter, what kind of assessments and how often would assessments be completed. DON B stated she would look. On 09/23/25 at 11:31 AM, Surveyor interviewed Regional Clinical (RC) C and DON B. RC C and DON B reported at the facility's last re-certification survey on 09/04/25, the facility identified a concern with nursing assessments and documentation. RC C and DON B reported they were in the process of creating new policies, procedures, templates, and checklists for documenting assessments upon admission, re-admission, and daily skilled assessments. RC C and DON B stated they did not have a performance improvement plan related to this. RC C stated, If you had come next week, we would have had it implemented. DON B acknowledged R2's documentation did not support R2 was assessed and monitored appropriately after his re-admission from the hospital. Interviews with DON B and RC C reported the facility did not have a current policy on comprehensive assessments and nurse documentation. DON B and RC C stated the facility was in the process of creating new policies and procedures related to assessments and documentation.

Based on observation and interview, the facility did not implement infection prevention and control interventions to provide a safe and sanitary environment to help prevent the development and transmission of infections. This had the potential to affect all 32 residents (R).Staff did not change gloves and wash hands after picking up a soiled item off the floor in the kitchen.Facility staff did not use personal protective equipment (PPE) when administering subcutaneous medication to a resident (R36). Facility staff did not conduct hand hygiene after removal of soiled gloves during cares for R29.Example 1 The facility policy dated 04/01/16, titled, Sanitation - Handwashing, states in part, Employees shall wash their hands: . (5) after handling soiled equipment; (6) as much as possible during food preparation to remove soil and contamination and to prevent cross contamination; (7) when changing tasks; . (10) after engaging in any activity or task which contaminates hands. On 09/03/25 at 11:46 AM, Surveyor observed Dietary Manager (DM) C take a tray of fruit cups from the refrigerator and place it on a prep table. One of the covers on one fruit cup fell off and landed on the floor. DM C had clean gloves on at this time. DM C picked the soiled cover off floor, threw it in garbage, and did not doff gloves or wash hands. DM C then reached into the refrigerator and took a salad out, then reached into clean utensil bin and placed utensils by hot foods. Surveyor asked about hand hygiene and glove change, and DM C stated she forgot. On 09/04/25 at 1:13 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and informed of above findings. NHA A reported that DM C already reported the error of not changing gloves and washing hands after picking item off the floor. NHA A verbalized hand hygiene and glove changes should have occurred. Example 2 The Center for Disease control and Prevention (CDC), Considerations for Blood Glucose Monitoring and Insulin Administration, 8/7/2024, reads in part: The required PPE for administering insulin in a nursing home is disposable gloves. The guidelines are based on Standard Precautions, which apply to the care of all residents. On 09/03/25 at 7:40 AM, Surveyor observed Registered Nurse (RN) E prime R36's insulin pen with 2 units and then set to 32 units at medication cart. RN E entered into R36's room after using hand sanitizer from the medication cart. RN E explained to R36 she was there to give him his insulin. RN E wiped R36's abdomen with alcohol wipe and injected insulin subcutaneously without applying gloves. After leaving R36's room, Surveyor interviewed RN E about the use of gloves with administration of a subcutaneous medication. RN E reported she had looked for gloves in his room and didn't see any, and she should wear gloves when injecting medications. On 9/04/2025 at approximately 12:00 PM, Surveyor interviewed Director of Clinical Services/ RN D, who stated the expectation would be that all facility staff wear gloves during administration of insulin/subcutaneous medication. Example 3 R29 was admitted to the facility on [DATE]. R29's current diagnoses include altered mental status, cognitive communication deficit, weakness, reduced mobility, and sepsis due to Escherichia coli. On 08/04/25 at 8:07 AM, Surveyor observed Registered Nurse (RN) G and Certified Nursing Assistant (CNA) F provide wound care to R29. On R29's door is a sign for enhanced barrier precautions and to the left of R29's room door is a bin with personal protective equipment. RN G did not sanitize hands and applied a gown and gloves. CNA F sanitized hands and applied gown and gloves. CNA F assisted to position R29 on right side. RN G, with gloved hands, cleansed R29's buttocks of stool. RN G did not remove gloves and touched a paper box of Healx calibrant to remove the adhesive wound marker and placed next to R29's wounds. With the same gloved hands, RN G touched the iPad to assess and measure R29's wounds. RN G removed gloves, did not perform hand hygiene and touched the iPad to continue to assess and measure R29's wounds. RN G removed gown, exited R29's room and RN G used hand sanitizer to cleanse hands. Surveyor interviewed RN G about hand hygiene. RN G stated she did not complete hand hygiene right after removing gloves. On 08/04/25 at 10:34 AM, Surveyor interviewed Director of Nursing (DON) B about proper infection control practices with personal cares for R29. DON B stated education will be provided to staff.

Based on observation and interview, the facility did not ensure proper sanitation practices to prevent the outbreak of foodborne illness, which had the potential to affect all 32 residents.-The facility did not label 2 opened cartons of soy milk.-The facility did not ensure thermometer probes remained sanitary prior to inserting into food. The facility policy titled, Food Storage - Refrigeration, dated 04/01/16, reads in part: Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labelled (sp) and dated with expiration dates.The facility policy titled, Food Preparation and Serviced, dated November 2022, reads in part: Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned.On 09/02/25 at 9:22 AM, Surveyor entered the kitchen to complete the initial tour. Surveyor discovered 2 cartons of soy milk with no open dates. Directions on the carton state to shake well and once opened, refrigerate 7-10 days. Surveyor asked Dietary Manager (DM) C to show Surveyor the open date. DM C stated there was not one and they should have one.On 09/03/25 at 11:42 AM, Surveyor observed DM C obtain food temperature checks for lunch. DM C wiped thermometer probe with disinfecting wipes, laid it on the prep table with probe tip touching the table, removed foil on hot food, picked thermometer up, and inserted the probe into chicken carbonara dish. DM C then sanitized the probe again and set it on the prep table. The probe tip again touched the prep table. DM C removed the foil on the next hot item, picked up the thermometer, and inserted the probe tip into the mechanical soft chicken carbonara. Surveyor asked DM C if there were any potential concerns with the thermometer probe touching the prep table. DM C stated that anyone could have come by and touched or coughed on the area. On 09/04/2025 at 1:13 PM, Surveyor interviewed Nursing Home Administrator (NHA) A informing of above findings. NHA A agreed the items in the fridge should have been dated, and the prep table could have the potential for bacteria concerns.

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice has potential to affect all 32 residents residing in the facility.Dietary Manager (DM) C has been in the position since February 2025 and has not enrolled in a nationally recognized/state approved course. The facility does not have a full-time Registered Dietician (RD) at the facility and has not applied for or received a waiver.On 09/03/25 at 1:21 PM, Surveyor interviewed Dietary Manager (DM) C who reported becoming Dietary Manager in February 2025. When DM C was asked about qualifications, DM C stated she was not a certified dietary manager, certified food service manager, nor had a related associate degree. DM C stated DM C is aware of the need to take the courses but was not currently enrolled. DM C stated Registered Dietician (RD) was at the facility once a month and less than 35 hours per week and the facility does not have and had not requested a waiver.On 2/26/25 at 7:15 AM, Nursing Home Administrator (NHA) A stated the facility did not have 35 hours per week of RD services and DM C is not certified. Staff list confirmed that DM C started as Dietary Manager on 02/11/25, working approximately 7 months without meeting qualifications.

Based on record review and interview, the facility did not complete a Significant Change in Status Assessment (SCSA) for 1 resident (R1) of 12 sampled residents reviewed. R1 was admitted to hospice care on 04/10/25. A SCSA was not completed for R1. This is evidenced by: According to the Resident Assessment Instrument (RAI) manual, a significant change in status is required when a resident enrolls in a hospice program. R1 was admitted to the facility on [DATE] and has diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), acute and chronic respiratory failure with hypoxia, quadriplegia, deaf and nonspeaking, unspecified psychosis. R1 has a BIMS score of 13/15, indicating R1 is cognitively intact. R1 is deaf and able to read lips and written communication. R1 verbally expresses self but difficult to understand speech. R1 makes own health care decisions. On 09/03/25, record review noted no SCSA done within 14 days of hospice admission on [DATE]. Most recent Quarterly MDS assessment done 08/26/25. Nursing Progress note dated 04/10/25 stated, Compassus Hospice met with resident this morning along with DON (Director of Nursing) and Social Services, and resident signed up for hospice effective today 4/10/2025. On 09/03/25 at 12:25 PM, Surveyor interviewed Social Worker (SW) K when a SCSA would be done for a resident. SW K stated when a resident was admitted to hospice as an example, and changed from Medicaid to hospice. Surveyor asked SW K if a MDS SCSA was done after R1 was admitted to hospice and SW K stated, No, I do not see one was done.

Based on observation, interview, and record review the facility did not notify a resident's primary provider when there was a change of condition for 2 of 12 residents (R32 and R137) reviewed for notification of changes. - R32's primary provider was not notified for seven days after new onset edema (swelling caused by excess fluid trapped in the body's tissues). Actual harm occurred when R32 was transferred to the emergency room and diagnosed with a deep vein thrombosis (DVT). R32 was prescribed a medication to treat and prevent blood clots. Note: a DVT is a blood clot in a vein. If the blood clot or part of the blood clot loosens it can travel through the bloodstream and restrict oxygen to the lungs, causing lung damage or death. - The facility did not update the physician as ordered when R137 had greater than a three pound weight increase in a day and when R137 was not weighed daily. This is evidenced by: According to the American Medical Directors Association (AMDA), edema should be immediately reported when there is sudden onset in a resident with lung, heart, or kidney disease. If know recent history of edema with progressive unilateral or bilateral edema increasing in severity should be reported on the next office day. A grading system is often used to determine the severity of edema on a scale from +1 to +4. Edema is assessed by applying pressure on the affected area and measuring the depth of the pit (depression) and how long it lasts (rebound time). -Grade +1: up to 2mm of depression, rebounding immediately. -Grade +2: 3-4mm of depression, rebounding in 15 seconds or less. -Grade +3: 5-6mm of depression, rebounding in 60 seconds. -Grade +4; 8mm of depression, rebounding in 2-3 minutes. (https://www.osmosis.org) Example 1 R32 was admitted to the facility on [DATE] with a primary diagnosis of right sided paralysis following a cerebrovascular accident (CVA or stroke). R32 does not have a diagnosis of edema. R32's most recent Minimum Data Set (MDS), dated [DATE], confirmed R32 scored 13/15 during Brief Interview for Mental Status (BIMS) indicating intact cognition. R32's speech is slurred and sometimes she has difficulty communicating; however, she is able to understand others. Due to R32's right sided paralysis she requires assistance with all activities of daily living (ADLs), as R32 does not have use of her right-hand arm. R32's care plan, dated 07/13/23, includes a focus area of full code status with an intervention to hospitalize R32 for acute status changes. R32's physician orders confirmed she does not take medication to reduce edema. Surveyor reviewed R32's record since admission and noted the following: -07/12/23: Admission note: +2 pitting edema in both right and left feet. -08/01/23: History of CVA with right sided deficit. Plus 4-5 pitting edema to right hand. Elevation encouraged and accepted. (Physician not notified of increased edema). -08/02/23: Resident has a history of CVA and has right side deficit. 3-4+ pitting edema noted to right hand. Denies pain/discomfort this shift. Encouraged hand to be elevated. -08/03/23: Resident has a history of CVA and has right side deficit. Denies pain/discomfort this shift. Encouraged hand to be elevated. -08/04/23: Resident has a history of CVA and has right side deficit. Denies pain/discomfort this shift. Encouraged hand to be elevated. On 08/06/23 at 1:26 PM, Surveyor observed R32 lying in her bed. R32's right hand was resting on a pillow placed alongside her right thigh. Surveyor observed R32's right hand to be notably larger than her left hand, as her left hand appeared normal size and without edema. R32's right hand was fluid filled with shiny skin stretching from her wrist to her fingertips. Surveyor did not observe R32's lower legs as they were covered with a sheet. Surveyor interviewed R32. R32 used her left hand to pick up and raise her right hand, to show this Surveyor her right hand more closely. R32's fingers were curled inwards in a C shape, with her hand resembling the size and shape of a softball. R32 stated she was aware of the edema in her hand, as her son recently visited and had noted this. R32 stated her son had updated the nursing staff when he visited, A few days ago. R32 denied pain in her hand but indicated her feet and lower legs were painful. R32 confirmed she has had swollen and painful feet in the past but could not recall her right hand being swollen before. On 08/06/23 at 1:37 PM, Surveyor interviewed Registered Nurse (RN) N. RN N reported last week R32 had swelling in her left hand and this week swelling in her right hand. Surveyor asked if edema in R32's hands was normal, RN N responded that sometimes R32 sleeps on her arm. RN N stated she was not working with R32, and suggested Surveyor talk with Licensed Practical Nurse (LPN) M. LPN M overheard this and stated she noticed R32's right hand was swollen yesterday (08/05/23), with trace amounts of edema but was worse today (08/06/23). LPN M stated she had not updated R32's provider but she had time now, so she would provide this update. On 08/06/23 at 2:30 PM, Surveyor reviewed progress note which read, Resident has +3 pitting edema noted to right hand, right arm, and right foot. Resident does complain of pain to the touch. Telehealth sent to update on call dr. Dr. called back and had venous doppler ordered. Writer put in order for venous doppler to be performed by STAT imaging. On 08/07/23 at 10:21 AM, Surveyor observed ultrasound technician present in R32's room to complete venous doppler. On 08/07/23 at 10:31 AM, Surveyor interviewed LPN I. LPN I stated she has been off for the last three days. LPN I reported R32's edema Comes and goes and [R32] falls asleep on her arm and can't feel it, so it is worse at times. She is on palliative care. I'm surprised there was an order yesterday (08/06/23) for a doppler at +3 edema when last week she had +6 and there were no orders. Surveyor asked what the expectation is for updating a provider. LPN I stated, [R32] is seen by [Nurse Practitioner (NP) O], so she would have been updated on Thursday (08/03/23). Surveyor asked LPN I if it usual for a provider to be updated without entering a progress note and LPN I stated, Unfortunately, it is common. On 08/07/23 at approximately 12:30 PM, Surveyor learned that R32 had been transported to the emergency room (ER) for suspected DVT. On 08/08/23, Surveyor reviewed progress note entered on 08/07/23 at 6:01 PM: New order received to begin Eliquis at 10 MG PO BID X 7 days and then reduce to 5 MG PO BID for DX of DVT. Labs completed at Aspirus hospital indicating GFR of > 60 and Creat 0.46. Labs are not concerning. On 08/08/23, Surveyor reviewed R32's ER notes from 08/07/23, confirming that R32's diagnosis was a DVT within the right axillary vein (a vein in the upper limb, armpit, and upper side of chest wall which carries blood to the heart). On 08/08/23 at 11:03 AM, Surveyor interviewed NP O via phone. NP O reported she was contacted by facility nurse on 08/07/23 reporting that doppler was performed on R32's right arm and indicated possible DVT. NP O recommended that R32 be sent to ER. Surveyor asked NP if she had been updated on R32's edema prior to 08/07/23, and she stated she had not. NP O reported she is present in the facility on Wednesdays, and her last visit would have been 8/2. NP O stated she would expect to be updated on new onset edema to one arm. 31086 Example 2 Facility policy titled Weight Assessment and Intervention dated 03/23, read in part: Weight Assessment: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team .3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation . Surveyor reviewed R137's medical record. R137 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease stage 3A, congestive heart failure, atrial fibrillation, morbid obesity, and hypertension. Surveyor reviewed R137's physician orders. On 06/21/23, there was a physician order for Daily weight; Notify provider if more than 3 pounds in a day or 5 pounds in a week. one time a day related to chronic diastolic (congestive) heart failure . On 06/20/23, there was a physician order for a diuretic medication Torsemide Oral Tablet 60 MG (Torsemide), Give 60 mg by mouth two times a day for HTN (Hypertension) . Surveyor reviewed R137's hospital discharge after visit summary for the dates of stay of 06/12/23 - 06/19/23. The weight recorded on 06/19/23 was 192 kg (423.3 pounds). Surveyor reviewed R137's facility recorded weights. R137 was not weighed on admitted [DATE]. On 06/20/23, R137 weighed 410 pounds, which is a 13.3 pound weight loss in one day from the hospital's recorded weight of 423.3 pounds. The facility did not notify the physician of the weight loss. On 06/21/23, R137's recorded weight was 410 pounds. On 06/22/23, R137's recorded weight was 428.6 pounds, which is a 18.6 pound weight increase in a day. The facility did not follow the physician order as given on 06/21/23 to notify provider of more than 3 pounds in a day. The facility did not weigh R137 on 06/23/23, 06/24/23, and 06/26/23. The physician was not notified of the facility not following the physician order for daily weights to be obtained. On 08/09/23 at 9:16 AM, Surveyor interviewed LPN I asking about R137's weights. LPN I indicated when a resident is admitted and arrives on a stretcher they will not be weighed until the next day and unless the resident refuses a weight. LPN I indicated they do not recall R137's weights. LPN I indicated when staff obtain a weight it is given to the nurse and they should be reviewing before entering. If there is a change then the resident would be reweighed to see if the weight is accurate. The physician should be notified if any changes per the order. On 08/09/23 at 10:00 AM, Surveyor interviewed the Nursing Home Administrator (NHA) K asking about weights on admission and when a physician should be notified of a weight change. NHA K indicated it is expected a new admission should be weighed daily for 72 hours and notified if there is a change of three pounds in a day. Surveyor reviewed with NHA K of R137's weights and order for notification to the physician of change of weights and no physician notification. NHA K indicated the weights should have been completed as ordered and the physician should have been updated.

Based on observation, interview and record review, the facility did not ensure treatment and care were provided in accordance with professional standards of practice for 2 of 12 sampled residents (R32, R12). - The facility did not thoroughly assess R32's new onset edema (swelling caused by excess fluid trapped in the body's tissues). Actual harm occurred, when after seven days, R32 was sent to the emergency room for medical evaluation that confirmed that R32 was diagnosed with a deep vein thrombosis. Note: a DVT is a blood clot in a vein. If the blood clot or part of the blood clot loosens it can travel through the bloodstream and restrict oxygen to the lungs, causing lung damage or death. - The facility did not ensure R12 received wound treatment on 7 occasions per physician orders. This is evidenced by: The American Medical Directors Association (AMDA) recommends the following facility procedures for recognizing an acute change of condition (ACOC): - Communication of all patient-related information follows a defined process -All interdisciplinary team members (not just nursing assistants) are expected to report findings that might represent ACOCs -Roles and responsibilities for identifying, analyzing, managing, and communicating information about ACOCs (e.g., who can recommend tests, treatments, or transfers) are clearly assigned -In-depth discussion of ACOCs occurs at specific times (e.g., during a change-of-shift report or review of a 24-hour report) -Interdisciplinary team members and consultants follow defined procedures to report concerns, observations, or information to the appropriate individuals -Responsibility for documenting sufficient details in the medical record about symptoms, observations, discussions with physicians, etc. is clearly assigned A grading system is often used to determine the severity of edema on a scale from +1 to +4. Edema is assessed by applying pressure on the affected area and measuring the depth of the pit (depression) and how long it lasts (rebound time). -Grade +1: up to 2mm of depression, rebounding immediately. -Grade +2: 3-4mm of depression, rebounding in 15 seconds or less. -Grade +3: 5-6mm of depression, rebounding in 60 seconds. -Grade +4; 8mm of depression, rebounding in 2-3 minutes. (https://www.osmosis.org) R32 was admitted to the facility on [DATE] with a primary diagnosis of right sided paralysis following a cerebrovascular accident (CVA or stroke). R32 does not have a diagnosis of edema. R32's most recent Minimum Data Set (MDS), dated [DATE], confirmed R32 scored 13/15 during Brief Interview for Mental Status (BIMS) indicating intact cognition. R32's speech is slurred and sometimes she has difficulty communicating; however, she is able to understand others. Due to R32's right sided paralysis she requires assistance with all activities of daily living (ADLs), as R32 does not have use of her right-hand arm. R32's care plan, dated 07/13/23, includes a focus area of full code status with an intervention to hospitalize R32 for acute status changes. R32's physician orders confirmed she does not take medication to reduce edema. Surveyor reviewed R32's record since admission and noted the following: -07/12/23: Admission note: +2 pitting edema in both right and left feet. -07/13/23-07/31/23: (Surveyor was unable to find documentation related to R32's edema). -08/01/23: History of CVA with right sided deficit. Plus 4-5 pitting edema to right hand. Elevation encouraged and accepted. (Documentation does not confirm if elevation was effective). -08/02/23: Resident has a history of CVA and has right side deficit. 3-4+ pitting edema noted to right hand. Denies pain/discomfort this shift. Encouraged hand to be elevated. (Documentation does not confirm if elevation was effective). -08/03/23: Resident has a history of CVA and has right side deficit. Denies pain/discomfort this shift. Encouraged hand to be elevated. (Documentation does not include assessment of edema. Documentation does not confirm if elevation was effective). -08/04/23: Resident has a history of CVA and has right side deficit. Denies pain/discomfort this shift. Encouraged hand to be elevated. (Documentation does not include assessment of edema. Documentation does not confirm if elevation was effective). On 08/06/23 at 1:26 PM, Surveyor observed R32 lying in her bed. R32's right hand was resting on a pillow placed alongside her right thigh. Surveyor observed R32's right hand to be notably larger than her left hand, as her left hand appeared normal size and without edema. R32's right hand was fluid filled with shiny skin stretching from her wrist to her fingertips. Surveyor did not observe R32's lower legs as they were covered with a sheet. Surveyor interviewed R32. R32 used her left hand to pick up and raise her right hand, to show this Surveyor her right hand more closely. R32's fingers were curled inwards in a C shape, with her hand resembling the size and shape of a softball. R32 stated she was aware of the edema in her hand, as her son recently visited and had noted this. R32 stated her son had updated the nursing staff when he visited, A few days ago. R32 denied pain in her hand but indicated her feet and lower legs were painful. R32 confirmed she has had swollen and painful feet in the past but could not recall her right hand being swollen before. On 08/06/23 at 1:37 PM, Surveyor interviewed Registered Nurse (RN) N. RN N reported last week R32 had swelling in her left hand and this week swelling in her right hand. Surveyor asked if edema in R32's hands was normal, RN N responded that sometimes R32 sleeps on her arm. RN N stated she was not working with R32, and suggested Surveyor talk with Licensed Practical Nurse (LPN) M. LPN M overheard this and stated she noticed R32's right hand was swollen yesterday (08/05/23), with trace amounts of edema but was worse today (08/06/23). On 08/06/23 at 2:30 PM, Surveyor reviewed progress note which read, Resident has +3 pitting edema noted to right hand, right arm, and right foot. Resident does complain of pain to the touch. Telehealth sent to update on call dr. Dr. called back and had venous doppler ordered. Writer put in order for venous doppler to be performed by STAT imaging. On 08/07/23 at 10:21 AM, Surveyor observed ultrasound technician present in R32's room to complete venous doppler. On 08/07/23 at 10:31 AM, Surveyor interviewed LPN I. LPN I stated she has been off for the last three days. LPN I reported R32's edema Comes and goes and R32 falls asleep on her arm and can't feel it, so it is worse at times. She is on palliative care. I'm surprised there was an order yesterday (08/06/23) for a doppler at +3 edema when last week she had +6 and there were no orders. On 08/07/23 at approximately 12:30 PM, Surveyor learned that R32 had been transported to emergency room (ER) for suspected DVT. On 08/08/23, Surveyor reviewed progress note entered on 08/07/23 at 6:01 PM: New order received to begin Eliquis at 10 MG PO BID X 7 days and then reduce to 5 MG PO BID for DX of DVT. Labs completed at Aspirus hospital indicating GFR of > 60 and Creat 0.46. Labs are not concerning. On 08/08/23, Surveyor reviewed R32's ER notes from 08/07/23, confirming that R32's diagnosis was a deep vein thrombosis within the right axillary vein (a vein in the upper limb, armpit, and upper side of chest wall which carries blood to the heart). 47657 Example 2 R12 was admitted to facility with primary diagnosis of acute osteomyelitis of left ankle and foot. R12 has a physician order for wound dressing change: Cleanse NS (normal saline), pack wound with packing strips, 4x4, and wrap with kerlix two times a day AM (morning) and HS (hour of sleep). On 08/07/23 at 9:44 AM, Surveyor reviewed R12's Treatment Administration Record (TAR) for twice a day wound dressing change with noted 7 blank entries indicating treatment was not completed on: AM: 7/22 and 7/24; PM 7/21, 7/26, 7/30, 7/31 and 8/1. On 08/08/23 at 12:12 PM, Surveyor interviewed LPN I regarding expectations of documenting wound treatments completed and what is expected if a resident was unavailable or refused. LPN I stated she would click the No button and a pop up comes up to document the specific reason why the treatment wasn't completed, including the availability to document information in the progress note. When asked regarding if blanks are left in the record, LPN I stated there should not be any blanks because of the different codes that could be used to indicate why the treatment wasn't completed. On 08/09/23 at 8:40 AM, Surveyor interviewed LPN I regarding the missing TAR entries for wound care. LPN I stated on several of the occasions she was the nurse working and knows she completed the dressing change but unable to state why the TAR was blank. LPN I was asked why any entry would be blank. LPN I stated there are different codes nurses can utilize and document reason why it was not completed; otherwise, a blank would indicate it was not completed. On 08/09/23 at 1:30 PM, Surveyor interviewed R12 regarding missing days of dressing changes. R12 stated one time she told a nurse she didn't get her dressing change the 2nd time for the day, and the nurse told her yes she did. R12 said she was pretty upset as she wants to go home soon. On 08/09/23 at 2:00 PM, Surveyor interviewed Interim Nursing Home Administrator A (INHA) regarding missing blanks on TAR. INHA A stated she was unaware of the blanks and knows a blank means it hasn't been done and would expect the treatment to be completed per physician orders.

Based on interview, record review, and observation, the facility did not establish and maintain an infection prevention and control program to prevent the development and transmission of communicable diseases, resulting in 5 deaths due to COVID-19. This had the potential to affect all 40 residents residing in the facility. - Infection control policies and procedures have not been updated or reviewed since 2020. - The facility has not had an infection preventionist since [DATE] to oversee the infection control program. - The facility did not have a system for accurate testing and documentation of staff and resident covid testing - There was no evidence of covid symptom monitoring for residents. - The facility did not track the vaccination status of residents for influenza, pnuemococcal, or covid vaccinations in the medical record. - The facility did not put new admission residents into quarantine status when unvaccinated, as they did not obtain the vaccination status. - The facility did not have evidence of isolation start and end dates for covid positive residents Facility failure to mitigate the development and spread of COVID-19 and other communicable infections created a finding of immediate jeopardy that began on [DATE]. NHA and interim DON were notified of the immediate jeopardy on [DATE] at 3:30 PM. The immediate jeopardy was removed on [DATE]; however the deficient practice continues at a scope/severity level of F (potential for more than minimal harm/widespread) as the facility continues to implement its action plan. Findings include: Transmission Based Precautions (TBP) According to the Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for [CONDITION(S)]-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure (day 0) if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. On [DATE], at 8:30 AM, Surveyors entered the facility. Upon entrance, Surveyors noted a sign on the door of the facility that stated the facility was currently in outbreak status due to 1 COVID-19 positive staff member (CNA-J). On [DATE], at 8:45 AM, Surveyor conducted an initial tour of the facility. Two hallways are noted to have Residents residing on them and the other 2 hallways are closed with no Residents residing on them. Upon tour of the Chase Rehab hallway, Surveyor noted 2 Residents (R11 and R14) who were in TBP (both airborne and droplet). Upon tour of the Austin hallway, Surveyor noted that no Residents were in TBP. On [DATE], at 10:20 AM, Surveyor reviewed the facility's COVID-19 vaccination status log for all Residents. Vaccination status log shows that there are 4 unvaccinated Residents who reside on Chase Rehab hallway, 1 of which is in TBP for quarantine due to new admission. There are 5 unvaccinated Residents who reside on Austin hallway, none of which were in TBP. On [DATE], at 9:00 AM, Surveyor reviewed the facility's last 30 days of staff schedules. Review of staff schedules shows that CNA-J worked on Austin hallway on [DATE] and was on the schedule as a float (works both hallways) for [DATE]. CNA-J works both hallways according to staff schedules. Staff line list states that CNA-J's last day worked in the facility was on [DATE], with a symptom onset dated [DATE]. Review of CNA-J's time card shows that she was not in the facility working as a float CNA on [DATE]. Policy, Procedures, and Facility Assessment: On [DATE], at 2:00 PM, Surveyor reviewed the facility's infection control policy & procedures, and facility assessment. The facility policy entitled, Coronavirus Infection Prevention and Recommendations dated [DATE] has not been updated, reviewed, or revised since then. The facility policy entitled, Infection Control Guidelines for All Nursing Procedures, dated [DATE] has not been updated, reviewed, or revised. The facility policy entitled, Recommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities, has not been updated, reviewed, or revised since [DATE]. The Facility Assessment for infection control has not been updated, reviewed, or revised since 2020. Refer to F838 F Infection Preventionist: In this facility, the Director of Nurses (DON) also acts as the Infection Preventionist (IP). On [DATE], at 2:30 PM, Surveyor reviewed PBJ (Payroll Based Journal) for quarter of [DATE] through [DATE], a 92-day period which shows 983.75 DON (Director of Nursing) hours reported. PBJ for quarter of [DATE] through [DATE], a 92-day period shows 4.5 DON hours reported. There is no evidence that the facility has had an Infection Preventionist or Director of Nursing since [DATE], the date of the previous DON/IP's (Infection Preventionist) last day of employment. The current interim DON/IP had not completed the CDC (Center for Disease Control) Module 12C for COVID-19 until [DATE], while Surveyors were in the facility. On [DATE], Surveyor interviewed 4 staff, 1 LPN (Licensed Practical Nurse) (LPN-C) and 3 Certified Nursing Assistants, (CNA-I, CNA-G, and CNA-H), none of whom could identify who the IP or DON is in the facility since [DATE]. Refer to F882 F. Infection Surveillance and Testing of Staff and Residents: QSO-,d+[DATE]-NH Memorandum revised [DATE] under the Testing of Staff and Residents During an Outbreak Investigation documents, A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission.'' Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contract tracing or broad-based (e.g. facility-wide) testing. Under the section Documentation of Testing documents, Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: Upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested , the dates that staff and residents who tested negative. This memo also notes, Collecting and handling specimens correctly and safely is imperative to ensure the accuracy of test results and prevent any unnecessary exposures. On [DATE], at 3:00 PM, Surveyor reviewed the facility's infection surveillance documentation. This includes line lists, testing logs, and lab results for staff and residents. Review of line lists show that since [DATE] there have been 5 outbreaks in the facility in which 5 Residents (R16, R17, R18, R19, R20) expired. [DATE]: [DATE] through [DATE] the facility was in outbreak with 2 positive (+) Residents and 2 + staff. [DATE]: [DATE] through [DATE] the facility was in outbreak with 1 + Resident and 3 + staff. [DATE]: [DATE] through [DATE] the facility was in outbreak with 3 + staff. No Residents are listed on line list for December. [DATE]: [DATE] through [DATE] the facility was in outbreak with 8 + Residents and 5 + staff. February 2022: [DATE] through [DATE] the facility was in outbreak with 1 + Resident and 3 + staff. Review of line list compared to testing logs shows some discrepancies between symptoms onset, last day in facility, and COVID-19 testing dates. One staff on the line list has a symptoms onset date with no other information entered. Refer to F886 F. On [DATE], at 9:00 AM, Surveyor interviewed NHA regarding staff and Resident testing. NHA stated that she performs COVID-19 PCR tests on residents and that Staff self-test with PCR twice a week. NHA does not have proof of proper training to administer PCR tests to residents or that staff have proper training to test themselves. Monitoring for COVID-19: According to the Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, Actively monitor all residents upon admission and at least daily for fever (temperature =100.0°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement precautions described in Section: Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection. On [DATE], at 10:20 AM, Surveyor reviewed the EHR (Electronic Health Record) for R1 through R20. All sampled Residents were reviewed for vaccination status, COVID-19 care plan, Physician orders, Influenza/Pneumococcal Immunizations, COVID-19 Immunization, infection surveillance, COVID-19 signs/symptoms monitoring and TBP (Transmission Based Precautions). There is no evidence or documentation for COVID-19 Monitoring for residents since [DATE]. On [DATE], at 12:40 PM, Surveyor interviewed LPN-D. LPN-D stated that prior to coming on board at the facility, COVID monitoring wasn't being done for Residents. LPN-D stated that she is not sure how long it was not being done. LPN-D stated, Just recently I implemented COVID monitoring and placed it under physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], at 2:30 PM, Surveyor requested all surveillance documentation to include COVID-19 monitoring for the 20 sampled Residents from interim DON/IP. This documentation was not received on this date. On [DATE], at 1:45 PM, interim DON/IP-B entered the conference room and and stated to Surveyor, We will be assigning people to do COVID-19 monitoring to start today. Surveyor did not receive any COVID-19 monitoring documentation from the facility. Influenza, Pneumococcal, and COVID-19 Immunizations: On [DATE], at 10:20 AM, Surveyor reviewed the EHR for R1 through R20 for documentation of Influenza, Pneumococcal, and COVID-19 Immunizations. Review of Influenza, Pneumococcal, and COVID-19 immunization shows that 1 of 20 sampled Residents (R12), had documentation of all Immunizations in EHR, 7 of 20 Residents, (R4, R8, R16, R17, R18, R19, R20), had no documentation of updated Influenza vaccine or whether the vaccine was offered and/or refused, and 12 of 20 Residents sampled, (R1, R2, R3, R5, R6, R7, R9, R10, R11, R13, R14, R15), had no documentation of Immunizations. Refer to F883 F and F887 F. Resident Record Review: R1 was admitted to the facility on [DATE] and is vaccinated. R1 has admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No care plan could be found for R1. No influenza, pneumococcal, or COVID-19 immunizations are documented for R1. R2 was admitted to the facility on [DATE] and discharged on [DATE]. R2 has an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 has an unknown COVID-19 vaccination status. R2 has a COVID-19 care plan with initiation date of [DATE], that states, I am to have temperature and O2 sats as well as respiratory assessment done every shift, and If signs/symptoms present, initiate airborne precautions. There is no evidence that COVID-19 monitoring (T, O2 %, Resp. Assess.) was done or TBP were initiated. No influenza, pneumococcal, or COVID-19 immunizations are documented for R2. R3 was admitted on [DATE] and is vaccinated. R3 has admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no evidence that COVID-19 monitoring (T, O2 %, Resp. Assess.) was done or TBP were initiated. No influenza, pneumococcal, or COVID-19 immunizations are documented for R3. R4 was admitted on [DATE] and discharged on [DATE]. R4 has an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 is on facility line list as PCR + [DATE]. R4 does not have a COVID-19 care plan. There is no evidence of COVID-19 monitoring (T, O2, Resp. assessments) or TBP being initiated. No current influenza immunization is documented for R4, or that it has been offered and/or refused. R5 was admitted on [DATE] and expired on [DATE] under Hospice care. R5 had an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 has a COVID-19 care plan with initiation date of [DATE] that states, I am to have temperature and O2 sats as well as respiratory assessment done every shift, and If signs/symptoms present, initiate airborne precautions. There is no evidence that COVID-19 monitoring (T, O2 %, Resp. Assess.) was done or TBP were initiated. No influenza, pneumococcal, or COVID-19 immunizations are documented for R5. R6 was admitted on [DATE]. R6 has a BIMS of 13, meaning R6 is cognitively intact. R6 has an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 is unvaccinated for COVID-19. R6 does not have a COVID-19 care plan. There is no evidence that COVID-19 monitoring (T, O2 %, Resp. Assess.) was done or TBP were initiated. No influenza, pneumococcal, or COVID-19 immunizations are documented for R6. On [DATE], at 2:16 PM, Surveyor interviewed R6. R6 stated that she came to the facility on [DATE] after being treated at the hospital for 5 months for COVID-19. R6 stated that she was in a coma and on a respirator. R6 stated, It was a miracle that I came through it. R6 stated that she was not placed in quarantine or isolation when she came to the facility. R6 stated, some staff wore yellow gowns, some staff didn't. R7 was admitted on [DATE]. R7 has an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 is unvaccinated for COVID-19. R7 has a COVID-19 care plan with initiation date of [DATE], that states, I am to have temperature and O2 sats as well as respiratory assessment done every shift, and If signs/symptoms present, initiate airborne precautions. There is no evidence that COVID-19 monitoring (T, O2 %, Resp. Assess.) was done or TBP were initiated. No influenza, pneumococcal, or COVID-19 immunizations are documented for R7. R8 was admitted on [DATE]. R8 has an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 is vaccinated for COVID-19. R8 has minimal nursing documentation since admission. EHR shows 4 nurses' notes from [DATE] through [DATE]. No current influenza immunization is documented for R8, or that it has been offered and/or refused. R9 was admitted on [DATE]. R9 is unvaccinated for COVID-19. R9 has an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 has a COVID-19 care plan, with initiation date of [DATE], that states, I am to have temperature and O2 sats as well as respiratory assessment done every shift, and If signs/symptoms present, initiate airborne precautions. There is no evidence that COVID-19 monitoring (T, O2 %, Resp. Assess.) was done or TBP were initiated. No influenza, pneumococcal, or COVID-19 immunizations are documented for R9. R10 was admitted on [DATE]. R10 has an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R10 is vaccinated for COVID-19. No influenza, pneumococcal, or COVID-19 immunizations are documented for R10. R11 was admitted on [DATE]. R11 has admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 is unvaccinated for COVID-19. R11 has no COVID-19 care plan. There is no evidence of COVID-19 monitoring (T, O2, Resp. assessment). R11 is observed by Surveyor to be in airborne/droplet precautions for 14 days. No influenza, pneumococcal, or COVID-19 immunizations are documented for R11. R12 was admitted on [DATE] and discharged on [DATE]. R12 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 is vaccinated for COVID-19. R12 is on the line list as PCR + on [DATE]. R12 does not have a COVID-19 care plan. There is no evidence of COVID-19 monitoring (T, O2, Resp. assessment) or TBP. R13 was admitted on [DATE]. R13 has chronic kidney disease stage 4 with dependence on [CONDITION(S)]. R13 is vaccinated for COVID-19. R13 has a COVID-19 care plan with initiation date of [DATE] that states, I am to have temperature and O2 sats as well as respiratory assessment done every shift, and If signs/symptoms present, initiate airborne precautions. There is no evidence that COVID-19 monitoring (T, O2 %, Resp. Assess.) was done or TBP were initiated. No influenza, pneumococcal, or COVID-19 immunizations are documented for R13. R14 was admitted on [DATE]. R14 is vaccinated for COVID-19. Observation made by Surveyor of R14 shows that he is in airborne/contact TBP for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 does have a pneumonia care plan. No influenza, pneumococcal, or COVID-19 immunizations are documented for R14. R15 was admitted on [DATE]. R15 is vaccinated for COVID-19. R15 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . COVID-19 monitoring (T, O2 %, Resp. Assess.) is not being done as stated in care plan. No influenza, pneumococcal, or COVID-19 immunizations are documented for R15. R16 was admitted on [DATE] and expired on [DATE] at the facility. R16 was vaccinated for COVID-19. R16 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R16 is on the line list as PCR+ on [DATE]. R16 does not have a COVID-19 care plan. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EHR shows inconsistent documentation. Nurses' notes show R16 was assessed 1 time a day from [DATE] through [DATE]. Nurses' notes [DATE] through [DATE] show no COVID-19 documentation. Nurses' note dated [DATE] shows R17 was assessed 1 time that day. Nurses' note on [DATE] shows no assessment, but states R16 is off TBP. COVID-19 monitoring (T, O2, resp. assess.) shows inconsistent documentation from [DATE] through [DATE] (1xd, 2xd, 3xd). R16 does not have a COVID-19 care plan. R16's medical record has no evidence of isolation precautions being implemented for R16. R16 was admitted to Hospice care on [DATE]. No current influenza immunization is documented for R16, or that it had been offered and/or refused. R17 was admitted on [DATE] and expired on [DATE] in the facility. R17 is vaccinated for COVID-19. R17 has no COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) documentation shows R17 was hospitalized on [DATE] and returned on [DATE]. Line list shows R17 was PCR+ on [DATE]. R17 does not have a COVID-19 care plan. Evidence of isolation for R17 when covid positive is not located. There is no evidence of COVID-19 monitoring (T, O2, Resp. assess.). No current influenza immunization is documented for R17, or that it had been offered and/or refused. R17 was admitted to Hospice care on [DATE]. R18 was admitted on [DATE] and expired on [DATE]. R18 was vaccinated for COVID-19. R18 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Line list shows R18 was PCR+ on [DATE]. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 has a COVID-19 care plan, with initiation date of [DATE], that states, I am to have temperature and O2 sats as well as respiratory assessment done every shift, and If signs/symptoms present, initiate airborne precautions. Documentation shows inconsistent COVID-19 monitoring (T, O2 %, Resp. Assess.) Temps and O2 % were taken 1xd (one time per day), 2xd, and 3xd. There is no evidence of Respiratory assessments being done. There is one nurses' note dated [DATE] that states that R18 is in isolation for COVID-19. Nurses' note dated [DATE] states, POA updated on residents' possible exposure to COVID-19 and having to be started on isolation precautions. R18 was not tested with PCR until [DATE] per facility line list. No current influenza immunization is documented for R18, or that it had been offered and/or refused. R18 was admitted to Hospice care on [DATE]. R19 was admitted on [DATE] and expired at a sister facility on [DATE]. R19 was partially vaccinated for COVID-19 and received 1 dose on [DATE]. R19 has a COVID-19 care plan with initiation date of [DATE] that states, If signs/symptoms present, initiate airborne precautions. This is incomplete from all other Resident care plans for COVID-19 reviewed. There is no evidence that COVID-19 monitoring (T, O2 %, Resp. Assess.) was done or TBP were initiated. R19 is on the line list as PCR+ on [DATE]. Nurses' note dated [DATE] at 1:45 PM states, Talked with NP updated on covid positive and transfer to our other facility with covid. Resident update and is ok with going NP gave verbal ok to transfer knowing he will return to facility after 10 days or when asymptomatic. There is no documentation of when R19 was transferred to the sister facility in Kenosha, WI. There is no evidence of COVID-19 monitoring or isolation precautions prior to transfer to sister facility. No current influenza immunization is documented for R19, or that it had been offered and/or refused. R20 was admitted on [DATE] and expired on [DATE] at a sister facility. R20 was vaccinated for COVID-19. Line list shows R20 as PCR+ on [DATE]. Nurses' note on [DATE] at 1:21 PM states, Talked with Son POA informed of positive covid test, at this time does not show symptoms. Facility has a covid building in Kenosha POA ok with resident being transferred there for the 10 days or until asymptomatic whichever is longer. There is no documentation of when R20 was transferred to the sister facility in Kenosha, WI. There is no evidence of COVID-19 monitoring or isolation precautions prior to transfer to sister facility. No current influenza immunization is documented for R20, or that it had been offered and/or refused. There is no evidence of a start date or end date for isolation precautions when Surveyor reviewed the medical records. Interview with DON/IP B on [DATE] verified the facility has no system in place to track implementing or stopping isolation precautions. Facility failure to implement precautions to prevent the development of COVID-19, to detect its presence, and to prevent the spread of infection created a reasonable likelihood that serious harm could occur, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it had completed the following: All staff educated on proper procedure for testing self for COVID 19. All Licensed Nurses and Administrator educated on procedure for testing residents for COVID 19. All Licensed Nurses educated regarding monitoring and documenting of signs and symptoms of COVID. Licensed Nurses staff to assess for Temperatures and Oxygen saturation levels daily. Education includes other signs/symptoms of COVID. All staff education provided regarding isolation procedures for residents whom are unvaccinated for COVID upon admission or vaccination status is unknown. This education includes types of isolation required and length of time. All education will be provided to staff listed above prior to the start of their next scheduled shift. Interim Director of Nursing is current Infection Preventionist. Unit Manager will sign up for IP course. Interim Director of Nursing will continue as Infection Preventionist until someone has completed IP course. Audit all residents' vaccination status to identify residents who are not up to date on vaccines. All residents not up to date on vaccines will be offered vaccines. COVID 19 policy and procedure updated [DATE] in coordination with medical director regarding evaluating residents for symptoms of COVID 19 daily to include temperature and oxygen saturation level. Policies are in place and reviewed for Pneumococcal, Influenza, and COVID vaccines. Policy includes assessing for current vaccination status upon admission. Facility to create a COVID testing log to ensure testing data and medical record are accurate. Admissions will collect COVID vaccination status to determine need for isolation prior to admission. Facility to create a Isolation log for residents newly admitted without COVID vaccinations, positive for COVID, or unknown vaccination status.

Based on interview and record review, the facility did not provide care and services for 1 (R1) out of 3 residents with a foley catheter to prevent infection and complications of a foley catheter. R1 had a foley catheter replaced on 08/21/2021. R1 developed fever, pain, and changes in mental status on 08/31/2021 and was transferred to the hospital for evaluation. The CT (computed tomography) scan showed R1's foley catheter was not placed inside the bladder, but rather in the urethra causing partial obstruction of the flow of urine. R1 was hospitalized and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional hospital diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was hospitalized from 08/31/2021 through 09/13/2021 and treated with intravenous antibiotics. This is evidenced by: Surveyor reviewed facility policy titled Foley Catheter Insertion, Male Resident and noted the procedure required a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Once urine began to flow, advance the catheter an additional 2 inches then slowly inflate the balloon. If the resident complains of pain, deflate the balloon and advance another inch. If the resident continues to complain of pain, deflate the balloon and call for assistance. Once the balloon is inflated, gently pull on the catheter to check for placement. R1 was admitted to the facility for short term rehabilitation on 06/11/2021 with the following, but not all inclusive Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed an admission assessment on 06/18/21 and quarterly MDS (minimum data set) assessment on 09/18/21 for R1. Both assessments revealed R1 had no memory deficits and was cognitively intact. The BIMS (brief interview for mental status) score was 15 out of 15. In addition, R1 required extensive to total staff assistance with toilet use and had an indwelling foley catheter. R1 has been hospitalized on [DATE] with a [CONDITION(S)] and returned to the facility on [DATE]. Hospital notes indicated the foley catheter inserted on 06/21/21 was a latex style and R1 had a known allergy to latex. Upon return to the facility the physician ordered R1 to have a 16 French silicone foley catheter with a 10 milliliter balloon to be changed monthly due to kidney stones and occlusion. Review of the nurses notes dated 08/21/2021 revealed RN (Registered Nurse) - C replaced R1's foley catheter without problems. The documentation does not identify why the catheter was changed nor does it include any description of the size, type, or balloon inserted. R1 does have a latex allergy and required the catheter to be latex free. Review of the nurses notes from 08/21/21 through 08/31/21 noted R1 had adequate urine output and no complaints of abdominal pain, pressure, or bladder spasms. Review of R1's urine output prior to and after 08/21/21 was variable. R1 had 4000 mls to 6500 mls of urine daily. There was no information provided regarding R1's fluid intake. Urine output varies with fluid intake. There was no assessment or analysis regarding R1's fluid intake compared to urine output. Complete obstruction of the bladder due to an inflated foley balloon would be evidenced by no urine output, progressive pain, bladder spasms, and abdominal distention. Partial obstruction of the bladder due to an inflated foley balloon would be evidenced by reduced urine output, pain, abdominal distention, bladder spasms, and infection. According to the nurses notes on 08/31/2021 late morning, R1 developed a fever of 103. R1 was given medications to reduce fever but as the day progressed, R1 had additional symptoms of weakness, perspiration, return of fever, and shortness of breath. Initially, R1 declined an evaluation at the hospital but later agreed to a hospital transfer. R1 was transferred to the hospital at approximately 9:30 p.m. Review of the physician's admission evaluation indicated R1 had abdominal distention and tenderness especially on the left side, R1 had a rapid heart rate and respiratory rate. Initial laboratory data showed an elevated white blood count (indicative of an acute infection) but a negative chest X-ray. Urinalysis revealed blood, bacteria, and cloudy urine. Upon admission, R1 was treated with antibiotics for a probable [CONDITION(S)]. Review of the physician's discharge summary dated 09/13/2021 noted the CT scan showed the foley balloon was inserted in the urethra, kidney stones on both sides, and possible left side pyelonephritis (kidney infection). The discharge summary noted R1 was septic from staphylococcus aureus in the urine. In addition, R1 was having severe scrotal swelling, redness, tenderness, and brown purulent drainage from the urethra. R1 had an ultrasound of both testicles which revealed a left orchitis. The physician ordered R1 to be transferred back to the nursing home on 09/13/21 with continued use of antibiotics. On 10/05/2021 at 11:45 a.m., Surveyor interviewed R1 regarding past medical history and care concerns. R1 confirmed the hospital stay on 06/22/2021 because of a latex catheter which resulted in inflammation and a [CONDITION(S)]. R1 also confirmed the hospital stay on 08/31/2021 for a [CONDITION(S)] caused by the foley catheter balloon being inflated in the urethra, not in the bladder. R1 stated he had reported bladder pain and spasms immediately after the foley was changed on 08/21/2021, but RN-C who inserted the foley did not come back and assess the pain complaints. R1 stated due to the MS, the ability to move and sense pain or pressure in the lower part of the body was reduced, but R1 stated he felt bladder pain and the facility did not assess source of the pain. R1 stated he does take narcotics for pain control and had been given narcotics for pain complaints since foley was inserted on 08/21/2021.

Based on observation, record review, policy review, and interview the facility did not consult with the attending physician or resident representative, for 1 resident (R1) out of 6 sampled residents, when R1 had a significant change in status. R1 had physician orders [REDACTED]. R1 had twelve episodes of blood sugars less than 70 and there was no evidence of resident representative consultation and only two consultations with the medical provider when blood sugars were less than parameters. R1 was hospitalized fron 10/10/20 until 10/14/20 due to low blood sugars. R1 had physician orders [REDACTED]. R1 was taking three cardiac medications for hypertension and [MEDICAL CONDITION]. There were seventeen episodes of low blood pressure and there was no evidence of physician or resident representative consultation regarding low blood pressure. R1 was hosptalized on [DATE] with kidney failure secondary to low blood pressure, unstable diabetes, and dehydration. R1 had a fall out of bed on 10/20/20. R1 had a decline in food and fluid intakes, swallowing, transfers, and mobility beginning on 10/21/20. There was no evidence of physician consultation or resident representative condition updates. This is evidenced by: On 10/28/20 at 10:17 a.m., Surveyor interviewed Director of Nurses (DON)-B and Corporate Clinical Consultant (CCC)-F regarding change in resident condition. CCC F stated all licensed nurses are expected to consult with the physician when a resident had a change in condition. CCC F stated licensed nurses use the American Medical Director Association (AMDA) guidelines on the urgency of physician consultation, but most changes in condition are reviewed with the physician within 24 hours unless the resident demonstrates an emergency change. CCC F stated when an emergency presents, the licensed nurse would call 911 and transfer the resident to the hospital if desired by resident or representative. Surveyor reviewed the facility's policy titled Change in a Resident's Condition or Status and noted facility shall promptly notify the resident, his or her Attending Physician, and representative .of changes in the resident's medical .condition and/or status . R1 was admitted to the facility on [DATE] following a spinal fusion. Additional [DIAGNOSES REDACTED]. LOW BLOOD SUGARS On 09/30/20 the physician ordered R1 to receive [MEDICATION NAME](long acting) 40 units daily with breakfast and [MEDICATION NAME](rapid acting) 12 units three times per day with meals. R1 had orders for nursing to check blood sugar four times daily, prior to meals and at bedtime and to notify physician if blood sugar was less than 70 or greater than 400. Review of R1's blood sugar values noted the following: ~10/01/20--63 at bedtime. ~10/03/20--69 at supper and bedtime. ~10/08/20--69 at supper ~10/09/20--59 at lunch. ~10/16/20--52 at breakfast. ~10/16/20--63 random check at midnight. ~10/18/20--40 random check at midnight. ~10/22/20--50 at breakfast. ~10/22/20--55 at lunch. ~10/23/20--68 at bedtime. ~10/27/20--64 random check at midnight. On 10/07/20, R1 was examined by the Nurse Practitioner who noted stable diabetes with no changes to R1's insulin orders. Nurses progress notes on 10/10/20 and again on 10/18/20 indicate R1 was found unresponsive. R1 was transferred via ambulance to the hospital on [DATE] at approximately 6:00 p.m. and was given [MEDICATION NAME] injection.to treat episodes of low blood sugar and again on 10/18/20 at approximately 12:30 a.m. On 10/10/20, R1's blood sugar was 34 and on 10/18/20, R1's blood sugar was 40. The physician was not consulted and orders to change R1's insulin dosage were not given until 10/19/20. According to AMDA guidelines, a low blood sugar and decreased responsiveness require an immediate physician consult. Review of the MAR indicated [REDACTED] ~10/17/20 at bedtime. ~10/18/20 at bedtime. ~10/20/20 at supper. ~10/22/20 at lunch. ~10/223/20 at lunch and supper. ~10/24/20 at lunch. ~10/25/20 at lunch and supper ~10/26/20 at lunch. ~10/27/20 at lunch. The facility did not give R1's prescribed insulin eleven times, yet there was no physician consultation to hold medication. R1 was readmitted to the nursing home on 10/14/20 with orders to give [MEDICATION NAME]8 units three times per day with meals and [MEDICATION NAME]30 units daily at bedtime. Surveyor reviewed R1's nurse progress notes and change in condition assessments beginning on 10/01/20 through 10/27/20 and found no physician consultation regarding low blood sugars except on 10/10/20 when R1 was transferred to the hospital, 10/19/20 for low blood sugar, and 10/27/20 when R1 was again transferred to the hospital. On 10/19/20 the medical provider reduced R1's [MEDICATION NAME]to 25 units daily at bedtime and [MEDICATION NAME]was reduced to 6 units three times per day with meals. LOW BLOOD PRESSURES Review of the physician orders [REDACTED]. All three medications treat [MEDICAL CONDITION] and hypertension (high blood pressure) with side effects of [MEDICAL CONDITION]. The physician also ordered to notify physician if R1's blood pressure was greater than 170 systolic or 90 diastolic or less than 98 systolic or 60 diastolic. On 10/07/20 R1 was examined by the Nurse Practitioner who noted stable hypertension with no changes to R1's cardiac medications. Review of R1's blood pressure readings noted the following values: ~10/02/20--96/51. ~10/16/20--96/48. ~10/17/20--109/59. ~10/18/20--112/53. ~10/20/20--99/52, 74/35, 92/52, 94/55, 117/59, 92/64, 113/58, 99/52, and 107/50. ~10/21/20--77/45, 107/50, and 174/135. ~10/22/20--72/35. There were no blood pressures recorded after 10/22/20. Surveyor reviewed R1's nurse progress notes and the change in condition assessments and found no physician consultation regarding blood pressure readings outside physician parameters FUNCTIONAL DECLINE Review of nurse progress notes beginning on 10/21/20 through 10/27/20 indicated R1 had a decline in oral intakes, transfers, toilet use, ambulation, and swallowing. During the above time period, there were 28 nurses notes that identified R1 was not eating, swallowing, drinking, transferring, had functional decline, had abdominal pain/tenderness, and required total staff assist and full mechanical lift transfers. Review of the 28 nurses notes of R1's documented decline did not include any assessments, physician consultations, resident representative updates, or possible reasons for R1's decline. On 10/26/20, Licensed Practical Nurse (LPN) C faxed a condition change document to the Nurse Practitioner which noted R1 was pocketing food. LPN C requested a Speech Therapy evaluation. On 10/26/20, the Nurse Practitioner ordered a Speech Therapy evaluation and changed R1's diet to mechanical soft. LPN C did not include an assessment of R1's oral intakes, weight loss, hydration assessment, vital signs, medications, recent fall on 10/20/20, or other functional declines noted in the nurse progress notes. R1's weight on 09/30/20 was recorded as 250#. Review of hospital records dated 10/14/20 noted R1 to weigh 210-214#. Surveyor reviewed R1's oral intakes from 10/21/20 through 10/27/20. R1's total daily fluid intake was 120 mls (milliliters) to 630 mls. R1's fluid needs based on weight and medical [DIAGNOSES REDACTED]. Review of the comprehensive medical record was absent of any hydration risk assessment or evaluation for hydration and there is no documentation that staff notified the physician of this change until 10/27/20. Surveyor reviewed R1's food intakes from 10/21/20 through 10/27/20. From a possible 18 delivered meals only 8 meal intakes were recorded. R1 consumed 0-25% for 3 meals, consumed 26-50% for 1 meal, 76-100% for 1 meal, and refused 3 meals. The only weight recorded for R1 was on 09/30/20 at 250#. There was no assessment of R1's nutritional status. On 10/27/20 beginning at 11:20 a.m., Surveyor observed R1 lying in bed. At 12:10 p.m., Certified Nursing Assistant (CNA) D entered R1's room to assist with lunch. R1 was served sweet potatoes, carrots, ground chicken with gravy, pumpkin dessert, and chocolate milk. CNA D attempted to awake R1, but R1 was sleeping soundly. After 15-20 minutes of CNA D waking R1, CNA D contacted LPN C about R1's inability to wake up and eat lunch. Review of the nurse progress notes for 10/27/20 shows no assessment of R1 following the above observation of R1's somnolence. On the evening of 10/27/20, the licensed nurse contacted the on call physician and was ordered to send R1 to the emergency department for an evaluation. R1 was admitted to the hospital with [REDACTED]. On 10/27/20 at 12:00 noon, Surveyor interviewed CNA G regarding R1's care needs. CNA G stated R1 has had a decline in function and now required total staff assist for all ADLs (activities of daily living) including eating. CNA G stated R1 was no longer able to transfer onto the toilet or into the wheelchair. CNA G stated R1 required a full mechanical lift for all transfers in and out of bed. CNA G stated R1's oral intakes had also declined and R1 was no longer able to swallow food. CNA G stated R1 would drink at times, but not very well. CNA G stated R1 required staff to feed him and help him drink. CNA G stated R1's decline had been discussed with nursing several days ago, but was unsure how long the decline had been noted. On 10/27/20 at 12:50 p.m., Surveyor interviewed CNA D regarding R1's care. CNA D stated R1 was unable to swallow food and no longer was able to feed himself. CNA D stated staff will spoon food into R1's mouth, but staff will have to retrieve food from R1's mouth because he will not swallow the food. CNA D stated R1 does drink some fluids. CNA D stated R1 had declined in function from being able to feed self and transfer onto the toilet to now required full mechanical lift from bed to wheelchair and was staff total assist for all food and fluids. Surveyor reviewed R1's comprehensive electronic and physical hard medical record and was unable to find any evidence of physician consultation regarding R1's low blood sugars, low blood pressures, or functional decline with the exceptions of R1's two hospital transfers, the low blood sugar episode of 10/18/20, post fall on 10/20/20, and the pocketing of food concern on 10/26/20. Surveyor reviewed R1's comprehensive electronic medical record and R1's hard medical record and noted only resident representative condition updates on 10/10/20 when R1's was transferred to the hospital via 911 due to low blood sugar, 10/20/20 after R1 fell , and 10/27/20 when R1 was again transferred to the hospital. Surveyor requested any evidence of physician and resident representative consultations when R1 had a decline in function, low blood pressure, low blood sugars, or change in status. There was no additional information provided to support R1's physician or representative was consulted when R1 had changes in condition that required medical evaluation or intervention. On 10/29/20, Surveyor received an email from NHA (Nursing Home Administrator)-A stating NP (Nurse Practitioner)-H had access to R1's medical record electronically and offsite and all pertinent information regarding R1's condition was made available to NP-H. NHA-A provided contact information and asked for Surveyor to contact NP-H for further discussion. On 11/02/20 at 10:16 a.m., Surveyor discussed R1's medical condition via telephone with NP-H. Surveyor asked if NP-H had access to all electronic medical records and when she would access these records. NP-H stated she had access to nurses notes, orders, vital signs, diagnostic data, physician progress notes [REDACTED]. NP-H stated the nursing home staff would alert NP-H to a problem or concern via fax or telephone call and include data to review; however NP-H stated she would also independently review additional resident information electronically and offsite. Surveyor asked NP-H if she was made aware of R1's low blood sugars or low blood pressures either through facility staff or via alerts from the electronic medical record and NP-H stated she was not aware of these vital signs or conditions. NP-H referenced an in person examination of R1 on 10/07/20 in which she addressed R1's blood sugars and blood pressure as stable with no changes. Surveyor asked NP-H if she was made aware of R1's decline in physical function and nutritional intakes either through facility staff or via alerts from the electronic medical record and NP-H stated she was not made aware of these changes until 10/26/20 when she received a fax requesting a speech evaluation due to R1's pocketing food. Surveyor asked NP-H if she was made aware of R1's fall on 10/20/20 and the use of Eliquis for clot prevention. NP-H stated she was not made aware of R1's anti-coagulation medication at the time of the fall, but did have access to all medications given to R1. NP-H could not recall if she had reviewed R1's medications at the time of the fall on 10/20/20. NP-H stated she kept a day to day notebook of telephone calls and fax requests from facilities and was unable to locate any additional facility notification of R1's condition in her notebook from 09/30/20 through 10/27/20. NP-H stated documentation was an important part of what nurses do and if there was no documentation in R1's medical record and NP-H had no documentation in her day to day notebook, then the facility did not consult with NP-H regarding blood sugars, blood pressures, or a decline in R1's condition.

Based on observations, interview, and record review the facility did not manage 1 of 15 sampled resident's bowel incontinence to prevent skin erosion. R33 has a predictable bowel pattern and is able to verbalize her pattern to staff. Despite this, staff are not proactively taking R33 to the bathroom and R33 is documented as being totally incontinent of bowel. R33 has diffuse MASD/IAD (Moisture-associated Skin Damage/ Incontinence-associated [MEDICAL CONDITION]), over both buttocks and in the groin. R33 also has several open areas in the MASD/IAD which are not being assessed by licensed nursing staff. This is evidenced by: R33 has been a resident since (MONTH) (YEAR). Her [DIAGNOSES REDACTED]. The latest MDS (Minimum Data Set) dated 6/7/19 indicated R33 needs the assistance of 2 staff persons for her personal hygiene and transferring and 1 staff person for dressing. R33 is coded as being totally incontinent of bowel since 12/2018. R33 also has a BIMS (Brief Interview for Mental Status) of 15 out of 15 indicating she is alert and oriented. R33 is able to make her needs known. R33 has an indwelling urinary catheter. The current care kardex for the CNAs (Certified Nursing Assistants) indicates R33 is to be Prompted to go to the toilet upon rising, before and after each meal, at bedtime, and as requested by R33. On 8/21/19 at 11:50 a.m. Surveyor interviewed R33 about her incontinence and her skin issues. R33 stated the she has the skin issues since (MONTH) (YEAR) and it was sore already then. R33 stated the cause is 2 fold, with part being her inability to control her bowels and her inability to move. R33 stated she has concerns about the timeliness of staff responding when does have to have a bowel movement. R33 indicated she has a brief warning from when she firsts has the urge until she has a bowel movement. R33 stated she used to be assisted to the toilet when she first was admitted , but was unsure of why she no longer is. R33 stated that she has a life long habit of having a bowel movement at specific times. She stated that she will have a large bowel movement first thing in the morning, then again after breakfast, after lunch, and then at bedtime. She stated that her movements are always soft. R33 stated that her bottom is either pink or red and she has never seen it, but it hurts all the time. There are no interventions in R33's care plan related to her usual bowel pattern. On 8/20/19 at 10:00 a.m. Surveyor observed CNA-W and CNA-AA help R33 with her morning hygiene, dressing, and transfer out of bed. As R33's bed was reclined, R33 stated, Oh crap. I'm gonna poop. She was not offered the toilet. The CNAs simply began her morning cares. CNA-W was observed to wash a large amount of very soft brown feces from the front of R33's perineal area and then patted her dry. Both staff assisted R33 to roll back and forth during this time. While CNA-W washed the feces off of her bottom, perineum, and foley catheter R33 was noted to cry out Oooo! and Ow! and That really hurts! whenever the washcloth or towel would touch her skin. CNA-W apologized and stated she was trying to be gentle but she had to get the feces off of her skin. The surveyor observed 3 linear open areas that were 4 cm (centimeters) long and 4 mm (millimeters) wide over under her left ishium, 2 areas under her right gluteal fold that were 5 cm long and 4 mm wide with one area being circular in shape and 2 cm in diameter. In addition, between her inner right thigh she had a 3 cm long by 3 mm wide open area. Her entire buttocks, gluteal fold, inner thighs, and perineum was dark ruby colored in an upside-down heart shape. CNA-W opened a specimen container and applied the cream inside to R33's buttocks and inner thighs including the areas of non-intact skin. CNA-AA stated that R33's bottom looks so much better than it did last week and didn't look as sore. CNA-AA told Surveyor the nurses had put this cream in the specimen sample container for the CNAs to put on R33's entire bottom when they cleaned up any of R33's incontinence and with morning cares. Neither CNA notified MT-FF (Medication Technician) or a nurse of the open areas. On 8/21/19 Surveyor observed CNA-X and CNA-R assist R33 with her morning hygiene and dressing. Surveyor asked the staff about R33's toileting schedule. The aides stated they would have to check the care plan in the hall as they did not know what her specific schedule was. Both staff stated R33 is not put on a toilet. CNA-X stated R33 can't be put on the toilet anymore since she requires the use of a Hoyer lift. CNA-R stated residents using Hoyer lifts could still use the bathroom. The staff stated R33 calls them when she needs to be changed and that she is not routinely assisted to lie on her side as she will, throw the pillows or the wedge-shaped cushion off onto the floor. There is no reassessment or care plan on how to manage moisture on R33's skin. On 8/21/19 at 10:50 a.m., Surveyor interviewed RN-B (Registered Nurse) about R33's bottom. RN-B is the facility's wound care nurse. RN-B stated she was first told about the open areas on R33's skin a today (8/21/19) by RN-CC. RN-B stated she had not had a chance to look at the open wounds as R33 was already up in her wheelchair. RN-B stated Cavalon barrier had been used once a week since (MONTH) and R33's skin issues were from chronic stooling. RN-B stated every nurse who works with R33 is responsible to assess for the condition of R33's skin and request from the physician any treatment orders that would be needed to heal her skin. On 8/21/19 at 11:00 a.m. Surveyor asked the DON (Director of Nursing) about R33's skin erosion and any bowel assessments. The DON gave Surveyor an order dated 3/6/19 for the Cavalon barrier treatment that is done weekly. A bowel evaluation done on 3/20/19 indicates R33 is totally incontinent and not a candidate for any toileting plan. The assessment did not offer any information about when she became incontinent, any response to previous attempts to try to restore her continence, and states she is assisted with incontinence care as needed. Surveyor asked the DON for any other information about the skin on her bottom and was told that this information was all she could locate. There was no evidence a licensed nurse assessed R33's MASD/IAD. In addition, the treatment of [REDACTED]. On 8/21/19 at 2:25 p.m. Surveyor interviewed CNA-R about what she recalled about the condition of R33's bottom. CNA-R stated it has been raw, chapped and had bleeding sores since she had started at the facility in (MONTH) 2019. CNA-R stated that she has not been putting R33's brief on at night because the briefs hold in the sweat and moisture and it's not as red when she does so.

Based on observation record review and interview the facility did not ensure 1 of 3 residents (R365) at risk for falls received the necessary care and services to prevent falls. R365 had a history of [REDACTED]. R365 had 2 falls within 4 days of admission. The facility identified R365 was transferring without assistance in order to use the bathroom. Although interventions of an individualized toileting schedule were discussed, there was no evidence the care plan was updated to include this approach. R365 experienced a third fall, again responding to a need to use the bathroom. R365 was transferred to this hospital and was admitted with a [MEDICAL CONDITION] and a subdural hematoma. A fourth fall resulted in 3 fractured ribs. Following the fourth and fifth fall, the facility did not complete a thorough investigation in order to complete a root cause anlysis by determining if care plan interventions were being followed, what factors may have contributed to the falls, what the resident was doing at the time of the fall, etc. The facility did not implement interventions based on the root cause In addition, staff did not consistently implement interventions identified on the care plan. The facility's failure to identify the root cause and implement appropriate intterventions created a finding of immediate jeopardy that began on 4/15/19. The NHA (Nursing Home Administrator) was notified on the immediate jeopardy at 8:32 a.m. on 7/3/19. The immediate jeopardy was removed on 6/28/19. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility contines to implement its action plan. This is evidenced by: R365 was admitted [DATE] with [DIAGNOSES REDACTED]. The Fall Risk Assessment, dated 3/30/19, includes additional [DIAGNOSES REDACTED]. The Fall Risk Assessment identifies R365 as being high risk for falls with a score of 25. R365 had 2 falls within 4 days of admission: ~3/30/19, 11:25 p.m. Unwitnessed Fall. While writer doing routine rounds checking on residents, went to his room and noted R365 laying on the floor on his left side. He was away from his bed and w/c (wheel chair) was between him and his bed. He was continent. Immediate Action Taken: .During further assessment, noted 2 x 1.7 cm (centimeter) skin tear on the left elbow with surrounding tissue bruising .Other Info: Self transfer d/t (due to) toilet need. On 4/01/19 the IDT (Interdisciplinary Team) reviewed R365's fall and determined R365 had attempted to self-transfer to use bathroom. The IDT recommended completion of a 3 day bladder diary and to develop a toileting plan to include offering toileting at HS (hour of sleep). R365's care plan included a focus area of at risk for falls developed on 3/28/19. Interventions included Complete 3 day B/B (bowel/bladder) diary and schedule toileting if appropriate. This approach was marked as resolved on 4/1/19. Continued review of R365's care plan found a focus area of bladder incontinence also started on 3/28/19. Approaches include, Check resident before and after meals, at HS and prn for incontinence. There were no individualized interventions developed and implemented based on the R365's patterns and needs. ~4/02/19, 2:00 a.m. Unwitnessed Fall. Resident had an unwitnessed fall while attempting to self-transfer from bed to the bathroom and back, CNA (Certified Nursing Assistant) stated the urinal that was placed near resident was found in the bathroom sink. Resident did have a slightly reddened area to his left shoulder blade/back but denied pain .Intervention: Toilet resident every 2 hours during N[NAME] (night) shift. On 4/2/19, the IDT review stated, IDT reviewed unwitnessed fall on 4/2 N[NAME], noted fall occurred while ambulating without assistance to use the bathroom. New intervention initiated to offer toileting Q (every) 2 hours to resident from 2000-0600 (10:00 p.m. to 6:00 a.m.) .resident continues to work with therapy, therapy aware of fall, care plan updated. R365's care plan was updated on 4/2/19 to include an approach of, Offer toileting every 2 hours from 2000-0600 and as needed for poor safety awareness. R365's care plan did not include an individualized toileting plan based on the bladder assessment completed on 4/1/19. A Fall Risk assessment dated [DATE] indicates R365 scored 23 which is high risk. The Admission MDS (Minimum Data Set) dated 4/03/19 indicated R365 ~Is able to understand others; ~Is able to make self-understood; ~Has severely impaired cognition; ~Requires extensive assist of 1 to 2 staff for bed mobility, transfer, dressing, toilet use and personal hygiene; ~Is frequently incontinent of bladder and not on a toileting plan; ~Had experienced falls within 2 - 6 months of admission to the facility; and ~Had 2 falls since admission with no injuries. On 4/04/19, progress notes stated, IDT met to discuss resident current falls. Fall on 4/1 (sic) and 4/2 x2 both resident self transferred as he was wanting to use the restroom .Current intervention: toileting q2 hours from 2000 to 0600 .Current fall risk score=23, high on 4/2/19. Resident does need some cues and reminder throughout the day as he is somtimes forgetful . R365's fall reports continue: ~4/15/19 6:30 a.m., Unwitnessed fall. Writer heard a thud noise, entered residents room and noted his bathroom light to be on .resident lying on his right side under the sink. Blood noted on the floor beneath his head .resident wearing gripper socks, a white t-shirt and a tabbed brief at time of fall. Resident w/c beside him with brakes locked. Immediate Action Taken: .Hoyer used to lift resident from floor and place his (sic) in bed. Wounds assessment and treatments performed. Initial bleeding from R (right) [MEDICAL CONDITION] subsided within 5 minutes of fall. Bleeding from skin tear to R elbow subsided within 15 minutes. Later that same day, R365 began to complain of pain and an order was received to send him to the emergency room for evaluation. R365 was diagnosed with [REDACTED]. R365 was admitted to the hospital and did not return to the facility until 4/17/19. A Fall Risk assessment dated [DATE] incidates R365 scored 16 which is high risk. The IDT note from 4/18/19 states, IDT discussed resident's fall sustained on 4/16/19 (sic), and was sent out to hospital. He suffered injury of brain bleed and fracture of right hip. Resident is toileted approximately every 2 hours. Rearrangement of room. Resident has a history of [MEDICAL CONDITION]. This is R365's third fall related to his trying to use the bathroom. Despite this, the facility discontinued the approach to toilet R365 every 2 hours from 10:00 p.m. to 6:00 a.m. No new interventions or indivualized toileting program were added to the care plan. A progress note on 5/2/19 states, IDT met and discussed fall from 4/15. No falls since current interventions effective. Continue with toileting schedule and is now a hoyer lift. On 5/9/19, the IDT documented, .No fall since 4/15/19 .Current interventions appropriate at this time .Care plan reviewed. Will continue to monitor. The most recent MDS dated [DATE] indicates R365 has declined: ~Is now dependent on 2 staff for transfer (previsouly required extensive assistance of 1-2 staff); and, ~Is now totally incontinent of bowel (previously was continent of bowel). R365's fall reports continue: ~5/15/19, 2:00 p.m. Unwitnessed Fall. Heard a bang. Went to residents room to find him laying on the floor on his left side head against the wall. There was no additional information on the fall report. The progress notes dated 5/15/19 state, Resident had an witnessed (sic) fall. Resident was found in his room on his left side. He stated he was trying to stand up out of his wheel chair .Complained of hitting his head . NP wants resident sent to ER due to history of subdural hematoma .Received call from Aspirus ER nurse. Resident will be returned to the facility. CT scan of head negative. Left side rib fractures, 6th, 7th and 8th rib . The facility submitted a self-report of this incident to the State Agency. There were no investigative documents submitted. Surveyor was provided a copy of an undated statement written by Activities-EE that stated, .Staff asked resident what happened and he said I stood up to see what was going on . A Fall Risk assessment dated [DATE] incidates R365 scored 18 which is high risk. A 5/17/19 progress note states, IDT met and reviewed residents recent fall, root cause analysis, resident is spontaneous, impulsive, with [DIAGNOSES REDACTED]. Resident stood quickly from his wheelchair stated he 'was trying to see what was going on.' Immediate intervention, call placed to 911, resident was c-collered and sent to ER for evaluation. Interventions implemented were continued encouragement to attend group activities. POA/son, has requested and insisted on placement of a seatbelt alarm, risk/benefit teaching completed. Clip alarm will be placed until seatbelt alarm is obtained. Care plan reviewed and updated. R365's care plan was updated on 5/17/19 to include an approach of a clip alarm while in wheelchair. A 5/23/19 progress notes states, IDT met to review residents recent falls. Pt (patient) had a fall on 5/15/19 standing from his WC to look out the window. resident sustained [REDACTED]. Per the request of the son/POA (power of attorney) a clip alarm was placed on the resident, with an order of a self release seatbelt alarm being made .Care plan reviewed and updated. All other interventions appropriate at this time . None of the documentation identifies where the fall occurred. There is no evidence of a thorough investigation to determine a root cause of the fall. IDT notes indicates R365 was standing to look out the window; however, there is no indication as to how they came to that conclusion. R365's fall reports continue: ~6/11/19, 11:45 a.m. Unwitnessed fall. At approximately 11:45, heard loud sound which sounded consistent with a fall. Checked rooms and found resident on floor in supine position with legs elevated in the air . A Fall Risk assessment dated [DATE] incidates R365 scored 23 which is high risk. On 6/12/19 the IDT documented, .Root cause analysis: due to progressing dementia and decreased safety awareness, resident self-transfers and does not use call light for assistance. Intervention at time of fall was to get resident up and took (sic) to activity prior to lunch time. New intervention to have clip alarm per POA request added to the recliner when resident is sitting in recliner, then put back onto WC when transferred back to WC. Care plan reviewed and updated. Continue per P[NAME] (plan of care). The investigation is not thorough, showing no staff interview or factors that may have contributed to R365's fall. The facility only identified R365's [DIAGNOSES REDACTED]. The IDT indicates R365 was to be taken to an activity prior to lunch. There is no indication of this approach on the care plan or that R365 was in an activity at the time of the fall. On 6/25/19 at 3:30 p.m., Surveyor spoke with RN-B (Registered Nurse) about the facility's investigative procedure when a resident falls. RN-B explained the unit nurse begins the investigation once the resident assessment and care of injury is addressed. RN-B further explained unit nurses are supposed to put an immediate measure in place in an attempt to prevent a future fall. The IDT team meets the next day to review the fall and put measures in place based on the root cause of the fall. Surveyor asked RN-B about interviewing staff as part of the investigation to gain insight on what the resident needs may have been at the time of the fall. RN-B responded if a fall is witnessed the nurse will obtain a witness statement. It is not the facility's practice to interview staff if the fall is not witnessed. Surveyor and RN-B reviewed R365's falls. Surveyor asked RN-B if a thorough investigation was done with R365's falls. RN-B indicated most falls did not address an immediate action to prevent a fall, did not include staff interview as to what may have been R365's needs at the time of the fall, did not include a root cause based on a thorough investigation and did not always include a change in resident care plan based on a root cause. R365 has an approach on the care plan of dycem in the wheelchair. On 6/25/19 at 8:12 a.m. and 11:57 a.m. the surveyor observed R365 sitting in his wheelchair in the dining room. Surveyor could not see dycem in his wheel chair. On 6/25/19 at 1:02 p.m. the surveyor noted R365 in bed. His wheel chair contained no dycem in the seat. The surveyor did not see dycem in R365's room. Call, Don't Fall sign is not posted in his room. R365's care pan includes an intervention of a sign hung in R365's room to remind R365 to Call, Don't Fall. On 6/25/19 at 1:02 p.m. the surveyor did not see the Call, Don't Fall sign in R365's room. On 6/25/19 at 8:40 a.m. Surveyor noted no sign in R365's room. On 6/25/19 at 1:07 p.m. Surveyor spoke with CNA-X (Certified Nursing Assistant). CNA-X indicated she has worked at the facility for 3 and a half years and often cares for R365. CNA-X stated she had gotten R365 up that morning. Surveyor asked CNA-X if she had placed dycem in his wheelchair before R365 was seated. CNA-X indicated she had not placed dycem in his chair. CNA-X stated R365 has never had dycem in his room to place in his chair and she has never placed dycem in his wheel chair. Surveyor asked CNA-X about a sign in R365's room indicating Call, Don't Fall. CNA-X stated R365 had a sign in his room once, but she was unsure when it disappeared or where it went. CNA-X further expressed there is a sign in his bathroom but one should be in his room. CNA-X stated R365 attempts to transfer himself in his room and the sign from the bathroom is not visible to R365 in his room. On 6/25/19 at 1:15 p.m., Surveyor spoke with LPN-BB (Licensed Practical Nurse) about R365's fall precautions. LPN-BB indicated he has worked at the facility 6 years and is familiar with R365. LPN-BB stated he is responsible for oversight of CNAs and care plan approaches on the dementia care wing. LPN-BB indicated the approach for dycem in the wheel chair was initiated 3/28/19 and is definitely needed due to R365's posture in his wheel chair and concerns of him sliding. LPN-BB confirmed there should be a sign up in his room reminding R365 to call for assistance. LPN-BB further expressed the sign was added to R365's care plan on 4/23/19. LPN-BB stated the sign was in the room once, but he is unsure where it went. On 6/26/19 at 10:20 a.m. Surveyor spoke with FM-DD (Family Member) who is R365's son and power of attorney for health care. FM-DD indicated he visits often and has never seen dycem in R365's wheelchair or a posted sign in his room as described by Surveyor. FM-DD indicated his father has had 4 or 5 falls since his admission. 2 of his falls resulted in trip to the emergency room with very serious injury. FM-DD further indicated he wants the facility to do whatever they can to try to prevent a fall. He further indicated that if the facility thought the sign and dycem was a good idea, it should have been in place right away. The failure to identify the root cause of R365's falls, to develop interventions to address the root cause, and to provide the needed interventions to prevent falls created a finding of immediate jeopardy. The facility removed the jeopardy on 6/28/19 when it had completed the following: 1. All licensed nurses were edicated on fall scene investigation, root cause analysis, uimmediate interventions and care plan updates related to falls; 2. Reviewed last 30 days of risk management reports to ensure appropriate interventions were in place; 3. All resident care plans were reviewed for appropriate fall interventions with updates completed as needed; 4. Began audits of care plan interventions being implemented; and 5. Leadership team educated on plan and follow-up.

Based on observations, interviews and resident reviews, the facility did not consistently provide care, treatment and services to promote healing, prevent infection and prevent pressure ulcer development or worsening of existing pressure ulcers. This affected 2 of 4 reviewed for pressure injuries (R2 and R21). R2 had a Stage III Pressure Injury (PI) that was nearly healed. An extended observation of 4 hours was conducted on 3/19/19 in which R2 was not repositioned to offload her wound. On 3/21/19 the treatment to the wound was observed with a dramatic decline to the wound noted. During this observation, inappropriate hand hygiene was noted during the treatment. R21 has a history of PIs. R21 developed a stage 2 coccyx pressure injury after she was not repositioned for 6 hours. R21's plan of care was not implemented directing staff to reposition her every 2 hours due to her history of pressure injury and continued risk for developing pressure injury. This is evidenced by: Example 1 R2 has medical [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment dated [DATE] indicates R2: ~Requires extensive assistance for bed mobility and personal hygiene; ~Is non-ambulatory; ~Has an indwelling Foley catheter and [MEDICAL CONDITION]; ~Is on hospice. R2's care plan includes a problem of potential for impaired skin integrity, dated 11/11/18, that includes an approach for repositioning every 2 hours. R2's hospice care plan also indicates R2 is to be repositioned every 2 hours. Surveyor reviewed R2's wound documentation. The PI was first identified on R2's admission to the facility The right trochanter (hip) wound was first observed upon admission to the facility on [DATE] and was identified as a Stage III. The subsequent wound notes indicate the PI is healing. On 3/14/19, the PI was 0.6 cm L x 0.1 cm W x 0 cm D. On 3/18/19 at 10:12 AM, Surveyor spoke with LPN-I about R2's PI. LPN-I statedIt is nearly gone. It was initially smaller than a dime coin but has since healed. It is now smaller than a pencil tip. On 3/19/19 Surveyor began a continuous observation of R2 at 6:00 a.m. R2 was in bed laying on her right back with the PI in direct contact with the mattress. At 8:15 AM, CNA-P (Certified Nursing Assistant) brought R2 her meal. CNA-P pulled on the lift sheet underneath R2, creating a microshift to place R2 more onto her back. The PI remained against the mattress. At 9:17 AM, LPN-I completed a microshift of R2's body. The wound was directly against the mattress following this repositioning. No other staff offered or assisted R2 with repositioning. At 10:00 AM, Surveyor approached LPN-I and informed her R2 had been positioned for 4 hours on the right hip. LPN-I stated, I was in there and repositioned her The surveyor explained the repositioning provided did not completely offload the PI. Staff then entered R2's room and changed her position. At 10:18 AM the surveyor interviewed CNA-P regarding R2's needs. CNA-P was assigned to care for R2 on this date. CNA-P stated that R2 required total care by staff and that she should be repositioned .every 2 hours. I guess she has a sore on her bottom. Surveyor asked R2 if she could look at her hip. R2 declined. On 3/21/19, R2 was agreeable to allow Surveyor to watch the treatment to the PI. On 3/21/19 at 10:25 AM, RN-B (Registered Nurse) entered R2's room with dressing supplies. LPN-A also entered to assist with the treatment. RN-B placed the dressing supplies on R2's over-the bed table, without a protective barrier. RN-B then opened a chux pad and placed it on the bed then transferred the dressing supplies to this chux pad. The practice of placing clean treatment supplies on a dirty table increases the risk for wound contamination. RN-B sanitized her hands then gloved. RN-B then removed the incontinent pad and old right hip dressing from R2. Without removing her gloves and sanitizing or washing her hands, RN-B proceeded to clean the hip wound. RN-B stated that previously the wound was about the size of a dollar coin. Surveyor noted scarring that was pink in color. RN-B stated, It is most definitely worse than last week. The surveyor asked RN-B what R2's repositioning schedule is. RN-B replied, At a minimum, every 2 hours. She should be completely off her right side. Sometimes she will roll back if you put her on her left as she doesn't like to lay on her left. RN-B said It was nearly healed. Last week, we could barely see it, it's much worse now and there is a new area. RN-B continued to poke around the wound and poked the new wound with the same gloves on that she removed the brief and old dressing with. Again, no hand hygiene was completed prior to this act. RN-B then measured the right hip wound, and found it to be 3.0 cm L (centimeters length) x 0.6 cm w (width) x 0.3 cm D (depth). The wound was linear shaped with a very tiny area of slough approximately at 2.8 cm from the top of the wound. This is nearly 3x's the size of the last measurement taken 7 days earlier. Surveyor asked if the redevelopment could be caused by lack of offloading. Both staff agreed that it was a very strong probability. The new PI was slightly above the original wound and measured 1.0 cm L x 1.0 cm W, not open but reddish-purple in color with a tiny pimple at 5 0' Clock. Both staff poked around the wound and stated there was a pimple-like hardness under the surface. After completing the treatment and applying a new dressing, RN-B removed her gloves and applied a new pair and repositioned R2. She then washed her hands. Surveyor asked RN-B about hand hygiene when completing a dressing change. RN-B stated that she would wash Before entering room, glove, then remove old dressing, then sanitize or wash and reglove, do the treatment, then remove gloves and wash or sanitize. Surveyor asked RN-B why she did not perform hand hygiene between the removal of the old dressing and before cleansing and applying new dressing. RN-B stated that she did, however, this was not observed by the surveyor. Surveyor was in full view and did not observe RN-B remove soiled gloves and perform hand hygiene. On 3/21/19 at 12:20 PM, Surveyor interviewed the acting DON (Director of Nursing) regarding repositioning needs of residents. The DON stated that repositioning should be completed based on individual need, resident wishes, risk factors. Surveyor asked the DON what the needs are for R2. The DON stated It should be based on her weight and medical conditions. She should be repositioned at least every hour . due to her size. Example 2: The surveyor reviewed R21's record and noted the following: Most recent Quarterly Minimum Data Set ((MDS) dated [DATE] indicates: ~Severely impaired cognition ~Does not reject care ~Requires extensive assistance of 2 staff for bed mobility and transfer ~Is frequently incontinent of bowel movement ~Is at risk for the development of pressure injury Quarterly MDS dated [DATE] notes resident with stage 2 pressure injury. Previous comprehensive Annual ((MDS) dated [DATE] notes: ~Severely impaired cognition ~Does not reject care ~Requires extensive assistance of staff for bed mobility and transfer ~Is occasionally incontinent of bowel movement ~Is at risk for the development of pressure injury Braden Scale assessment dated [DATE] notes resident at moderate risk for the development of pressure injury with the following risk factors: Sensory Perception (ability to respond meaningfully to pressure related discomfort): Slightly limited Moisture (degree to which skin is exposed to moisture): occasionally moist Activity (degree of physical activity): chairfast Mobility (ability to change and control body position): very limited Nutrition (usual food intake pattern): adequate, meets most nutritional needs. Friction and Shear: Problem Comprehensive Care plan does not note R21's risk for development of pressure injury or approaches to prevent pressure injury. Problem: I have bowel incontinence Goal: I will be continent during the day time through review date Target date: 4/25/19 Approach: Check resident approximately every 2 hours and assist with toileting, keep skin clean and dry. Point click care certified nursing assistant care card dated 12/06/18; an extension of the comprehensive care plan, directs staff as follows: Turn and reposition Frequency: every 2 hours R21's Weekly Wound Assessments Notes were reviewed with the following noted: 11/01/18: Site: Coccyx Type: Pressure Length: 1.2 Width: 1.0 Depth: 0 Stage: II The area is noted to be healed. On 3/18/19 at 8:40 a.m. Surveyor observed R21 in her wheel chair in the dining room. R21 remained in the dining room for activities until 10:16 a.m. when CNA-D and CNA-E took her to a room adjacent to the dining room. R21 returned to the dining room at 10:20 a.m. where she remained in her wheel chair for activities and lunch. At 1:05 p.m. CNA-D took R21 to her room accompanied by RN-C. CNA-D indicated she needed to check if resident is now a hoyer lift and exited room. RN-C indicated R21 is a now hoyer transfer due to difficulty standing earlier. At 1:35 p.m. after locating a hoyer and appropriate fitting sling, R21 was transferred to bed. CNA-D placed blue boots on R21 and began gathering supplies. The surveyor asked CNA-D if she needed to do anything else for R21. CNA-D responded she needed to empty her catheter and would be returning to do so. Surveyor asked CNA-D and RN-C about R21's usual schedule. RN-C indicated R21 usually lays down after breakfast, but today was hectic so she didn't lay down until now. Surveyor asked RN-C about R21's care plan and risk for PI development. RN-C indicated R21 has an alternating air mattress due to history of PI to her coccyx and being at a high risk for PI development. RN-C stated R21 should have been laid down. Surveyor asked CNA-D what time R21 had gotten up. CNA-D stated it was between 7:30 a.m. and 7:45a.m. Surveyor asked CNA-D if R21 had been stood from her wheel chair. CNA-D indicated she and CNA-E had attempted to stand R21 even though she is now a hoyer left transfer, when she was taken to out of the dining room to adjust her catheter tubing. Surveyor asked CNA-D if R21 had stood less than 15 seconds. CNA-D responded it was less than 15 seconds. On 3/18/19 at 1:38 p.m. Surveyor requested RN-C complete a skin check on R21. On removal of the brief, it was noted R21 had been incontinent of bowel. After cleansing, RN-C inspected R21's skin and identified a PI in the same area that had been documented as healed. RN-C indicated the area measured 1.2 c.m. x .5cm and was superficial. RN-C stated she would notify the wound nurse. R21's wound notes on 3/18/19 indicated a PI measuring 1.2 cm x 0.5 cm x 0.2 cm was identified. There was no doucmentation of a Stage or description of the wound bed and/or surrounding tissue. On 3/19/19, at 10:00 a.m., R21 was seen by nurse practioner who assessed the redeveloped PI and staged it at a Stage II. On 3/20/19 at 2:30 p.m. Surveyor spoke with RN-C regarding R21's pressure injury and plan of care. RN-C indicated staff are expected to lay R21 down in bed between meals and reposition her in bed every 2 hours due to pressure injury risks. R21 should be checked for bowel incontinence every 2 hours when laid down. RN-C confirmed repositioning and incontinence care did not occur and R21 developed a PI. On 3/20/19 at 1:55 p.m., Surveyor spoke with the acting DON regarding R21's PI and plan of care. The DON indicated she would expect R21's care plan to be followed to prevent reoccurrence of her pressure injury. The acting DON stated R21 should have been repositioned every 2 hours and checked for soiling when laid down.

Based on observations, staff and family interviews and record review, the facility did not consistently provide care, treatment and services to promote healing, prevent infection and prevent pressure ulcer development or worsening of existing pressure ulcers. This affected 5 of 5 residents reviewed for current pressure ulcers (R10, R12, R13, R9 and R5.) R10 had a stage 2 pressure ulcer upon admission to the facility which progressed to a stage 3. Multiple observations were made in which the facility did not: - reposition R10 according to his written comprehensive care plan; - provide an air mattress to assist in the prevention of worsening of the pressure ulcer; - an improper wound treatment was completed for a time period of 10 days; and - complete weekly wound assessments As a result, R10's pressure injury worsened from a stage 2 to a stage 2I, became larger and deeper, and developed areas of induration. R12 had a recurring PI to the coccyx. The facility: - did not update hospice or the Nurse Practitioner with the worsening of a stage 2 to an unstageable with the development of slough. This delayed an appropriate treatment to be ordered; - when receiving a new treatment order, the facility did not carry out the orders consistently; - delayed in obtaining an air mattress to assist in the prevention of the worsening of the wound; and - did not consistently complete Weekly Wound Assessments. R13 has a history of recurrent stage 2 pressure ulcers. - An observation was made of a treatment in which R13 had a newly developed stage 2 as a result of her Indwelling Foley Catheter tubing. R13 did not have a security strap in place, causing the tubing to fall between her legs and place pressure on her inner thighs, which resulted in this newly developed pressure ulcer. - R13 had various openings of excoriation to her skin and the Certified Nursing Assistants (CNA's) applied Skin Barrier Cream to these open wounds. - The facility did not consistently complete Weekly Wound Assessments for R13's wounds. For R9 the facility did not ensure the routine assessments and documentation of the condition of the PIs on his feet. During the time frame when the assessments were not completed, the wounds deteriorated and became larger. R5 was being seen by the wound clinic for non pressure injuries to her leg and fingers. eekly skin checks completed for the last month, including one on 9/7/18 indicated there were no skin issues on R5's buttocks. However, on 9/7/18, the wound clinic sent notification to the facility of the presence of a stage 3 pressure injury to R5's buttocks with an order for [REDACTED]. of tasks. This is evidenced by: Example 1: R10 has current medical [DIAGNOSES REDACTED]. R10 was admitted to the facility on [DATE] with an existing pressure injury (PI) to his sacrum. R10 is nonverbal and according to the initial Minimum Data Set assessment dated [DATE], R10 is totally dependent on staff to meet his daily needs of bathing, dressing, personal hygiene, repositioning, transfers and toileting. He receives nutrition and hydration through a Gastrostomy tube ([DEVICE]). He also has an indwelling Foley urinary catheter. He is 73 inches in height and 240 pounds as of this assessment. A Braden Assessment was completed on 6/1/18 and R10 scored 11, indicating a high risk for the development or worsening of PI's. A score of 10-12 indicates a high risk for PI development. A score of 13-14 indicates a moderate risk. On 6/2/18, hospice Services were initiated. The initial skin assessment was dated 6/1/18 and stated the wound measured 4.2 cm (centimeters) length x 0.5 cm wide. The facility staged this wound as a stage 2 upon admission but did not include a depth measurement. There was no description of the wound including: - whether there was drainage present and how much; - whether there was induration present, which would indicate destruction of underlying tissue; - whether there was an odor present, which would indicate infection presence; and/or, - the presence of any predisposing factors such as [MEDICAL CONDITION], undermining, tunneling, redness or maceration. On 6/12/18, the wound was measured to be 5 cm length x 1.0 cm wide x 0.5 cm deep. This is an increase in the size of the PI. hospice provided R10 with a circulating air mattress on 6/16/18, 17 days after admission. The treatment at this time was Stoma Powder to the wound with [MEDICATION NAME] cream R10's care plan, dated 6/1/18 included a problem for .impaired skin integrity R/T (related to) Coccyx wound . The approaches included: 1. Air Mattress to bed (initiated 6/17/18) 2. Reposition approximately every 1-2 hours (initiated 8/30/18) Despite R10 having been admitted with a PI, the facility did not implement a repositioning program until 8/30/18. In addition, the care plan does not direct staff on side to side offloading of the PI. On 7/21/18, R10's spouse requested he be sent to the emergency room to be evaluated as she noted him to be very ill. The facility tried to educate her in the fact that R10 was on hospice and hospice provides comfort care and not hospitalization . The spouse insisted and R10 was sent to be evaluated. As a result of this hospitalization , hospice services were discontinued. With the discontinuation of these services, the air mattress was removed from his bed, as this belonged to hospice. R10 returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. This is the typical nursing home mattress and not a specialized mattress for a resident with an existing stage 2 PI. Other orders with his return from the hospital included: 1. Cleanse sacral wound with normal saline. Dakins solution to wound bed and dry 4 x 4 gauze pad to cover. 2. Cefpodoxine 100 mg (milligrams) QD for 5 days. This is an antibiotic that was to treat R10's [MEDICAL CONDITION]. On 8/6/18 the facility identified an error, with the treatment ordered from his hospitalization . The treatment of [REDACTED]. From 7/27/18 - 8/6/18, R10 had been receiving the incorrect treatment. On 9/12/18 at 1:46 p.m., the Surveyor interviewed RD-J (Regional Director) regarding the error report completed for the missing treatment. RD-J stated the expectation when completing an investigation would be for staff to document in the Notes section of the investigation. She stated in reviewing this particular error, it appeared no investigation was conducted. Further record review identified concerns with Weekly Wound Assessments either being incomplete or not completed at all. The facility completed an initial Weekly Wound Assessment for R10's sacral PI on 6/1/18, as noted above, however also noted was that this assessment was incomplete of data and descriptions. The facility completed the following assessments thereafter: - 6/6/18: (5.0 cm length x 1.0 width) stage 2. No depth was given and no descriptions of the wound or surrounding tissues were identified. No predisposing factors were listed. In the section to notify the Power of Attorney or Physician, these areas were marked as non-applicable even though there was decline noted in the wound. The wound progress was marked as being stable/no change even though staff had identified a decline in the wound. A Braden Assessment was completed on 6/8/18 and R10 scored 12, which continues to be high risk for PI development. - 6/12/18: (5.0 cm length x 1.0 cm width x 0.5 cm depth) stage 2. No other information regarding the PI was documented and notification was not yet completed with the POA (Power of Attorney) or Physician. A Braden Assessment was completed on 6/15/18 and scored 13, which now indicates R10 is at moderate risk - 6/19/18: (4.0 cm length x 2 cm width) stage 2. Again, there was no depth measurement. This assessment indicated there was 75% [MEDICATION NAME] of the wound. Note: This is an inaccurate term. [MEDICATION NAME] indicates new healthy [MEDICATION NAME] tissue covering the wound. Instead, the term should be granulation. Granulation is the development of new capillaries and fibroblasts to the area which gives the wound a beefy red appearance. The development of granulation allows [MEDICATION NAME] to occur, which is the complete closing of the wound with new skin tissue. Another Braden Risk Assessment was completed on 6/22/18 and scored R10 as 11- High Risk - 6/26/18: Weekly Assessment was not completed. - 7/2/18: Weekly Assessment was not completed - 7/4/18 (5.0 cm length x 1.0 cm width) stage 2- Again no depth was recorded. The wound was now described as having 25% granulation tissue, indicating new healthy tissue growth and the filling in of the wound. - 7/11/18: Weekly Assessment not completed. - 7/18/18: (4.5 cm length x 1.0 cm width x 1.0 cm depth) stage 2- This is an increase in the last recorded depth of 0.5 cm. This assessment indicates the wound continues to have 25% granulation tissue, no predisposing factors listed and POA and Physician is marked non-applicable indicating contact of the decline was not made. The wound is also marked as being stable/no change. A Braden Assessment was completed on 7/20/18 and 7/27/18. Both scored R10 as 10, indicating high risk. R10 was in the hospital 7/21/18 and returned 7/27/18. - 7/27/18 No Weekly Assessment was completed with R10's return from the hospital. - 7/31/18 (4.0 cm length x 1.0 cm width x 1.0 cm depth) stage 3 NOTE this is a decline in the wound from a stage 2 to a stage 3. The wound is described as having 25% slough. Slough is nonviable, or dead tissue and must be removed in order for wound healing to occur. Again, there are no predisposing factors or drainage listed. The wound was identified as stable/no changes and contact with the POA and Physician were marked as non-applicable. Notification should have been made to allow the decision to change the treatment in order to clean the wound of the slough. Surveyor requested any additional wound assessments and received no further information. During this time, R10 was being seen at the wound clinic. Surveyor found no documents in R10's medical record from the wound clinic. The Surveyor requested all Wound Clinic notes and was provided 1 dated 8/17/18. The physician from the Wound Clinic described the sacral ulcer to now be 6.5 cm length x 7.0 cm width x 1.1 cm depth and an area of full thickness destruction of 3.0 cm length x 1.2 cm width x 1.1 cm depth directly over the Gluteal cleft with evidence of necrotic fat in its base. The Wound Clinic progress note stated .The patient's ulcers have .worsened .sacrum considerably . The wound clinic staged the PI as a stage 3. The plan was to offload the area with the alternating air mattress and a treatment change to Silver Alginate with [MEDICATION NAME] to cover. On 9/7/18, R10 again went to the Wound Clinic and even though the Progress Note does not give measurements, the Physician wrote .Coccyx wound deeper . The treatment was changed to DiDakSol moistened open weave gauze into wound bed, cover with ABD pad and secure with medfix tape. Change twice daily and as needed. Surveyor made the following observations: 9/10/18 at 9:00 a.m.: During the initial tour of the facility, R10 was laying in bed on his back. There was an air mattress on the bed. He was asleep. 9/10/18 at 1:24 p.m.: Surveyor entered R10's room with RN-A (Registered Nurse) and CNA-B (Certified Nursing Assistant) in order to observe the treatment to his wound. R10 was positioned on his back with the head of bed elevated to approximately 30 degrees. R10 had a large loose stool that first required cleansing. In so doing, CNA-B positioned R10 onto his side. It was at that time the Surveyor noted there was no dressing in place to the sacral wound. RN-A stated that the dressing was soiled from earlier and that she instructed the staff to leave it off and she would replace it when she completed the treatment. CNA-B stated she had notified RN-A of the soiled dressing at 12:00 p.m. sharp. Surveyor asked if R10 had been without the dressing for approximately 1 1/2 hours with direct pressure to the wound, (as he was positioned on his back), both replied, Yes. Surveyor also asked what R10's positioning should be while in bed. CNA-B stated, He should be side to side. RN-A affirmed this and stated, He should never be on his back because of this wound. Surveyor entered the facility in the early morning hours of 9/11/18. On 9/11/18 at 4:00 a.m., R10 was positioned in bed laying partially on his left but mostly on his back. There were pillows under his knees and a pillow at his back. Surveyor sought out the nurse on duty, RN-D and asked her to accompany Surveyor to R10's room, which she did. Surveyor asked RN-D how R10 should be positioned while in bed. RN-D stated He should be completely off of his bottom, side to side. Surveyor then asked if his current positioning is what she would consider side to side. RN-D stated, No, the pillow came out. We did have him way over but somehow he ended up over again on his back. Surveyor asked CNA-E, who was responsible to reposition R10 on this night shift, about R10's positioning. CNA-E stated that R10 was to be positioned side to side and stated that she had him completely over onto his side and I don't know how the pillow came out. It might be when he coughs because he coughs with a lot of force. At 5:00 a.m., the two staff repositioned R10 onto his right side. At 8:40 a.m., Surveyor observed R10 to still be on his right. Surveyor asked CNA-F about R10's positioning. CNA-F stated she completed repositioning at 6:30 a.m. but that it was just a little lift of the drawsheet. When describing how she repositioned him it appeared as a microshift, pulling up slightly on the linens underneath R10. When asked if this repositioning was considered a micro-shift, CNA-F stated Yes. From 5:00 a.m., a.m., to 8:55 a.m., R10 was laying on his right side. According to the care plan, R10 is to be repositioned every 1-2 hours, however in this observation he was not repositioned for 3 hours and 55 minutes. At 8:55 a.m., Surveyor approached RN-A and asked her what repositioning means. RN-A stated that for R10 it means .completely off his back with side to side positioning so the sore is completely offloaded. RN-A stated repositioning for R10 should be a minimum of every 2 hours. It was at this time that RN-A and CNA-F repositioned R10 onto his left side. It was also at this time Family-C was in the room. Family-C stated that when R10 returned from the hospital the facility provided him with a regular mattress. She stated that hospice took their mattress back. It was in R10's closet but that R10 was not allowed to use it. She then opened the closet and there was an air mattress rolled up and covered in a plastic bag. She stated that she argued with the facility on why they couldn't use the mattress and if not, can the facility get him an air mattress for his wound. Family-C stated she argued with the facility for weeks. Family-C stated she went with R10 to his (MONTH) wound clinic appointment in order to see R10's wound. She stated she told the wound physician that R10 was on a regular mattress and wondered if a special mattress should be provided. Family-C stated the physician was under the assumption that R10 had an air mattress this whole time and wrote an order to the facility for them to provide one. Family-C also stated that R10 has two blue wedges in his closet that he came back from the hospital with. She stated that she had requested staff use them to help R10 hold his position over onto his side, but they do not listen to her. She also pulled these from R10's closet to show to Surveyor. Family-C stated, .I got so tired of asking them (facility) for an air mattress that I went out and rented one on my own from an organization called The Good News Place on 5th Avenue. She further stated the mattress came the third or forth week in August. Family-C stated, It was so upsetting, when hospice stopped (7/21/18) they took away the air mattress and it just sat there. They (facility) kept putting it off. Weeks went by, so I took it upon myself . Surveyor called the Good News Project on 9/12/18 at 9:10 a.m. They stated that they are a non-profit lending closet for people in the community who have a need for medical equipment and devices that they would not be able to afford if they would seek to purchase the equipment. Staff there verified they provided R10 with an air mattress on 8/23/18 for a donation cost of $50.00 paid by Family-C. Surveyor then approached UM-K (Unit Manager), and asked her what the procedure was for obtaining a specialized air mattress for R10. UM-K directed the Surveyor to RN-O. She stated that RN-O would have ordered the mattress. On 9/11/18 at 9:16 a.m., Surveyor interviewed the Interim Director of Nursing, RN-O regarding R10 and his care expectations. RN-O stated R10 was to be positioned side to side every 1-2 hours and totally off the wound as able. When asked what could happen should R10 not be offloaded, RN-O stated, Well, the wound would get worse and progress, maybe develop infection. RN-O further stated, We need to look at something different for repositioning (R10) to maintain the side to side positioning. Surveyor asked RN-O about the air mattress and when it was provided. RN-O stated that when hospice was discontinued 7/21/18, the facility provided R10 with a regular nursing home mattress and Surveyor would need to check with Maintenance on the specifications of the mattress. She then stated the Wound Clinic ordered the Air Mattress for R10 at his (MONTH) appointment and that she placed the order but R10's spouse went out on her own and brought one in the following day. RN-O stated MR-G (Medical Records) would have placed the order. On 9/11/18 at 9:26 a.m., Surveyor interviewed MR-G on ordering the air mattress for R10. MR-G stated that she didn't order the mattress. MR-G indicated she had sent a request to the corporation for the mattress. She stated that time went by without any reply so she sent out another e-mail to the corporation asking the status of the request. MR-G stated she received an e-mail back, but that e-mail was just clarification on what was needed, not permission to actually place the order. Surveyor requested and received a copy of the e-mail on 9/12/18. The e-mail correspondence did not give MR-G permission to order the mattress only clarification on what is needed. On 9/11/18 at 9:30 a.m. Surveyor interviewed Maintenance-H regarding the requisition of an air mattress for R10. Maintenance-H stated it was a verbal request so there was no paper work involved. He stated that when R10 returned from the hospital in (MONTH) (7/27/18) and he had placed a standard mattress on the bed. He recalled R10 being discharged from hospice and that hospice wanted their air mattress removed. Maintenance-H stated Family-C requested the mattress to be wider and he was able to grant that request but that he had no air mattresses available that were not in-use at the time and that a special mattress would need to be rented. He then recalled Family-C bringing in an air mattress that she wanted placed on R10's bed, which he did. On 9/11/18, at 9:47 a.m., Surveyor observed the treatment to R10's wound by RN-O and RN-I. The wound measured 10.2 cm length x 5.4 cm width x 2.5 cm depth. There was undermining at 12 o'clock of 1.5 cm. and 30% slough to the wound bed. This is a significant decline in the wound from its last measurement by the facility (7/31/18) and the Wound Clinic (8/17/18) with the addition of undermining and an increase in size and the development of slough. On 9/12/18 at 7:20 a.m. R10 was positioned partially on his right side but his buttocks was directly against the bed mattress. There were two pillows at his back. Surveyor approached CNA-L and interviewed her on R10's positioning. CNA-L stated R10 was positioned at 7:15 a.m. and is to be side to side in bed and turned every 2 hours. CNA-L and Surveyor went to R10's room. Surveyor asked CNA-L if this is how she positioned R10. CNA-L indicated it was. Surveyor then asked CNA-L if she thought his positioning achieved offloading of R10's buttocks, where the wound was located. CNA-L stated that R10 was not offloaded and pressure remained on the sore. She stated that R10 needs something different besides pillows to keep him over. At 8:26 a.m., CNA-L approached Surveyor and stated that she located wedges in R10's closet and she placed them at his back, which seemed to keep him over and off the sore. Surveyor went to view the position of R10 and he was indeed being maintained on his right side with the two wedges. On 9/13/18 at 8:25 a.m., R10 was positioned on his right side. He remained on his right side until 11:30 a.m. R10 had been in the same position for 3 hours. At 11:30 A.M., Surveyor approached CNA-B and interviewed her on various topics, including the last time she was in to reposition R10. CNA-B stated that she repositioned him around 8:30 a.m. Once the interview was completed, CNA-B entered R10's room and repositioned him. On 9/13/18 at 1:00 p.m., Surveyor interviewed CNA-B regarding what she recalls regarding the mattress R10 had been on when he returned from the hospital. CNA-B stated that R10 was on a regular mattress, like everyone else has, until his wife brought one in. On 9/13/18 at 3:40 p.m., R10 was positioned on his back in bed with the head of the bed elevated to approximately 60 degrees. Surveyor spoke with CNA-E and CNA-Y, who were the two staff on-duty at this time. The Surveyor asked what R10's positioning in bed should be. CNA-Y stated, He is supposed to be side to side. The Surveyor then asked why R10 was on his back if he is supposed to be side to side. CNA-Y stated, We can't get him over for fear of him falling out of bed. The bed isn't big enough to get him onto his side. There were repeated failures in the provision of services to meet R10's needs including the facility not obtaining a specialized air mattress upon his return from the hospital and after hospice removed their mattress from his bed (7/27/18), the fact that R10's spouse had to obtain an air mattress as she wasn't seeing progress from the facility in obtaining one, the incomplete and missing Weekly Wound Assessments, the repeated cases of R10 not being offloaded from his wound with deterioration noted with the wound and the repositioning not being completed every 1-2 hours as written in the care plan. Also noted, R10's care plan does not address the need for side to side repositioning. Perhaps with this directive, staff would have been more diligent in providing the true offloading and repositioning. Example 2: R12 had medical [DIAGNOSES REDACTED]. R12 passed away at the facility on 8/12/18. R12 was admitted to the facility on [DATE] with an area to her coccyx that was described in the Nursing Progress Notes (NPN) as being red but blanchable. According to the most recent MDS, dated [DATE], R12 required extensive assistance of staff to meet her most basic needs of bathing, personal hygiene, toileting, repositioning, dressing and eating. She was always incontinent of urine and frequently of bowel. The Certified Nursing Assistant (CNA) Care Kardex for R12 is not dated and does not address R12's repositioning needs. The care plan was initiated 2/22/18 and addresses a problem of Resident has Actual moister (sic) cleft associated integrity r/t (related to) Coccyx wound. Basically what this is saying is that R12 has an actual wound to her coccyx that developed as a result of moisture. Interventions include, but are not limited to: - staff to reposition every hour to keep her off her bottom and toilet routinely every round. (Initiated 2/28/18 and revised on 3/1/18) - Perform treatment to wounds per current orders (2/22/18) - Assess wounds for signs of infection with each dressing change. Report positive findings of redness, warmth, swelling, increased drainage and increased pain. (2/22/18) - Report wound healing to MD (physician) with any changes or lack of response to treatment (2/22/18) - Cushion to wheelchair, Basic Reduction Mattress to bed (2/22/18) There was no assessment for the initial wound noted on admission of 2/20/18, other than the Nursing Progress Note (NPN) entry that stated .Coccyx is red and blanchable . and the 2/21/18 NPN entry that states, .Coccyx healing fragile area measured 2 x 0.5 cm with blanchable red surrounding tissue . The facility does indicate in the NPN's that the wound is slit-like in shape. - 2/26/18. This assessment indicates R12's wound is located on her Sacrum and measured 2.0 cm (centimeters) in length x 0.25 cm width. There is no depth noted and the Stage stated N/A or non-applicable. There are no predisposing factors noted, such as redness, [MEDICAL CONDITION], maceration, etc. The wound was described as having a scant amount of drainage, serous in nature. Serous drainage is a clear, pale yellow, thin watery drainage. The cause of the wound is noted as being trauma. The facility checked the box that POA (Power of Attorney)/Responsible party was notified, but left the area to notify the physician blank. In comparison to the NPN entered on this date, the Assistant Director of Nursing (ADON), who is no longer working at this facility wrote an entry that states, Open area found to coccyx area, covered with 100% slough. POA was notified. PCP (Primary Care Provider or Physician) aware and stated may follow wound nurses recommendations. Wound nurse notified .Coccyx area is fragile with little to no fad (sic) pad, high risk for skin breakdown. Staff encouraged to shift resident's weight in w/c (wheelchair) and repo (reposition) with rounds. Slough is a nonviable, dead tissue that signifies wound deterioration. This is an extreme negative determinant of healing. Healing will not occur until the slough is removed. - 3/5/18 Wound measures 2.0 cm length x 1.0 cm width. Again there is no depth measurement and the Stage was left blank. The wound now has 25% slough, and the note includes 75% [MEDICATION NAME]. Redness is listed as well as a scant amount of Serous drainage, no odor. The term [MEDICATION NAME] would be an inaccurate term in this particular case. [MEDICATION NAME] indicates new healthy [MEDICATION NAME] tissue covering the wound. Instead, the term should be granulation. Granulation is the development of new capillaries and fibroblasts to the area which gives the wound a beefy red appearance. The development of granulation allows [MEDICATION NAME] to occur, which is the complete closing of the wound with new skin tissue. - 3/12/18 There is a new area in which the facility completed a Weekly Skin Assessment that indicates a rash that measures 2.0 cm length x 1.0 cm width. There is no depth or stage listed. Note: There is no way to determine if this wound is a different area of breakdown than noted under the previous assessments. This area is described as a maceration or breakdown of the skin related to moisture or urine, whereas the previous assessments determined trauma was the cause. - 3/16/18 Trauma wound: 2.0 cm length x 1.0 cm width, no stage or depth listed. The wound is described as 50% [MEDICATION NAME], which is an incorrect term and should be stated as granulation. R12 has redness and [MEDICAL CONDITION] listed as predisposing factors as well as recent illness. - 3/21/18 Wound measures 1.0 cm length x 0.5 cm width. The facility lists no depth but now includes a Stage as being II. The wound is also now described as having 100% granulation. This is an accurate term indicating the wound is filled in with new fibroblasts and capillaries and would then have a red, beefy appearance. - 3/28/18 The Coccyx wound is now described as being caused by pressure and measured 0.75 cm length x 0.5 cm width. There is no depth measurement and the facility staged this as a II. - 4/4/18: This assessment is missing. During this time frame, R12's health was declining and began treatment for [REDACTED]. On 4/5/18 a new treatment of [REDACTED]. - 4/9/18 The Coccyx wound is now described as being 1.25 cm length x 0.75 cm width. There is no depth listed. The wound now has 25% slough and 75% granulation. This is an increase in the size of the wound which indicates deterioration. The facility checked the box that POA (Power of Attorney)/Responsible party and notification of the physician is N/A. There is no corresponding NPN that indicates the wound deterioration or contact with the responsible party or Physician. - 4/16/18 The wound measurement was listed as being 1.25 cm length x 0.75 cm width. There is no depth or stage listed. Again, the wound is listed as being 100% [MEDICATION NAME], which is an incorrect term. The wound is noted as being stable/no change and contact has not been identified with the responsible party or Physician. - 4/22/18 Assessment is missing. There is no corresponding NPN related to the wound. - 4/27/18 The wound is measured as being 1.0 cm length x 1.0 cm width. No depth but facility staged the wound as a II. - 5/1/18 The wound is 1.0 cm length x 0.5 cm width. No depth is listed. Again, the wound is listed as being 100% [MEDICATION NAME]. There is now a scant amount of serosanguineous drainage. Note: Sanguineous (SS) drainage contains blood rather than the protein and white cells in serous drainage. This type of drainage usually occurs with partial or complete thickness wounds, indicating the term [MEDICATION NAME] is incorrect terminology. Also, the facility continued to mark N/A for contact with the responsible party and Physician. Also on this date, an order for [REDACTED]. The NPN dated 5/7/18 indicates the wound in 0.75 cm length x 0.5 cm width with scant amount of SS drainage. There was no other descriptions of the wound made. - 5/8/18 Assessment is missing; R12 was enrolled in the hospice Services on this date. - 5/15/18 The wound measured 0.25 cm length x slit for width, no depth and stage 2. Again, the wound is listed as being 100% [MEDICATION NAME], which is incorrect if the wound is open. - 5/22/18 The wound was documented as being closed/healed. - 6/5/18 The wound was fragile healed. Skin Prep was applied. There are no Weekly Assessments pertaining to R12's coccyx after this time frame until 7/13/18 as the wound appeared healed. On 6/26/18, R12 began treatment with an antibiotic for left lower l

Based on interviews, observations, and record reviews, the facility did not ensure that food was cooked to the proper internal temperature to prevent a food borne illness placing all 57 residents of the facility at risk for serious illness and death. Review of the facility's cooking temperature monitoring found staff consistently did not cook raw chicken to a minimum internal temperature of 165 degrees. When raw chicken is not cooked to a minimum temperature of 165 degrees, pathogens such as salmonella, can rapidly grow in the environment and place a vulnerable population at risk for the development of a food borne illness. The immediate jeopardy began on 1/22/17 when undercooked chicken was noted by residents and families. The NHA (Nursing Home Administrator) and Corporate Consultant were notified of the immediate jeopardy at 2:10 p.m. on 2/22/17. The immediate jeopardy was not removed by the exit of the survey. In addition, the facility does not have a system for monitoring the internal temperatures of the hot water sanitizing dish machine to ensure proper sanitation of the dishware. This is evidenced by: Example #1: On 2/20/17 6:00 p.m., upon entrance to the facility the current menus were obtained and reviewed by Surveyor to determine if chicken was being served during the duration of survey being conducted (2/20/17 - 2/22/17). The menus showed chicken was not being served during the survey. Surveyor asked the Dietary Manager (DM) if chicken is served to residents that originates from a raw state. The DM responded many of the recipes include chicken that originates from a raw state, both chicken with bone in and no bone. Surveyor and the DM reviewed recipes that included the ingredient of raw chicken. Surveyor noted recipes of chicken prepared by frying, baking and use in dishes such as casseroles and chicken ala king. The method of preparation on the recipes did not include a step to monitor the final cooking temperatures or or amount of time to cook the chicken to reach the desired internal temperature. Surveyor asked the DM, who is also one of the facility's primary cooks, about the process of monitoring cooking temperatures. The DM indicated the chicken is cut into and the cook looks at the juices to see if there is any color, and temperatures are taken after cooking. Surveyor asked the DM what is the minimum required cooking temperature of chicken. The DM indicated the final cooking temperature needs to be at least 140 degrees Fahrenheit. On 2/21/17 at 11:30 a.m. Surveyor observed serving of the lunch meal in the facility's kitchen. Diced chicken served as an alternate for that meal. The DM took food temperatures of all the foods, except for the diced chicken. The DM put the thermometer away and proceeded to ready items for tray line service. Surveyor asked the DM about the diced chicken and its temperature. The DM indicated the diced chicken originated from raw chicken breasts and the temperature was not taken. The DM stated the Meal Temperature Form does not include an area for alternate foods. The DM stopped preparation of tray line and appropriately took the temperature of the diced chicken being served to residents which exceeded the required 165 degrees. Surveyor again asked the DM what the safe internal temperature should be. The DM responded 140 degrees. Surveyor noted each food item had 2 temperatures noted. Surveyor asked the DM about the 2 temperatures recorded for each food item. The DM stated the first number is the final cooking temperature and the second number is the serving temperature of the food just before being served to residents. Surveyor requested Meal Temperature Forms for the current menu cycle. On 2/21/17 at 7:25 a.m. Surveyor spoke with R12 regarding any concerns related to under cooked foods. R12 indicated she has been served and has heard several complaints from other residents regarding undercooked chicken. The chicken was described as rubbery in texture, not cooked enough and pink in color. R12 further expressed she has resorted to eating snacks in her room versus eating particular menu items including the chicken as it is not edible. On 2/21/17 at 1:50 p.m. Surveyor spoke with R20. R20 indicated she has not been served any undercooked foods. R20 stated she has heard other residents complain at resident council about undercooked, rubbery and fatty chicken. On 2/22/17 at 11:55 a.m. Surveyor # spoke with R3. R3 indicated she had received undercooked chicken approximately 2 weeks ago. R3 indicated the chicken was bloody when I cut into it. R3 indicated she did not eat it. On 02/21/17 at 2:25 p.m., Surveyor spoke with R19. R19 said that she had to send her chicken back to the kitchen about 2 weeks ago as it was not done. R19 said the chicken was bloody inside the breast. On 2/21/17 at 1:45 p.m. Surveyor spoke with CNA-D (Certified Nursing Assistant), who has worked at the facility almost 1 year, and asked if she has witnessed under cooked foods or heard resident complaints of undercooked foods. CNA-D responded when cutting meat, she has found it to be rubbery in texture which she believed was related to both over cooking and under cooking at times. CNA-D also expressed she has heard residents complain of meat that was tough and did not taste right. CNA-D stated those residents believed the meat was both undercooked and overcooked at times. On 2/21/17 at 2:00 p.m. Surveyor spoke with CNA-E regarding any personal observations of undercooked foods at the facility. CNA-E expressed every once in awhile when preparing and cutting resident chicken, she would notice undercooked chicken on the bone. Further expressing the meat was pink and visible blood was noticed around the bone of the chicken. Surveyor asked CNA-E what she did when she noticed the pink meat and visible blood around the bone of the chicken. CNA-E responded, Cut off the pink and bloody piece before serving to the resident. On 2/21/17 at 1:30 p.m., Surveyor interviewed RN-G (Registered Nurse) of her knowledge of residents being served undercooked foods. RN-G stated she recalled one instance in January in which chicken was undercooked. She noticed the chicken after realizing residents were not eating it. When she questioned the residents as to why they were not eating the chicken, RN-G stated they told her to look at it. She inspected the chicken and noted the meat to be pink in color. RN-G stated she returned the chicken to the kitchen. On 02/21/17 at 2:00 p.m., Surveyor spoke with CNA-F (Certified Nursing Assistant). CNA-F said that about a month ago the residents were served chicken on the bone and that it was red by the bone. CNA-F said alot of residents complained about it and so she went and told the staff in the kitchen about the concerns. Surveyor reviewed the facility's current menu cycle and compared it to the facility's Meal Temperature Form with the following being noted from 10/30/17 to present: ~11/27/16: Teriyaki Chicken Wings were served for dinner (evening meal). Final cooking temperature recorded as 159 degrees Fahrenheit and serving temperature recorded as 162 degrees Fahrenheit (159/162). ~12/01/16: Chicken Pasta Casserole was served for dinner (163/165). ~12/11/16: Country Fried Chicken was served for lunch (161/167). ~12/31/16: Teriyaki Chicken wings were served for dinner (163/169). ~1/08/17: Country Fried Chicken was served for lunch (155/161). ~1/22/17: Country Fried Chicken was served for lunch (159/162). ~1/26/17: Chicken Pasta Casserole was served for dinner (162/167). ~2/05/17: Country Fried chicken was served for lunch (162/171). On 2/21/17 at 4:15 p.m. Surveyor again spoke with the DM. Surveyor reviewed the menus items with the DM. The DM confirmed the above food items served to residents originated from cooking with raw chicken. Surveyor asked the DM about the safe cooking and serving temperatures of the food items noted. Again the DM expressed the food items need to be cooked to a minimum internal temperature of at least 140 degrees Fahrenheit to keep them out of the Danger Zone of 40 degrees Fahrenheit to 139 degrees Fahrenheit. Surveyor asked the DM why it is important to fully cook and serve the noted food items. The DM responded due to hazards associated with serving under cooked foods such as Salmonella. Surveyor asked the DM what standard of practice is used to base the appropriate and safe cooking/serving temperatures. The DM responded the Wisconsin Food code is the standard of practice used by the facility. Surveyor requested the facility's policy related to the same. On 2/22/17 at 9:00 a.m. Surveyor and the DM reviewed the Wisconsin Food Code and the facility's policy titled Meal Service-Temperatures with an issued date of 04/21/16. the following was noted.: Wisconsin Food Code Fact Sheet: Temperature Guide: Cook foods to proper temperature: 165 Degrees for 15 seconds-Cooking poultry .and re-heating of left-over foods .for hot hold. Reheating for hot hold: Cooked and cooled potentially hazardous foods shall be re-hated to at least 165 degrees Fahrenheit for 15 seconds. Policy states: Purpose: to ensure appropriate food temperatures during meal service and to ensure food holding temperatures. Policy: Hot foods shall be cooked and heated to a temperature above 165 degrees. Surveyor asked the DM if the information she had told and provided to Surveyor was consistent with the Wisconsin food code and facility policy. The DM responded No she had thought 140 degrees was the safe cooking and serving temperature. Surveyor asked the DM if she had received training in aspects of safe cooking and serving temperatures. The DM responded while she was a cook for 4 years at the facility and she had received training from the previous Dietary Managers. The DM stated she is currently enrolled in a Dietary Managers course. Failure to cook chicken to at least 165 degrees Fahrenheit created a finding of immediate jeopardy. The immediate jeopardy that began on 1/22/17 was not removed at the time of the exit from the survey because the facility had not yet formulated a plan for removal. Example 2: On 2/20/17 at 6:00 p.m. Surveyor observed the DM loading and unloading dishes from the dish washer. Surveyor asked the DM if the dish washer was a chemical or hot water sanitization dish machine. The DM indicated the dishwasher was a hot water sanitation machine. Surveyor asked the DM about monitoring of the dish washer temperatures. The DM indicated the wash and rinse cycle temperatures are monitored after each meal. The DM and Surveyor reviewed the dish washer temperature logs which contained wash and rinse cycle temperatures. Surveyor asked the DM if the facility had a system in place for monitoring dishware surface temperatures by use of an irreversible registering temperature indicator. The DM responded the facility does not currently have a system in place.

Based on interview and record review, the facility did not ensure that 1 of 9 sampled residents with dementia, received care and treatment that promoted optimal mental and psychosocial well-being. Resident #6 has a [DIAGNOSES REDACTED]. The facility identified Resident #6 would scream, yell, and attempt to stomp on caregivers' feet during showers and incontinence care. Despite this, the specific targeted behaviors were not identified nor quantified. There was no care plan developed to direct staff on how to manage Resident #6's distress during showers and incontinence care. This is evidenced by: Resident #6's current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 9/1/15. The MDS indicated Resident #6: ~ Had both short and long-term memory problems; ~ Cognitive skills were severely impaired; ~ Rejected care four to six days during the seven-day look back period; ~ Walked with supervision; ~ Required extensive assistance for bathing, personal hygiene, and using the bathroom; and ~ Was frequently incontinent of bladder. Resident #6's most recent CAA (Care Area Assessment) for behavioral symptoms was dated 6/10/15. The CAA indicated, .has a [DIAGNOSES REDACTED].Does resist care and especially does not like to take a shower. Staff approaches her in a calm manner and reapproaches as needed .care planning to make sure resident's needs are met and to reduce behaviors . Resident #6's care plan for dementia care was dated 3/11/15. The care plan indicated Resident #6 would at times refuse care. The care plan had the following approaches: ~ 3/11/15, .When .resistive with cares, speak to her in a calm manner and reapproach as needed .Offer distraction . Resident #6's care plan problem titled .Self Care Performance Deficit was dated 3/9/15. The care plan had the following approaches: ~ 3/9/15, .At times will refuse showers and changing clothes. Staff to reapproach . There was no care plan that identified what triggers Resident #6's behaviors. There was no care plan that identified Resident #6's specific targeted behaviors. There was no care plan to direct staff on how to manage Resident #6's targeted behaviors. Surveyor # completed a review of Resident #6's behavior monitoring since 7/1/15. The behavior monitoring identified Resident #6's targeted behavior as .Refusal of cares . Refusing care is not a specific targeted behavior. From 7/1/15 through 7/31/15, Resident #6 had 40 episodes of refusing care. From 8/1/15 through 8/30/15, Resident #6 had 40 episodes of refusing care. From 9/1/15 through 9/15/15, Resident #6 had 11 episodes of refusing care. All targeted behavior as noted above was tallied by Surveyor # . Surveyor # completed a review of Resident #6's nursing notes and noted the following: ~ 6/4/15, .Behavior Review .continues to refuse cares .Allowed to calm down, staff reapproach . ~ 6/24/15, .Behavior Review .receive interventions 1:1 (one to one) and distraction .will continue to monitor for refusal of cares . ~ 8/27/15, .Behavior Meeting .Will continue to monitor for refusals of cares . ~ 9/3/15, .Behavior Meeting .Monitoring behaviors of refusing care .had several refusals in 2 days . None of the behavior meeting notes identified specific targeted behaviors. None of the behavior meeting notes quantified or tallied episodes of targeted behaviors. It is critical to identify specific targeted behaviors, and track and trend targeted behaviors in order to know if approaches implemented are effective. Surveyor # completed a review of Resident #6's physician progress notes [REDACTED].becoming increasingly difficult to perform all cares. On her shower days she usually puts up a fight and screams and yells during the bathing process . Surveyor # completed a review of a facility form titled Resident Functional Performance Record and noted the following: ~ From 7/1/15 through 7/31/15, Resident #6 received three showers. ~ From 8/16/15 through 8/31/15, Resident #6 received three showers. Surveyor # requested Resident #6's Resident Functional Performance Record for 8/1/15 through 8/15/15 and 9/1/15 through 9/16/15. No information was received. Surveyor # requested to observe staff perform care for Resident #6 on 9/16/15 on both the day and evening shifts. Surveyor # was never summoned by staff. On 9/16/15 at 1:45 p.m., Surveyor # spoke with CNA-A (Certified Nursing Assistant). CNA-A indicated Resident #6 got a shower once a week. CNA-A also indicated it was very challenging as Resident #6 did not want to take a shower. Surveyor # spoke with Staff-J (Anonymous). Staff-J indicated Resident #6 was very difficult and would yell out during cares. Staff-J stated Resident #6's husband indicated Resident #6 had been a very modest person. On 9/17/15 at 8:40 a.m., Surveyor # spoke with CNA-B. CNA-B indicated she worked full time on the unit in which Resident #6 resided. CNA-B indicated Resident #6's behaviors included yelling and screaming during cares. CNA-B also indicated Resident #6 would attempt to stomp on her feet when attempting cares that Resident #6 did not want done. CNA-B indicated Resident #6 was very modest and did not want anyone to see her without any clothes. CNA-B also indicated she did not recall the facility ever talking with her about the difficulties in providing care to Resident #6 nor what approaches to take in order to minimize or eliminate Resident #6's distress. On 9/17/15 at 10:25 a.m., Surveyor # spoke with CNA-I. CNA-I indicated Resident #6 didn't like taking a shower and would yell out until the shower was done. CNA-I stated Resident #6 gets pretty upset but once the shower was done Resident #6 calmed down. CNA-I indicated Resident #6 likes her clothes and doesn't like getting undressed. Surveyor # asked CNA-I why they gave Resident #6 a shower. CNA-I indicated she didn't know why other than it was what Resident #6's care plan indicated. On 9/17/15 at 8:55 a.m., Surveyor # spoke with RN-M (Registered Nurse). RN-M indicated she was the full time nurse on the unit where Resident #6 resides. RN-M stated Resident #6 would scream and call out when staff completed cares, including a shower. RN-M indicated she felt Resident #6's behavior was related to the progression of Resident #6's dementia. RN-M indicated Resident #6 liked to take kotex pads and pile them into her underwear. RN-M indicated Resident #6 did not comprehend she needed to change them. On 9/17/15 at 9:07 a.m., Surveyor # spoke with the SSS (Social Services Supervisor). SSS indicated she was aware and identified concerns with the facility's Behavior Management Program. SSS indicated the facility was in the process of implementing strategies to improve their program. On 9/17/15 at 10:40 a.m., Surveyor # spoke with the DON (Director of Nursing). The DON indicated refusing care was not a behavior and was normal and expected for residents with dementia. The DON indicated she was aware of Resident #6's behaviors during cares but Resident #6 needed to have care because of odors caused by incontinence. Despite knowledge that Resident #6 was a modest person, did not like getting undressed and was resistive to taking a shower, the facility did not develop alternative approaches to showering the resident. Consequently, Resident #6 experienced psychological distress, as evidenced by screaming, yelling out, putting up a fight, and stomping on caregivers' feet whenever staff attempted to give her a shower.

Based on observation, interview, and record review, the facility did not ensure that 1 of 15 sampled residents' pain was controlled. Resident #6 does not speak or understand English. Resident #6 had significant pressure ulcers, including one on the right shin due to a historical fractured protruding bone, arthritis, and back pain. While the facility identified pain and placed Resident #6 on a pain management program, the program was not re-evaluated to determine if, in fact, the medications Resident #6 was receiving were adequate to control pain. Resident #6 was subsequently observed to holler out and have facial grimacing during cares. Additionally, treatment modalities to ensure Resident #6's functional status did not decline, were not initiated due to Resident #6's complaints of being "tortured." This is evidenced by: Resident #6 has current [DIAGNOSES REDACTED]. Resident #6 was also noted to have contractures of both knees and right hand, as well as multiple pressure ulcers. According to Resident #6's hospital records dated 12/15/13, Resident #6 had a historical fibula/tibular fracture (shin bones) which was not repaired until [AGE] years ago at which time Resident #6 had a bone graft placed. Hospital records indicated Resident #6 had a 2-week history of a bone protruding through the skin causing the development of the stage IV pressure ulcer and subsequent osteomylitis. The most current MDS (Minimum Data Set), dated 7/17/14, indicated Resident #6: ~Has short-term memory problems; ~Requires extensive to total assistance of 1 to 2 staff persons for all aspects of care including bed mobility, ~Weighs 69 pounds; ~Has pain, almost constantly, which Resident #6 rated at as mild according to a verbal scale; ~Has 2 stage II pressure ulcers; and ~Has 1 stage IV pressure ulcer. Resident #6's most current CAA (Care Area Summary) for pain was dated 4/28/14. The CAA indicated Resident #6 had non-verbal indicators of pain including facial expressions and vocalizations. The CAA indicated, "...pain effect on function...Adversely affects mood...Resident expresses pain that occurs constantly to 'bottom.' Not able to expound further...has pressure areas...R.F (Risk Factors) loss of appetite communication deficit not picking up on nonverbal indicators of pot (potential) pain...Care plan to address pain and to minimize any...risk factors..." Resident #6 has a pain care plan dated 1/2/14. The care plan directed staff to monitor for pain, offer non-pharmacological modalities, offer pain medications, use communication cards as well as non-verbal indicators of pain to identify pain. Resident #6's most current pain assessment was dated 4/30/14. The pain assessment indicated, "...Pain Location...'my bottom'...Frequency of Pain 'constant'...Non-Verbal Pain Score: 6...Conclusion...Pain management intervention is necessary, refer to resident plan of care..." According to the pain assessment non-verbal scoring system, a score of 6 indicated, "...Moderate significant pain, Moderate intermittent pain at rest, Moderate significant pain with movement..." Surveyor # completed a review of Resident #6's "Medication Review Report" and noted the following orders with start date: ~12/17/13, [MEDICATION NAME] 400 mg (milligrams) every 6 hours as needed for mild pain; ~12/17/13, [MEDICATION NAME] 10 mg every 4 hours as needed for severe pain; ~12/17/13, Tylenol 650 mg every 4 hours as needed for mild pain; and ~12/17/13, [MEDICATION NAME] 100 mg twice a day noted for chronic pain. ~4/29/14, [MEDICATION NAME] 1 tablet 3 times a day; Surveyor # completed a review of Resident #6's MAR (Medication Administration Record) from 5/1/14 through 7/31/14 and noted the following: ~From 5/1/14 through 5/31/14, Resident #6 received the scheduled medications of [MEDICATION NAME] and [MEDICATION NAME] as ordered, [MEDICATION NAME] - 0, Tylenol - 2 times, and MS ([MEDICATION NAME]) 23 times. The reason the Tylenol was given and the effectiveness of the medication was not documented. The reason the MS was given and the effectiveness of the medication was not documented 16 of the 23 times. ~From 6/1/14 through 6/30/14, Resident #6 received the scheduled medications of [MEDICATION NAME] and [MEDICATION NAME] as ordered, Tylenol - 0, [MEDICATION NAME] - 0, and MS - 23 times. The reason the MS was given and the effectiveness of the medication was not documented for the entire month. ~From 7/1/14 through 7/31/14, Resident #6 received the scheduled medications of [MEDICATION NAME] and [MEDICATION NAME] as ordered, Tylenol - 0, [MEDICATION NAME] - 0, and MS - 26 times. The reason the MS was given and the effectiveness of the medication was not documented for the entire month. The reason for administration and the resident's response to the medication is critical in determining the effectiveness of a pain management program. The facility utilizes a form titled "Behavior Evaluation." Surveyor # completed a review of Resident #6's "Behavior Evaluation" form dated 7/18/14. The form indicated Resident #6 had a history of [REDACTED].#6 also had behaviors which occurred daily. The behaviors were noted as "yelling out" and "calling out." On 8/4/14 at 1:45 p.m., Surveyor # observed CNA-D (Certified Nursing Assistant) and CNA-E assist Resident #6 into bed via a Hoyer lift. During this process, Resident #6 was noted to holler out, grimace, and frown. On 8/5/14 at 10:50 a.m., Surveyor # observed RN/RN/CM-B (Registered Nures/Clinical Manager) and LPN-A (Licensed Practical Nurse) complete a dressing change on Resident #6's pressure ulcers. While LPN-A was removing a dressing, Resident #6 began to holler out. LPN-A indicated Resident #6 was calling out because it "hurts when I take the patches off." LPN-A stated Resident #6 had been pre-medicated with MS somewhere between 8:30 a.m. and 9:00 a.m. During the process of rolling Resident #6 from side to side throughout the treatment processes, Resident #6 called out and had facial grimacing. On 8/5/14 at 4:00 p.m. Surveyor # observed Resident #6 in bed and calling out. On 8/6/14 at 5:50 a.m., Surveyor # entered the wing where Resident #6 lives. Surveyor # could hear Resident #6 calling out. The door to Resident #6's room was almost closed. On 8/6/14 at 7:05 a.m., Surveyor # observed the DON (Director of Nursing), RN/CM-B, and RN/CM-C assess Resident #6's pressure ulcers. During this process Resident #6 called out and had facial grimacing. On 8/5/14 at 10:45 a.m. Surveyor # spoke with RT-H (Rehabilitation Technician). RT-H is also an interpreter for Resident #6. Surveyor # requested RT-H to ask Resident #6 if she was having any pain. Resident #6 responded by stating her body ached, her buttock hurts sometimes, and it sometimes hurts when she was positioned in bed. Surveyor # asked RT-H what the word for pain was. RT-H stated, "Maw." RT-H also stated, "No was no and yes was ah." On 8/5/14 at 11:25 a.m., after the dressing change was completed, Surveyor # spoke with Resident #6. Surveyor # observed a translation book in Resident #6's room. According to the translation book, this surveyor confirmed that "Maw" meant pain. Surveyor # asked Resident #6 "Maw?" Resident #6's response was, "Ah," meaning yes. On 8/5/14 at 4:10 p.m., Surveyor # spoke with LPN-I about Resident #6's calling out and pain. LPN-I stated Resident #6 called out "a lot." LPN-I stated Resident #6 had a communication book in her room but it was "hit or miss" as to determining the reason Resident #6 was calling out. On 8/5/14 at 4:20 p.m., observed CNA-J speak with Resident #6. CNA-J was also an interpreter for the facility. CNA-J stated Resident #6 was complaining her buttock was hurting. On 8/5/14 at 5:00 p.m., Surveyor # spoke with CNA-F. CNA-F stated Resident #6 "calls out quite often." CNA-F stated she felt Resident #6 was often calling out for her family, but wasn't sure why Resident #6 was calling out. CNA-F stated she did not think Resident #6 had pain. On 8/6/14 at 1:10 p.m., Surveyor # spoke with the Rehab Director about Resident #6. The Rehab Director indicated Resident #6 was not put on a ROM (Range of Motion) program because Resident #6 "yells out in pain" when ROM was attempted. The Rehab Director also stated physical therapy was completing electrical stimulation to Resident #6's pressure ulcers. The Rehab Director stated Resident #6 has indicated this treatment felt like something was "biting" her. The Rehab Director stated she had reported this to the nursing department. On 8/6/14 at 1:45 p.m., Surveyor # spoke with LPN-A and LPN-K. LPN-A and LPN-K indicated between the two of them, they work the unit where Resident #6 lives every day, "when one is not here, the other is." Both LPN-A and LPN-K indicated the therapy department "never" came to them regarding Resident #6's complaints of pain during therapies. On 8/6/14 at 3:00 p.m., Surveyor # spoke with PTA-L (Physical Therapy Assistant) about Resident #6. PTA-L indicated she was able to communicate with Resident #6 via RT-H. PTA-L stated during therapy sessions, Resident #6 would holler out and complain we were "ripping her leg off, breaking her fingers, and torturing her." PTA-L indicated she had spoken with RN/CM-B about her concerns. On 8/7/14 at 8:15 a.m., Surveyor # spoke with RN/CM-B about Resident #6's pain. RN/CM-B stated she did recall therapy's concerns regarding Resident #6's complaints of pain. RN/CM-B stated however, she felt Resident #6's pain was controlled.

Based on observation, interview, and record review, the facility did not ensure that 2 of 2 sampled residents with limitations in range of motion, received the necessary care and treatment to maintain or improve function. Resident #14 had a decline in functional ROM (Range of Motion) of the lower extremities and was noted to have bilateral knee contractures. While the therapy department indicated lower extremities ROM was required to maintain function and/or improve function, a program of ROM was never implemented. Resident #6 had a decline in functional ROM of the right hand and was noted to have a contracture of the right hand. Despite this, there was no ROM implemented to maintain and/or improve function. This is evidenced by: Example #1: Surveyor # completed a review of Resident #14's clinical record and noted the following. Resident #14's current [DIAGNOSES REDACTED]. Resident #14's most current MDS (Minimum Data Set) was dated 5/23/14. The MDS indicated Resident #14: ~ Had both long and short-term memory problems; ~ Cognitive skills were severely impaired; ~ Required total assistance with all aspects of care including mobility, ~ Did not walk; and ~ Had no functional limitation in ROM. Surveyor # completed a review of Resident #14's MDSs dated 3/5/14 and 12/10/13. Both MDSs indicated Resident #14 had a functional limitation in ROM on one side of the upper extremity. Resident #14's care plan dated 12/13/12 indicated, "...Decrease in LE (Lower Extremity) mobility...Tight Hamstring...Restorative Program...Hamstring stretches..." Surveyor # completed a review of Resident #14's CNA (Certified Nursing Assistant) care plan. The care plan was undated. Surveyor # noted no direction to staff to complete ROM. Surveyor # completed a review of a facility form titled "Physical Therapy Evaluation" dated 5/2/14 for Resident #14. The evaluation indicated Resident #14 had increased contractures of both lower extremities. Surveyor # completed a review of a facility form titled "Physical Therapy Discharge Summary" dated 6/12/14 for Resident #14. The form indicated Resident #14's lower extremities knee contractures had improved. The discharge recommendations included a FMP (Function Maintenance Program) of ROM to the lower extremities. On 8/6/14 at 11:50 a.m., Surveyor # observed CNA-D and CNA-N assist Resident #14 into bed. Surveyor # noted Resident #14 had bilateral knee contractures greater than 90 degrees. On 8/4/14 at 5:00 p.m. Surveyor # spoke with CNA-F about ROM. CNA-F stated ROM was done on the day shift. CNA-F stated she would not do ROM unless the nurse directed her to complete it. On 8/6/14 at 12:12 p.m., Surveyor # spoke with RA-G (Restorative Aide) about the facility's Restorative Program. RA-G stated the therapy department developed both a Restorative Program as well as a FMP (Functional Maintenance Program) for all residents. RA-G stated the plan, as developed by therapy, was given to the MDSC (Minimum Data Set Coordinator) who was also the restorative nurse. RA-G indicated resident FMPs were added to each resident's plan of care. Surveyor # asked if Resident #14 had a Restorative Program or FMP for ROM. RA-G stated Resident #14 did not. RA-G also indicated she worked on the floor on occasion. Surveyor # asked RA-G when she did ROM when working the floor. RA-G stated she wouldn't do ROM. RA-G stated she would expect the restorative CNA to complete the FMP or Restorative Program. On 8/6/14 at 12:50 p.m., Surveyor # spoke with the MDSC. The MDSC indicated she was also the restorative nurse. The MDSC stated all Restorative Programs as well as FMPs were developed by therapy. The MDSC stated she would not independently setup any type of program. Surveyor # asked the MDSC who did ROM. The MDSC stated ROM should be completed by the CNAs when they were doing cares. The MDSC stated if a resident had a contracture she would expect to see more extensive ROM, which would be developed by the therapy department. Surveyor # asked the MDSC if Resident #14 was on a Restorative Program or FMP. The MDSC stated she was unsure. The MDSC stated Resident #14 had been on one for a knee contracture and Resident #14's Restorative Program included bike riding. The MDSC stated due to the progression of Resident #14 dementia, she could no longer comprehend how to use the bike. The MDSC indicated it was therefore discontinued. The MDSC indicated Resident #14 had been referred back to the therapy department for the contractures. The MDSC stated the therapy department indicated a program of ROM was needed however it "never happened." The MDSC stated the program should have started approximately 2 months ago. On 8/6/14 at at 3:00 p.m., Surveyor # spoke with PTA-L (Physical Therapy Assistant). Surveyor # asked PTA-L about Resident #14. PTA-L stated Resident #14 had recently been seen by therapy. PTA-L stated when therapy was discontinued a program of ROM was "overlooked and should have been done." PTA-L stated she was unsure if Resident #14 has had further decline in ROM. PTA-L however stated Resident #14 "automatically pulls self into a fetal position" when laid down. On 8/6/14 at 1:10 p.m., Surveyor # spoke with the Rehab Director. Surveyor # asked the Rehab Director about Resident #14. The Rehab Director indicated Resident #14 had been recently seen by therapy. The Rehab Director stated the last day of treatment was 6/12/14. The Rehab Director indicated no program for ROM was setup for Resident #14. The Rehab Director stated, "In hind sight, should have." Example #2: Resident #6's current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 7/17/14. The MDS indicated Resident #6: ~ Had short-term memory problems; ~ Required extensive to total assistance of 1 to 2 staff persons for all aspects of care including bed mobility, ~ Had no functional limitation in ROM in the upper extremities; and ~ Had a functional limitation in ROM in the lower extremities on one side. Resident #6's comprehensive care plan was undated. The care plan did not contain a problem regarding Resident #6's limited functional ROM. There was no direction to staff on how to manage Resident #6's limited ROM. Surveyor # completed a review of a facility form titled "Referral/Screen to Rehab Services." A "Referral/Screen to Rehab Services" form for Resident #6 dated 7/9/14 indicated, "...R (right) hand contractures. Holds in fisted position..." Surveyor # completed a review of a facility form titled "Occupation Therapy Plan of Care" for Resident #6 dated 7/10/14. The form indicated, "...demonstrates PROM (Passive Range of Motion) of right fingers to approximately 25% of functional range...holds fingers in flexed position...Goal...palm protector during the day and hand roll at night..." On 8/4/14 at 1:45 p.m., Surveyor # observed CNA-D (Certified Nursing Assistant) and CNA-E assist Resident #6 into bed. Surveyor # noted a hand roll in Resident #6's right hand. Resident #6's fingers were curved around the hand roll. On 8/4/14 at 5:00 p.m., Surveyor # spoke with CNA-F about ROM. CNA-F stated ROM was done on the day shift. CNA-F stated she would not do ROM unless the nurse directed her to complete it. On 8/6/14 at 12:12 p.m., Surveyor # spoke with RA-G (Restorative Aide) about the facility's Restorative Program. RA-G stated the therapy department developed both a Restorative Program as well as a FMP (Functional Maintenance Program) for all residents. RA-G stated the plan, as developed by therapy, was given to the MDSC (Minimum Data Set Coordinator) who was also the restorative nurse. RA-G indicated resident FMPs were added to each resident's plan of care. Surveyor # asked if Resident #6 had a FMP. RA-G stated Resident #6 did not. RA-G also indicated she worked on the floor on occasion. Surveyor # asked RA-G when she did ROM when working the floor. RA-G stated she wouldn't do ROM as she would expect the restorative CNA would complete a FMP or Restorative Program. On 8/6/14 at 12:50 p.m., Surveyor # spoke with the MDSC. The MDSC indicated she was also the restorative nurse. The MDSC stated all Restorative Programs as well as FMP's were developed by therapy. The MDSC stated she would not independently setup any type of program. Surveyor # asked the MDSC who did ROM. The MDSC stated ROM should be completed by the CNAs when they were doing cares. The MDSC stated if a resident had a contracture she would expect to see more extensive ROM, which would be developed by the therapy department. Surveyor # asked if Resident #6 was on a Restorative Program or FMP. The MDSC indicated Resident #6 was not. Surveyor # asked the MDSC why she hadn't placed Resident #6 on a FMP. The MDSC stated because the therapy department developed the FMPs. On 8/6/14 at 1:10 p.m., Surveyor # spoke with the Rehab Director. Surveyor # asked the Rehab Director about Resident #6. The Rehab Director indicated a ROM had not been setup for Resident #6's upper extremities.

Based on observation, interview, and record review, the facility did not ensure 3 of 6 sampled resident with pressure ulcers received the necessary care and treatment to promote healing and prevent new pressure ulcers from developing. According to facility records, Resident #6 was admitted to the facility with a stage II pressure ulcer on the right sacrum. Since admission, Resident #6 has developed 4 additional pressure ulcers, 2 of which have healed. However, the other 2 have worsened with necrotic tissue and tunneling present. Despite the worsening of 3 of Resident #6's pressure ulcers, the facility did not: ~Identify and correctly stage pressure ulcers; ~Implement appropriate and timely treatments to promote wound healing according to current standards of practice; and ~Evaluate and revise treatment regimen when wound healing did not occur. Resident #14 had a history of [REDACTED].#14's left and right buttock. According to the facility on [DATE], the left buttock had healed and then re-opened on 8/5/14. Observations on 8/6/14 revealed Resident #14 did not have IAD but unstageable pressure ulcers to both the right and left lower sacrum. Additionally, observations revealed Resident #14 to have uninterrupted sitting for 3 hours and 35 minutes. The facility did not: ~ Correctly identify and stage Resident #14's pressure ulcers; and ~ Make changes to Resident #14's plan of care to direct staff on how to manage the pressure ulcers. On 6/30/14, Resident #7 developed facility defined IAD (Incontinence Associated [MEDICAL CONDITION]) on the left gluteal crease. The gluteal crease is the area where the upper thigh meets the buttock. This is also the area where the ischium (buttock bone) is located. Observations on 8/6/14 revealed the wound had deteriorated and presented as an unstageable suspected DTI (Deep Tissue Injury). Additionally during this period of time, Resident #7 also developed a stage II pressure ulcer on the coccyx. The facility did not: ~ Correctly identify and stage Resident #7's pressure ulcer, ~ Make changes to Resident #7's plan of care to direct staff on how to manage the pressure ulcers. Resident #7 subsequently went 37 days before changes were made to the plan of care to promote healing. During this period of time, Resident #7's pressure ulcer deteriorated and Resident #7 developed a stage II pressure ulcer. This is evidenced by: According to the NPUAP (National Pressure Ulcer Advisory Panel) and EPUAP (European Pressure Advisory Panel) "Pressure Ulcer Treatment Quick Reference Guide" dated 2009, "...A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a body prominence, as a result of pressure, or pressure in combination with sheer..." The "Pressure Ulcer Treatment Quick Reference Guide" categorizes pressure ulcers as follows, ~ Stage I, "...Intact skin with non-blanchable redness of a localized area usually over a bony prominence..." ~ Stage II, "...Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough...or bruising..." ~ Stage III, "...Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed..." ~ Stage IV, "...Full thickness tissue loss with exposed bone, tendon or muscle...Often includes undermining and tunneling..." ~ Unstageable, "...Full thickness loss in which actual depth of the ulcer is completely obscured by slough...and/or eschar...in the wound bed... ~ Suspected Deep Tissue Injury, "..Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear..." The "Pressure Ulcer Treatment Quick Reference Guide" indicated, ~ "...Reassess the individual if the ulcer does not show signs of healing as expected..." ~ "...Expect some signs of healing in most individuals within 2 weeks..." ~ "...With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment...wound improvement, wound deterioration, more or less exudate, signs of infection..." ~ "...Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within 2 weeks..." ~ "...Signs of deterioration should be addressed immediately..." ~ "...Offer vitamin and mineral supplements when dietary intake is poor..." ~ "...If pressure ulcers are not healing...Re-evaluate the individual and his/hers pressure ulcer...Intensify prevention strategies...Consider changing the support surface..." ~ "...Use a pressure-redistribution cushion in the chair..." ~ "...If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface..." ~ Do not use film dressing as the tissue interface layer over moderately to heavily exudating ulcers..." ~ "...Have a high index of suspicion for the likelihood of infection in pressure ulcers that have necrotic tissue...have been present for a long period of time...are large in size or deep..." ~ "...Have a high index of suspicion for local wound infection in individuals with...protein-calorie under nutrition..." ~ "...Have a high index of suspicion for local infection in pressure ulcers when there are no signs of healing for 2 weeks..." ~ "...Reduce the bacterial load in the pressure ulcer...Necrotic tissue and slough promote bacterial growth...Cleansing removes loose debris and...bacteria...Abridgement is often required to remove adherent slough and eschar, as well as biofilms (bacteria)..." ~ "...Consider the use of hydrogel dressings on shallow, minimally exudating pressure ulcers..." ~ "...Consider the use of hydrogel dressings for treatment of [REDACTED]. ~ "...Consider the use of amorphous hydrogel for pressure ulcers that are not infected and are granulating..." Example #1: Resident #6 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. According to Resident #6's hospital records dated 12/15/13, Resident #6 had a historical fibular/tibular fracture (shin bones) which was not repaired until [AGE] years ago at which time Resident #6 had a bone graft placed. Hospital records indicated Resident #6 had a 2-week history of a bone protruding through the skin causing the development of the stage IV pressure ulcer and subsequent osteomylitis. The most current MDS (Minimum Data Set), dated 7/17/14, indicated Resident #6: ~Has short-term memory problems; ~Requires extensive to total assistance of 1 to 2 staff persons for all aspects of care including bed mobility, ~Has a Foley catheter; ~Is always incontinent of bowel; ~Weighs 69 pounds; ~Has 2 stage II pressure ulcers; and ~Has 1 stage IV pressure ulcer. In comparison, Resident #6's admission MDS, dated [DATE], indicated Resident #6 had one stage II pressure ulcer and one stage IV pressure ulcer. Resident #6's most current CAA (Care Area Assessment) summary for pressure ulcers was dated 4/28/14. The CAA indicated Resident #6 had current pressure ulcers, was dependent for bed mobility, and had malnutrition. The CAA indicated, "...Care plan to address skin and to minimize any...risk facters (sic) with intent to show healing and no further areas of breakdown..." The CAA was incomplete and did not critically assess nor analyze Resident #6's pressure ulcers. Resident #6's skin care plan was dated 12/19/13. The care plan had the following approaches: ~12/19/13, "...air mattress...float heel when refuses sage boots...Reposition approximately every 1 - 2 hours...treatments as ordered...monitor wounds for increased... [MEDICAL CONDITION]" ~1/31/14, "...No attend (incontinent brief) while in bed...utilize a chux while in bed..." ~4/3/14, "...Clinitron bed..." ~Undated, "...up in w/c (wheelchair) for approx (approximately) 1 hr (hour) increments..." Resident #6's most current skin risk assessment was dated 8/4/14. The risk assessment had a cumulative score of 13. According to the facility's scoring system, a score of 13 indicated Resident #6 was at moderate risk for the development of a pressure ulcer. The accuracy of the skin risk assessment is questionable due to Resident #6's pressure ulcers upon admission and the development of pressure ulcers after admission. RIGHT SACRUM Surveyor # completed a review of Resident #6's weekly skin charting (noted with ~) and noted the following: ~12/17/13 (date of admission), "...Stage II...1.8 x 1.2...Loosely adherent yellow slough...75% (percent) to 100% of wound covered..." The facility incorrectly staged the wound. According to the wound characteristics, the pressure ulcer should have been staged as unstageable. This is of importance as the stage of a wound, including wound characteristic, determines the most appropriate dressing to promote healing. ~12/19/13, "...admitted with stage II pressure ulcer to coccyx (sacrum). Presents with granulation..." ~1/9/14, "...Coccyx (sacrum)...show s/sx (signs and symptoms) of healing. O (no) slough noted..." Granulation and no slough is indicative that the wound was healing. ~1/22/14, "...Stage II...2 x 0.9 (2.0 cm by 0.9 cm)...Necrotic Tissue...< (less than) 25% of wound bed...Exudate...None..." ~1/23/14, "...continues with wound to coccyx (sacrum)...Coccyx...showed area of yellow slough..." Necrotic tissue and yellow slough is indicative that the wound was deteriorating. On 1/23/14, the facility obtained a physician order [REDACTED].#6's pressure ulcer from a [MEDICATION NAME] to [MEDICATION NAME] twice a day. ~1/29/14, "Stage II...2.5 x 2.0...Necrotic Tissue...< (less than) 25% of wound bed covered..." ~2/4/14, "Unstageable...3.0 x 3.0...Necrotic Tissue...< 25% of wound bed..." On 2/5/14, the facility obtained a physician's orders [REDACTED].#6's pressure ulcer from silvadine to a [MEDICATION NAME]. This treatment had been used before and had been ineffective. ~2/6/14, "...Area to coccyx (sacrum) presents as discolored purple 3.0 x 3.0 necrotizing tissue..." According to the documentation, Resident #6's sacral pressure ulcer was initially healing. The pressure ulcer on 2/6/14 presented as a DTI (Deep Tissue Injury). This was indicative of extended unrelieved pressure and wound deterioration. ~2/12/14, "...Unstageable...4.5 x 3.2...Necrotic Tissues...> (greater than) 50% and <75% of wound covered...Exudate...Bloody...Exudate Amount...Small..." On 2/12/14 the facility obtained a physician's orders [REDACTED].#6's dressing to hydrogel. ~2/13/14, "...continues with pressure area to coccyx (sacrum)...with deterioration noted in appearance as wound bed dark purplish color..." According to the nursing notes, Resident #6's mattress was upgraded to a different type of air mattress. This was not noted on the care plan. The only bed change on the care plan was dated 4/3/14. This was also not noted on the timeline of treatments Surveyor # received from the facility. ~2/26/14, "...Unstageable...3.5 x 2.5...Edges...Distinct...attached, even with wound base...Necrotic Tissue...75% to 100% of wound covered..." On 2/27/14, the facility obtained a physician's orders [REDACTED].#6's dressing to santyl, a [MEDICATION NAME] agent. On 2/27/14, the facility also obtained an order for [REDACTED]. ~3/5/14, "...Unstageable...3.5 x 2.8...Necrotic Tissue...75% to 100% of wound covered..." ~3/19/14, "...Unstageable...3.7 x 2.6...Necrotic Tissue...75% to 100% of wound covered..." Resident #6's pressure ulcer continued to deteriorate. There were no changes made to Resident #6's plan of care. On 3/25/14, PT (Physical Therapy) completed an evaluation on Resident #6 and recommended Electrical Stimulation to promote wound healing. This treatment was initiated on 3/26/14. ~3/26/14, "...Unstageable...4 x 4 (4.0 cm x 4.0 cm)...Necrotic Tissue...75% to 100% of wound covered..." ~4/2/14, "...Unstageable...4.2 x 3.7...Edges...Well-defined not attached wound base...Undermining 2.5 (2.5 cm)...Necrotic Tissue...75% to 100% of wound [MEDICAL CONDITION]" On 4/3/14, Resident #6's care plan was updated to indicate the initiation of the Clinitron bed. No other changes were made to the care plan despite the worsening of the pressure ulcer. ~4/9/14, "...Unstageable...4.0 x 3.0...Edges...attached, even with wound base...Undermining...3.0 cm @ (at) 12 o'clock...Necrotic Tissue...< 25% of wound bed covered..." ~4/30/14, "...Unstageable...3.0 x 2.5...Undermining...12 o'clock 2.3 (2.3 cm)...Necrotic tissue...Not visible..." On 4/30/14 the facility obtained a physician's orders [REDACTED]. This was the last change to Resident #6's treatment. ~5/28/14, "...Stage III...Edges...attached, even with wound base...Undermining...12 o'clock 3.0...Exudate...Serous...Exudate Amount...Moderate..." ~6/18/14, "...Stage II...2.5 x 2.0...Edges...attached, even with wound base...Undermining...12 o'clock 1.5 (1.5 cm)..." ~7/30/14, "...Stage II...3.0 x 1.7...Edges...attached, even with wound base...Undermining 12-3 1.0 cm..." On 8/4/14 at 10:50 a.m., Surveyor # observed RN/CM-B (Registered Nurse/Clinical Manager) and LPN-A (Licensed Practical Nurse) complete a dressing change on Resident #6's right sacral pressure ulcer. Surveyor # noted the wound base was covered with a light shiny yellow slough (bioburden). On the lower right corner, at approximately 4 o'clock, there was an area of bluish discoloration. The wound edges were not adhered to the wound base and moved freely over Resident #6's fascia. RN/CM-B indicated to Surveyor # that Resident #6's wound "presents at a stage II." The dressing change consisted of a collagen patch covered by gauze secured with a transparent dressing. Surveyor # noted during the dressing change, that RN/CM-B placed the collagen patch into the wound bed, RN/CM-B obtained gauze and fluffed it up into a small ball. The dressing was then secured with a transparent dressing. The act of fluffing up the gauze into a small ball, placing the gauze ball over the collagen patch and covering the dressing with a transparent dressing had the potential to cause increased pressure on the wound bed. During the dressing change, Surveyor # noted the old dressing was saturated with serosanguineous drainage. Surveyor # also noted the fabric covering on the clinitron bed was approximately 75% covered with old drainage. Surveyor # asked RN/CM-B about the drainage as noted. RN/CM-B stated they were unable to change the fabric covering. RN/CM-B stated the only way to get a clean fabric covering was to obtain a new bed. RN/RN/CM-B stated this had been done approximately 2 weeks ago. According to current standards of practice for staging pressure ulcers, Resident #6's pressure ulcer was unstageable as the wound had an area of bluish discoloration and the base was not clearly visible. The entire wound base was also covered with a light shiny yellow slough or bioburden. This was highly suspicious of infection. The appropriate stage and wound characteristics were not accurately assessed by the facility. An accurate description is critical in determining the appropriate treatment to promote healing. On 8/6/14 at 7:05 a.m. Surveyor # observed RN/CM-B, RN/CM-C, and the DON assess Resident #6's right sacral pressure ulcer. RN/CM-B indicated the wound measured 3.8 cm x 2.7 cm with 1.0 cm of tunneling from 12 o'clock to 3 o'clock. The wound had worsened since the last assessment on 7/30/14. Surveyor # again noted the wound edges were not adhered to the wound base and the wound was completely covered with a light shiny yellow slough. Surveyor # also noted the wound now had 2 areas of bluish discoloration: one again at approximately 4 o'clock and a new area at approximately 11 o'clock. Each area was approximately 0.5 cm in diameter. Surveyor # also noted a 2 mm (millimeters) to 3 mm reddened lip surrounding the wound. The dressing change again consisted of a collagen patch covered by gauze and secured with a transparent dressing. Surveyor # completed a review of the facility's weekly skin charting dated 8/6/14. The facility identified the wound as a stage III with 25% to 50% of the wound base covered with slough. LEFT ILIAC CREST (Hip Bone) Surveyor # completed a review of Resident #6's weekly skin charting (noted with ~) and noted the following: ~1/26/14, "...L (left ) pelvic bone...Stage I....3x5 cm (3.0 cm x 5.0 cm)..." Surveyor # completed a review of a nursing note dated 1/27/14. The nursing note indicated, "...late entry...Noted 1/26/14 L (left) pelvic bone redness 3x5 cm with darker area tissue @ (at) center approx (approximately) 1 cm..." ~ 1/29/14, "...0.5 x 0.6...Stage...2..." Surveyor # completed a review of a nursing note dated 2/3/14. The nursing note indicated, "...increased redness L hip with area 1 cm dark moist tissue..." ~ 2/4/14, "...1.1 x 0.9...obscured by necrosis/Unstageable/Deep Tissues Injury... According to the weekly skin charting, the stage I progressed to a stage II on 1/29/14 to an unstageable suspected DTI by 2/4/14. There were no changes made to Resident #6's plan of care. On 2/5/14, a physician ordered a [MEDICATION NAME] dressing to Resident #6's left iliac crest. ~ 2/12/14, "....3 x 3.2...Obscured by necrosis..." A nursing note dated 2/13/14 indicated, "...L (left) hip area (left iliac crest)...with white, yellow, and dark necrotic tissue present...Bed has been upgraded to stat 4000..." (A stat 4000 is another type of a low air loss mattress.) However, this change was not reflected on Resident #6's care plan and it was not identified on the facility's timeline of Resident #6's pressure ulcer treatment. On 2/12/14, the physician changed Resident #6's treatment from a [MEDICATION NAME] to hydrogel. According to current standards of practice, hydrogel is not an appropriate dressing to use as the wound base contained slough. ~ 2/26/14, "...3 x 2.3...Obscured by necrosis...Edges...not attached wound base..." On 2/27/14, the facility obtained an order from a physician to discontinue the hydrogel and start santyl (a [MEDICATION NAME] agent). ~ 3/12/14, "...3 x 3.5...Obscured by necrosis...Edges...not attached wound base...Tunneling..." ~ 3/26/14, "...3 x 4.5...Unstageable...Edges...not attached wound base...Undermining...12 o'clock 1.0..." ~ 4/16/14, "...3.5 x 4.0...Stage...3...Edges...not attached wound base...Undermining...12 o'clock 1.0...Necrotic Tissue...Not visible..." According to a nursing note dated 4/17/14, Resident #6's wound had no slough. Santyl is used as a [MEDICATION NAME] agent utilized to remove slough. According to "Santyl, A Patient's Guide to [MEDICATION NAME] Santyl Ointment" 2014, once necrotic tissue has been removed and the wound bed is clean, santyl needs to be discontinued. The facility did not discontinue the treatment of [REDACTED]. ~ 4/30/14, "...3.0 x 4.0...Stage...2...Edges...not attached wound base...Undermining...12 o'clock 0.5..." On 4/30/14, the facility obtained a physician order [REDACTED]. This was the last change to Resident #6's pressure ulcer care and treament. ~ 5/28/14, "...2.5 x 2.9...Stage...2...Edges...not attached wound base...Undermining...3 o'clock 1.0..." ~ 6/4/14, "...2.5 x 3...Stage...2...Edges...not attached wound base...Undermining...9 o'clock to 3 o'clock 0.5..." ~ 7/2/14, "...2.3 x 2.5...Stage...2...Edges...not attached wound base...Undermining...0 (none)..." ~ 7/30/14, "...2.8 x 3.0...Stage...2...Edges...not attached wound base...Undermining...3 o'clock 0.5 cm..." On 8/4/14 at 10:50 a.m., Surveyor # observed RN/CM-B and LPN-A complete a dressing change on Resident #6's left iliac crest pressure ulcer. Surveyor # noted the wound base was covered with a light shiny yellow slough. At approximately 4 o'clock and 11 o'clock positions there was an area of approximately 0.5 cm of bluish discoloration. The wound edges were not adhered to the wound base and moved freely over Resident #6's fascia. The peri wound had an area of 3 to 4 mm of dark grayish discoloration. RN/CM-B indicated to Surveyor # that Resident #6's wound had been at a stage II. RN/CM-B stated because of the dark areas as noted in the wound, the wound presented as a DTI. RN/CM-B also indicated the areas of bluish discoloration "comes and goes." The dressing change consisted of a collagen patch covered by gauze secured with a transparent dressing. Surveyor # noted during the dressing change, that after RN/CM-B placed the collagen patch into the wound bed, RN/CM-B obtained gauze in which she fluffed up into a small ball. The dressing was then secured with a transparent dressing. The act of fluffing up the gauze into a small ball, placing the gauze ball over the collagen patch and covering the dressing with a transparent dressing had the potential to cause increased pressure on the wound bed. The entire wound base of this pressure ulcer was also covered with a light shiny yellow slough or bioburden. This was again highly suspicious of infection. On 8/6/14 at 7:05 a.m., Surveyor # observed the DON, RN/CM-B and CM-C assess Resident #6's left iliac crest wound. RN/CM-B measured the wound and indicated the wound measured 3.0 cm x 4.0 cm with tunneling of 0.4 cm at 10 o'clock and 0.5 cm at 3 o'clock. Surveyor # also noted the wound base was coated with a shiny light yellow slough or bioburden. Surveyor # also noted an area of bluish discoloration at 11 o'clock which measured approximately 1.5 cm in diameter. COCCYX Surveyor # completed a review of Resident #6's nursing notes and weekly skin charting (indicated with ~) and noted the following. On 8/4/14, a nursing note indicated, "...new area to coccyx buttocks noted. 1.0 x [MEDICATION NAME] applied" ~8/4/14 indicated, "...Stage II...1.0 x 0.5..." On 8/6/14 at 7:05 a.m., Surveyor # observed the DON, RN/CM-B and CM-C assess the pressure ulcer on Resident #6's coccyx. RN/CM-B indicated the wound measured 1.2 cm x 0.5 cm. Surveyor # noted the wound base was pink and clean. RIGHT HIP On 4/14/14, the facility identified a stage I pressure ulcer on Resident #6's right hip. This was noted as healed on 4/30/14. SCAPULA On 5/9/14, the facility noted a pressure ulcer on Resident #6's left scapula (shoulder blade). Surveyor # completed a review of Resident #6's weekly skin charting and noted the following: ~ 5/9/14, "...Unstageable/Deep Tissue Injury...6 x 1.5...Necrotic Tissue Type...White/Gray non-viable...Necrotic Tissue Amount...75% to 100% of wound covered..." ~ 5/14/14, "...Unstageable...2.0 x 7.5...Necrotic Tissue Type...Adherent, soft, black eschar...75% to 100% of wound covered..." On 6/11/14, the pressure ulcer was noted as healed. Since admission to the facility, Resident #6's right sacral pressure ulcer deteriorated and Resident #6 developed unstageable suspected DTI on the left iliac crest and left scapula. According to the care plan, Resident #6 had an air mattress in place on admission. On 2/12/14, the facility upgraded Resident #6's mattress. This was 57 days after Resident #6 had been admitted , 21 days after the facility identified Resident #6's right sacral pressure ulcer had deteriorated, and 18 days after Resident #6 developed a suspected DTI to the left iliac crest. On 4/3/14, the facility implemented a clinitron bed. A clinitron bed is a specialized bed designed to assist in the healing of pressure ulcers. This was 50 days since the last time the facility attempted a change in the type of surface or mattress for Resident #6. This was also the last change made to Resident #6's care plan. On 8/4/14 at 12:45 p.m., Surveyor # noted Resident #6 was up in a modified wheelchair seated in the dayroom being assisted to eat lunch. On 8/4/14 at 1:45 p.m., Surveyor # observed CNA-D (Certified Nursing Assistant) and CNA-E assist Resident #6 into bed. CNA-D and CNA-E utilized Hoyer lift to assist Resident #6 into bed. Surveyor # noted there was no type of pressure redistribution cushion on the seat of Resident #6's wheelchair. Resident #6 had been sitting directly on the seat of the modified wheelchair. On 8/7/14 at 8:05 a.m., Surveyor # noted a specialized cushion on the seat of Resident #6's wheelchair. On 8/5/14 at 7:35 a.m., Surveyor # spoke with LPN-A about the facility's Wound Management Program. LPN-A indicated the facility had a wound team consisting of the DON and CMs. LPN-A stated the wound team assessed and measured wounds weekly. LPN-A stated the floor nurses monitored wounds and completed dressing changes. Surveyor # asked LPN-A about Resident #6's pressure ulcers. LPN-A indicated Resident #6 had lost a lot of weight since admission and was "skin and bones." LPN-A indicated when Resident #6 first came into the facility, she wanted to go home so she refused to eat. LPN-A stated she felt Resident #6 developed pressure ulcers due to poor intake. On 8/5/14 at 4:30 p.m., Surveyor # spoke with RN/CM-B. RN/CM-B indicated the wound team generally recommends treatment and/or treatment changes to the physician. Surveyor # asked if any member of the wound team was certified in wound management. RN/CM-B stated there was not. Surveyor # asked RN/CM-B if the facility utilized a wound clinic. RN/CM-B indicated they did and named several residents who went to the wound clinic. RN/CM-B stated the wound team would make recommendations to the physician if they felt wound clinic involvement was necessary. RN/CM-B also indicated physicians would also make recommendations. Surveyor # asked RN/CM-B if Resident #6's physician had ever seen Resident #6's wounds. RN/CM-B stated he had not. RN/CM-B stated Resident #6's physician had a PA (Physician Assistant) who had seen Resident #6's wounds. Surveyor # asked RN/CM-B why Resident #6 had not been referred to the wound clinic. RN/CM-B stated she was unsure but thought the family did not want to send Resident #6 there. Surveyor # requested all the PA progress notes indicating Resident #6's wounds had been assessed by the PA. Surveyor # received 1 note which was dated 2/4/14. The progress note indicated, "...Patient seen and examined...Worsening sores on coccyx (sacrum) and iliac crest bilaterally. No new nursing concerns...Continue current cares..." According to the information given to Surveyor # by the facility, Resident #6 had her wounds assessed only 1 time by the PA. Surveyor # requested information regarding the family's decline for treatment by the wound clinic . None was received. On 8/7/14 at 8:15 a.m., Surveyor # spoke with RN/RN/CM-B. RN/CM-B indicated the facility had a wound team with consisted of the DON, herself and CM-C. RN/CM-B also indicated the facility had a nurse consultant who assisted the facility with wounds as needed. RN/CM-B stated the nurse consultant was in the building at least every 2 weeks, and was always available by phone. RN/CM-B stated the wound team determined stages of pressure ulcers as well as treatments to be used. Surveyor # asked RN/CM-B if she had ever requested the nurse consultant's assistance with Resident #6's wounds. RN/CM-B said she hadn't personally requested assistance but indicated the DON would usually be the one who contacted the nurse consultant. RN/CM-B indicated immediate interventions were put on the care plan when a wound was identified. RN/CM-B stated the facility had only 1 type of low loss air mattress and if the wound team determined a different type of mattress was necessary they would need to rent it. Surveyor # asked if the facility utilized any type of repositioning tools. RN/CM-B indicated they did. RN/CM-B stated she would use one if she felt it was needed. RN/CM-B also stated she would put out a more formal position tool if a resident required more than the normal every 2-hour turning schedule depending on the situation. Surveyor # asked RN/CM-B if a formal turning schedule was every utilized for Resident #6. RN/CM-B stated there had not been one used. RN/CM-B stated if she visualized staff turning residents, she didn't have a concern and knew repositioning was being done. Surveyor # asked RN/CM-B when the wound team considered treatment changes. RN/CM-B stated if there was no progress in healing for 2 weeks they would consider a treatment change. Surveyor # asked RN/CM-B why Resident #6's treatment had not changed since 4/30/14. RN/CM-B stated she felt the wound was showing signs of healing. Surveyor # asked RN/CM-B why it took so long to obtain a specialized bed for Resident #6. RN/CM-B stated she was not sure and would need to discuss it with the wound team. Surveyor # asked RN/CM-B about the observation of no cushion in Resident #6's wheelchair. RN/CM-B stated Resident #6 did have one. RN/RN/CM-B stated she thought the cushion may have been removed to be cleaned sometime in mid June when the facility had scabies and it was never replaced. RN/CM-B stated however she was unsure of how long it had been missing. On 8/7/14 at 10:10 a.m., Surveyor # spoke with the DON and NC (Nurse Consultant). The NC indicated she thought she had looked at Resident #6's wounds some time in April during a mock survey, however did not make a full assessment of Resident #6's wounds and did not write a note. The NC stated she reviewed the documentation the facility completed on Resident #6's wounds and concurred with the treatments. Example #2: According to "Clinical Management Incontinence and Incontinence-Associated [MEDICAL CONDITION]," "...IAD was defined as 'an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin'...It is important to distinguish IAD from stage I or stage II PrU's (pressure ulcers), which usually occur over a bony prominence such as the coccyx, whereas a moisture lesion is generally located over natal clefts and/or in the perianal area, and not over a bony prominence...There is no necrosis in a moisture [MEDICAL CONDITION]" Resident #14's current [DIAGNOSES REDACTED]. The most current MDS assessment was dated 5/23/14. The MDS indicated Resident #14: ~Had both long and short-term memory problems; ~Cognitive skills were severely impaired; ~Required total assistance with all aspects of care inclu

Based on observation, interview, and record review, the facility did not promote care for residents in a manner that maintained or enhanced each resident's dignity and respect in full recognition of the resident's individuality for 1 of 15 residents reviewed (Resident 11). During observation of cares on 6/19/13, staff took Resident #11 to the shower. Resident #11 repeatedly told staff she was scared, the water was too hot, she was fearful of getting soap in her eyes and stating she wants to go home. Staff did not respond to Resident #11's concerns and continued with the shower. When water was applied to Resident #11's head, she began to cry out. Throughout the shower, Resident #11 continued to call out with several fears of falling, being injured, being cold and pain in her ear when water got in it. Staff continued the shower without interventions. No other staff intervened while Resident #11 cried out. This is evidenced by: Surveyor # received and reviewed the facility's policy titled "Reflections and Passages Communities" dated 12/11/04, which outlines the following: Policy: Residents with a cognitive impairment who require a secured protected environment with specialized programing are provided through the Reflections and/or passages communities. Definition: Reflections Community: An area in the nursing center that provides special programing in a secure environment. Reflections model primarily targets residents in the early to middle stages of Alzheimer's or related dementia. Compliance Guidelines: The Reflections and Passages communities are certified to provide specialized programing. The Reflections and Passages communities are based upon a social model of care delivery. Emphasis is placed upon upon creating a homelike environment that encourages residents to engage in individual preferences and customary routines...Families and caregivers are involved in the overall care planning process and participation in recreational and social events. Staff assigned to the Reflections and/or Passages community is trained in the skills required to work with residents with a cognitive impairment. Skills checklist is completed and filed in the employees training record...Care plan implementation is based upon individual special programing needs of the resident and updated as necessary...A continuing education program is provided to promote development and improvement of knowledge and skills of involved program staff. Reflection Community staff is trained in the social model/recreational programs based upon cognitive requirement of the residents. Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. ~[MEDICAL CONDITION] (a decline in thinking caused by conditions that block or reduce blood flow to the brain); ~Hypersensitivity (enhanced internal sensation of pain)' ~Basal Ganglia Hemorrhage (bleeding at the base of the brain); ~Rapidly increasing intra-cranial pressure with herniation (high pressure that occurs when part of the brain is squeezed across the structure within the skull, moving brain tissue); ~Hearing impaired since birth; ~Ischemic Infarction both occipital lobes and cerebellum (restriction of blood supply with tissue death to parts of the brain that affect visual processing, motor skills and cognition); ~Residual left [MEDICAL CONDITION] (total paralysis of arm, leg and trunk of left side); and ~[MEDICAL CONDITION] (hardening of the arteries). Resident #11 resides on the Reflections Unit of the facility. The most recent annual MDS (Minimum Data Set) assessment, dated 4/16/13 indicates that Resident #11: ~Usually understands; ~Is usually understood; ~Has a hearing Aid or other appliance; ~With hearing aid has moderate difficulty hearing, speaker has to increase volume and speak distinctly; ~Moderately impaired cognition; ~Feeling or appearing down, depressed or hopeless on several days (based on staff interview); ~Trouble concentrating on things such as reading the newspaper or watching television half or more of the days (based on staff interview); ~Other behavioral not directed towards others (e.g...verbal /vocal symptoms like screaming, disruptive sounds)-behavior not exhibited; ~Total dependence on staff for dressing, personal hygiene and bathing; ~Resident unable to answer related to pain presence; and ~Staff assessment of pain-no Indicators of pain or possible pain. Resident #11 CAA (Care Area Assessment) dated 4/18/13 indicates the following: ~Mood State, area not triggered ~Psychosocial well-being, area not triggered dated 06/23/06: Resident will allow staff to complete bathing, dressing, grooming tasks daily and PRN (as needed) approaches; ~Behavioral Symptoms, area not triggered; and ~Cognitive Loss/Dementia, see care plan. Resident #11's care plan for activities of daily living dated 1/6/1994, indicated the following: Resident will allow staff to complete bathing, dressing, grooming tasks daily and as needed. Approach: Weekly bath: total assist. Apollo bath 1 time a week, bed bath attempts and patient has more agitation. Staff aware resident screams out during Apollo as "no water, no water"...Be aware Resident will scream/yell during transport to bath-staff to provide re-assurance...Prefers shower chair for shower transfer. Resident #11 care plan for Thought Process-Impaired dated 12/24/1997, indicated the following: FYI: frequent pounding/calling out noted during restlessness, also sings aloud which can be confused with yelling secondary to slurred speech, have ritual of bath and packing before leaving for weekend to help calm resident. Resident #11's care plan for altered comfort/pain dated 4/21/1998, indicated the following: Goal: Resident will continue to alert staff to discomfort. Approaches: 4/8/03: Administer medications as ordered. 7/18/03: Be aware resident does have increased agitation when up in wheelchair-increased yelling out, rocking and pounding rail or wall, stamping feet, pulls call light from wall. 4/8/03: Avoid soap and water contact with ears due to infection with use of ear molds to prevent water in ears during bathing and shampoo. 5/13/09: Nursing to assess for pain every shift and as needed with verbal and non-verbal assessment. Resident #11's Pain assessment dated [DATE], noted no indicators of pain. Resident #11's Monthly Behavior Monitoring flow sheets were reviewed for the past 6 months and indicated no record of Resident #11's behavior of yelling out. Resident #11's care card was reviewed with approaches indicating: calls/yells out during cares offer re-assurance and re-approach as needed. Resident #11's Interdisciplinary and Nursing notes were reviewed and indicated the following: *1/23/13, Annual assessment completed...hard of hearing...[DIAGNOSES REDACTED]. Signed by SW-H (Social Worker). *1/23/13, Quarterly assessment and progress note: Leisure routine includes almost weekly home passes...Resident does yell out at times, reassurance is offered...yelling is often related to showers or transitions... *2/13/13, Interdisciplinary Team: Care plan reviewed, at times resident yells out due to change and transitions. Staff to approach/calm/reassure... *2/18/13, Behavior team meeting: Sensory impairments, yells out. Behaviors reviewed, care plan updated and appropriate. *4/17/13, Resident continues to go out on home pass..Resident is HOH (hard of hearing)..has diagnosis (sic) of [MEDICAL CONDITION] with agitation...Does have a hard time with transitions (change), does yell at times. On 6/19/13 at 12:01 p.m., Surveyor # was seated in the Reflections dining room when loud yelling was heard beyond the nurses' station. Upon investigation, Surveyor # discovered the yelling was coming from Resident #11's room. Surveyor # knocked on Resident #11's room door, requested to enter and observed Resident #11 in her room in bed yelling. CNA-B (Certified Nursing Assistant) and LPN-C (Licensed Practical Nurse) had just finished incontinence care for Resident #11. Resident #11 stopped yelling shortly after the cares were completed and returned to a conversational tone and volume of voice. Surveyor # asked LPN-C about the observation and what was heard from the dining room. LPN-C replied, "That's just her, doesn't matter the approach used." LPN-C stated Resident #11 doesn't like to be changed, "you can explain and reassure but this is the response." LPN-C explained that changing her incontinence brief, showering and medication administration "makes her yell." On 6/19/13 at 2:18 p.m., Surveyor # spoke with CNA-B regarding the observation. CNA-B indicated she had worked at the facility for 6 years as a CNA and is Resident #11's primary caregiver. Surveyor # asked CNA-B about the observation with Resident #11. CNA-B indicated Resident #11 yells a lot with cares, with movement, when upset about her husband, with showering and when she can't hear. CNA-B explained the yelling occurs daily. Surveyor # asked CNA-B what approach works to calm Resident #11. CNA-B stated being calm, knowing what her "quirks are," she likes certain things like being shaved and using a wash cloth to cover her eyes in the shower. Surveyor # asked CNA-B if these approaches were in Resident #11's care plan. CNA-B referenced her care card and responded, "No." Surveyor # asked CNA-B about Resident #11's care plan approaches. CNA-B indicated she was not familiar with any other care plan other than her care cards. On 6/19/13 at 2:34 p.m., Surveyor # spoke with LPN-C regarding the observation with Resident #11. LPN-C explained that Resident #11 yells with each brief change, during showers and will put her hand up and yell with medication administration. LPN-C indicated Resident #11 will cooperate with medication administration if given cold water, lemon pudding and medications are crushed. Surveyor # asked LPN-C if the facility has ruled out medical reasons as the cause of Resident #11 yelling. LPN-C responded, "I don't think its pain," and expressed she was unaware of any trials being done regarding pain medication administration prior to movement. Surveyor # asked LPN-C if Resident #1's care plan addressed the yelling out. LPN-C indicated the behavior is not addressed on the care plan and behavior monitoring data is not collected. Surveyor # asked LPN-C if she had received any dementia specific training. LPN-C expressed she had not received any training from the facility regarding dementia. On 6/19/13 at 2:57 p.m., Surveyor # met with RN-D (Registered Nurse) who is the Clinical Manager for Resident #11. Surveyor # asked RN-D about the process for assessment, care planning and data collection when resident behaviors occur. RN-D indicated upon admission, if a resident is on [MEDICAL CONDITION] medication data collection for their behaviors is initiated, utilizing resident history and family interview. Surveyor # asked if behavioral data is collected for a person demonstrating behaviors that may not be on a [MEDICAL CONDITION]. RN-D responded, "We used to." RN-D further explained for a resident on [MEDICAL CONDITION] medication that the team reviews the behavior, looks at medications and approaches. Surveyor # asked RN-D if Resident #11's MDS addressed Resident #11's behaviors. RN-D indicated she was not sure and directed Surveyor # to speak with the MDS coordinator. Surveyor # asked RN-D if care plans or care cards address resident behaviors. RN-D responded, "It depends on the person." On 6/20/13 at 6:10 a.m., Surveyor # knocked and requested permission to enter Resident #11's room. Surveyor # observed CNA-A and CNA-B assist Resident #11 with morning cares. Surveyor # observed Resident #11 point to her ear. Surveyor # asked CNA-A if she was familiar with Resident #11. CNA-A responded she had worked at the facility for 2 1/2 years and was familiar with Resident #11. Surveyor # observed staff put Resident #11's socks on and sit Resident #11 on the edge of her bed. Resident #11 stated "heavy" and again pointed to her ear. Surveyor # asked staff if Resident #11 can hear without her hearing aids as Surveyor # wanted to obtain permission from Resident #11 to observe her cares. Staff retrieved Resident #11's hearing aids and placed them in her ears. Resident #11 stated, "I can hear a little bit." Surveyor # asked Resident #11's permission to observe cares. Resident #11 had no objections. Staff prepared Resident #11 for transfer. Resident #11 stated, "I'm scared, hot water, too hot, not too long, a little bit." Staff placed a gait belt on Resident #11 and again Resident #11 stated, "I'm scared." Staff did not respond to Resident #11's fears. CNA-A stated, "We're going to stand you up," and transferred Resident #11 to a shower chair. Resident #11 began to loudly vocalize "too hot, soap in my eyes." Staff again did not respond to Resident #11's fears. Resident #11 stated, "Not too long," and staff did not respond. Resident #11 was covered with a bath blanket, she stated, "I want to go home." CNA-B discussed Resident #11's family with her and Resident #11's voice lowered when discussing her family. Staff did not stop the shower preparation process and no other staff intervened on Resident #11's behalf. CNA-B took Resident #11 down the hall to shower. Resident #11 stated, "Don't hurt my legs, hot water, don't hurt me, don't burn me." Resident #11's voice tone and volume increased. CNA-B did not respond. Once in the shower, CNA-E joined and explained 2 staff are required to shower Resident #11 as she has slid out of her shower chair once. CNA-B removed Resident #11's footwear, turned on the water and uncovered Resident #11. CNA-B provided Resident #11 with a washcloth to cover her eyes. Resident #11 asked, "Gonna take out my hearing aids?" CNA-B removed the hearing aids. When water sprayed onto Resident #11's head she yelled out loudly. CNA-B began washing and Resident #11 stated, "Don't lose my ring." Resident #11 again yelled out loudly when soap was applied to wash cloth stating, "Don't get it in my eyes!" As staff were rinsing the soap off Resident #11, Resident #11 yelled, "Ow! Don't hurt me!" Staff did not stop the shower and no other staff intervened on Resident #11's behalf. CNA-B told Resident #11 she was going to wash her bottom and Resident #11 stated, "Ow! That hurts!" Staff did not respond. CNA-B told Resident #11 she was going to wash her hair. Resident #11 stated, "Don't want!" Staff did not honor Resident #11's request and continued to wash her hair. Resident #11 called out, "Too long! Not too long! Ohhhh! Too long! Ow! Ow! Too long!" Resident #11's voice got louder and with higher pitch with each verbalization of "too long!" Resident #11 told staff, "Shave my whiskers and under my arms." Resident #11 again called out, "Too long! Too long! Too long! Got it in my ears!" in a loud tone of voice with high pitch. CNA-B told Resident #11 she is going to dry her off and CNA-E put Resident #11's hearing aids in her ears. Resident #11 stated, "I can't hear, I got water in my ear." Staff did not respond and did not offer Resident #11 any assistance. Resident #11 then loudly stated, "Don't break my arm! Don't break my leg!" when staff were drying her off. Staff placed gripper socks on Resident #11 to which she stated, "Don't break my leg. I don't want to fall down and get hurt." Again, staff did not respond. Staff covered Resident #11 and transported her back to her room. Once in her room, staff proceeded to dress Resident #11. Resident #11 stated, "Water in my ear, I can't hear!" and cried out, "It hurts!" Resident #11 stated, "Don't comb my hair, want curly hair. Don't comb my hair." CNA-E raised Resident #11's arms and applied deodorant and Resident #11 stated, "Not too much, hurts my shoulder." Staff placed a gait belt on Resident #11 and communicated they were going to transfer her. Resident #11 stated, "Can't hear with this one" and pointed to her right ear, and again stating, "Can't hear nothing, my ears are wet." Staff did not respond or make any attempt to communicate what they were going to do and continued with transfer. Once seated in the recliner Resident #11 stated, "Feels better." Resident #11 again stated, "Can't hear," pointing to her right ear, "Sounds like water in it." CNA-B removed Resident #11's hearing aid and Resident #11 cried out, "Can't hear!" 3 times, with her voice getting louder and higher pitched with each repetition of the statement. Staff removed the second hearing aid and dried her ears. Resident #11 repeated, "Can't hear nothing!" 6 times, each time getting louder and louder, and crying. CNA-B got close to Resident #11's ear and explained they were going to take her hearing aids to be checked. Resident #11 stated, "I heard you talk, go home, you're no good, can't hear nothing." As staff exited the room, Surveyor # asked if there was anything else they needed to do. CNA-B responded, "Shave and brush teeth." Despite Resident #11's crying out during cares, staff did not stop. In addition, no other staff intervened. On 6/20/13 at 6:50 a.m., Surveyor # spoke with RN-F regarding the MDS assessment process. RN-F indicated Social Services completes the sections related to mood and behavior on the MDS, and develops care plan approaches based on the assessment. Nurse's notes, progress notes, staff interviews and behavior logs are used as part of the assessment. RN-F also explained if a resident is not on [MEDICAL CONDITION] medications, there may not be a behavior log. Surveyor # asked if Resident #11's MDS captures her behavior of yelling out with cares. RN-F responded, "No." Surveyor # asked RN-F if Resident #11's care plan addresses her behavior of yelling out during cares. RN-F responded, "No" and added, the activity portion addresses an approach of staff placing their arm on her shoulder to reassure her, and redirecting her to her room if upset. Surveyor # asked RN-F if the Interdisciplinary Team had discussed Resident #11's behavior of yelling out during cares. RN-F responded she could not see evidence of team discussions per the Social Services notes. RN-F directed Surveyor # to speak with the Social Services Director and Reflections Program Coordinator. On 06/20/13 at 8:21 a.m. while sitting in the Reflections Dining Room, Surveyor # again heard yelling coming from down the hall past the nurses' station. Upon responding investigation, Surveyor # observed RN-K with her medication cart outside of Resident #11's room and CNA-A was sitting next to Resident #11 in her room assisting with breakfast. From outside the door, Surveyor # asked RN-K and CNA-A where the yelling was from. CNA-A indicated Resident #11 was yelling due to medication administration. RN-K stated, "She (Resident #11) doesn't like chunks, bad medicine or crushed medication, so what do you do? I prefer chunks." Resident #11 stopped yelling after she swallowed the medication. CNA-A continued to assist Resident #11 with breakfast. On 6/20/13 at 9:10 a.m., Surveyor # met with RPC-G (Reflections Program Coordinator) and asked about the assessment process that is used on the unit. RPC-G explained she completes an assessment prior to admission and develops approaches based on her assessment. RPC-G indicated Resident #11's assessment resulted in Resident #11 being defined as "Red," or middle stage of dementia. (The facility uses a program called "Colorscapes" to assess and define a resident's progression with dementias.) RPC-G stated Resident #11's care plan for activities addresses coping with activity approaches such as music, family visits and touching base with Resident #11 before and after home visits on weekends. Surveyor # asked RPC-G if the care plan addresses approaches for Resident #11's activities of daily living. RPC-G responded she does not assess activities of daily living and would have to check. On 6/20/13 at 10:10 a.m., Surveyor # spoke with SW-H regarding the assessment and care planning processes for Resident #11's mood and behavior. SW-H explained she is responsible for completion of the sections C, D and E on the MDS which deal with mood and behavior. SW-H indicated she completes the sections based on staff interview, review of the chart, observation and family interview. SW-H explained she is aware Resident #11 is more vocal during transitional times before and after home visits. SW-H stated she is not aware of any other mood or behavioral issues and no behavior monitoring data is being collected. SW-H indicated she is not aware if the MDS captures Resident #11's behaviors during activities of daily living such as incontinence care, medication administration and showering or if the care plan addresses those behaviors. SW-H stated she would check to see if this information is addressed and get back to Surveyor # . On 6/20/13 at 12:37 p.m., SW-H informed Surveyor # she had been surprised to hear Resident #11 has been yelling out. SW-H indicated she spoke with staff regarding the behavior. SW-H further explained staff indicated the yelling out is "routine" for Resident #11. The facility informed Surveyor # that Resident #11's spouse is deaf and only communicates via TTY phone. Surveyor # made several attempts to reach Resident #11's spouse, who is also Resident #11's guardian. On 06/21/13 at 9:40 a.m. Surveyor # interviewed Family-V (Resident 11's family member) via phone. Family-V explained Resident #11's spouse is deaf and communicates via a TTY phone only. Surveyor # asked Family-V how often she is able to see Resident #11. Family-V stated each weekend when Resident #11 is on a home visit. Family-V informed Surveyor # that Resident #11 has had a long time fear of showers as water in her ear impedes her hearing and function of her hearing aids. Family-V expressed this information has been shared with the facility on numerous occasions. Family-V further explained Resident #11 used to receive baths at the facility. Surveyor # asked Family-V why the baths stopped. Family-V responded, "I think for ease and convenience for staff." Family-V informed Surveyor # that Resident #11's hearing aids have needed to be sent in for repair several times while at the facility. Surveyor # asked how reliant Resident #11 is on her hearing aids. Family-V responded Resident #11 relies on her hearing aids or she cannot hear. Surveyor # asked Family-V if she was aware of Resident #11 having any pain with movement or episodes of yelling with showers. Family-V responded Resident #11 is not showered when on home visits. Family-V further explained Resident #11 had a [MEDICAL CONDITION] which affected her left side causing paralysis and hyper sensitivity which resulted in Resident #11 yelling out when someon bumps her left leg. Family-V expressed, "It feels like pins and needles." Surveyor # asked Family-V if Resident #11's voice is any different when she is upset. Family-V explained that Resident #11's voice gets louder, more emotional, and more agitated with higher pitch when she is upset. On 06/21/13 at 12:55 p.m., Surveyor # was provided additional information from the facility. RN-D presented a care plan for Resident #11 with a goal dated 06/23/06: Resident will allow staff to complete bathing, dressing, grooming tasks daily and PRN (as needed) approaches: 10-19-04: Weekly bath: total assist. Apollo bath 1 time a week, bed bath attempts and patient has more agitation. Staff aware resident screams out during Apollo as "no water, no water!" Additionally, RN-D provided Surveyor # with General Education record dated 06-11-13: Identified Behavior: Bathing without a battle training. Intervention #1: Video, will begin training staff, start with Drake Hall (Resident #11 resides on Drake Hall). Surveyor # asked RN-D if training regarding Bathing Without a Battle has been provided to staff. RN-D responded training is planned but has not yet occurred.

Based on observation, interview, and record review, the facility did not provide care in a manner that allowed for 1 of 15 sampled residents to reach their highest practicable level of well-being. During observation of cares on 6/19/13, staff took Resident #11 to the shower. Resident #11 repeatedly told staff she was scared, the water was too hot, she was fearful of getting soap in her eyes and stating she wants to go home. Staff did not respond to Resident #11's concerns and continued with the shower. When water was applied to Resident #11's head, she began to cry out. Throughout the shower, Resident #11 continued to call out with several fears of falling, being injured, being cold and pain in her ear when water got in her ear. Staff continued the shower without interventions. No other staff intervened while Resident #11 cried out. Resident #11 also cried out during incontinence cares and medication administration. This is evidenced by: Surveyor # received and reviewed the facility's policy titled "Reflections and Passages Communities" dated 12/11/04 and outlined the following: Policy: Residents with a cognitive impairment who require a secured protected environment with specialized programing are provided through the Reflections and/or passages communities. Definition: Reflections Community: An area in the nursing center that provides special programing in a secure environment. Reflections model primarily targets residents in the early to middle stages of Alzheimer's or related dementia. Compliance Guidelines: The Reflections and Passages communities are certified to provide specialized programing. The Reflections and Passages communities are based upon a social model of care delivery. Emphasis is placed upon upon creating a homelike environment that encourages residents to engage in individual preferences and customary routines...Families and caregivers are involved in the overall care planning process and participation in recreational and social events. Staff assigned to the Reflections and/or Passages community is trained in the skills required to work with residents with a cognitive impairment. Skills checklist is completed and filed in the employees training record...Care plan implementation is based upon individual special programing needs of the resident and updated as necessary...A continuing education program is provided to promote development and improvement of knowledge and skills of involved program staff. Reflection Community staff is trained in the social model/recreational programs based upon cognitive requirement of the residents. Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. ~[MEDICAL CONDITION] (a decline in thinking caused by conditions that block or reduce blood flow to the brain); ~Hypersensitivity (enhanced internal sensation of pain); ~Basal Ganglia Hemorrhage (bleeding at the base of the brain); ~Rapidly increasing intra-cranial pressure with herniation (high pressure that occurs when part of the brain is squeezed across the structure within the skull, moving brain tissue); ~Hearing impaired since birth; ~Ischemic Infarction both occipital lobes and cerebellum (restriction of blood supply with tissue death to parts of the brain that affect visual processing, motor skills and cognition); ~Residual left [MEDICAL CONDITION] (total paralysis of arm, leg and trunk of left side); and ~[MEDICAL CONDITION] (hardening of the arteries). Resident #11 resides on the Reflections Unit of the facility. The most recent annual MDS (Minimum Data Set) assessment, dated 4/16/13, indicated Resident #11: ~Usually understands; ~Is usually understood; ~Has a hearing Aid or other appliance; ~With hearing aid has moderate difficulty hearing, speaker has to increase volume and speak distinctly; ~Moderately impaired cognition; ~Feeling or appearing down, depressed or hopeless on several days (based on staff interview); ~Trouble concentrating on things such as reading the newspaper or watching television half or more of the days (based on staff interview); ~Other behavioral not directed towards others (e.g., ...verbal /vocal symptoms like screaming, disruptive sounds), behavior not exhibited; ~Total dependence on staff for dressing, personal hygiene and bathing; ~Resident unable to answer related to pain presence; and ~Staff assessment of pain, no indicators of pain or possible pain. Resident #11's CAA (Care Area Assessment) dated 4/18/13, indicated the following: ~Mood State, area not triggered; ~Psychosocial well-being, area not triggered dated 06/23/06: Resident will allow staff to complete bathing, dressing, grooming tasks daily and PRN (as needed) approaches; ~Behavioral Symptoms, area not triggered; and ~Cognitive Loss/Dementia: See care plan. Resident #11's care plan for Activities of Daily Living dated 1/6/1994, indicated the following: Resident will allow staff to complete bathing, dressing, grooming tasks daily and as needed. Approach: Weekly bath: total assist. Apollo bath 1 time a week, bed bath attempts and patient has more agitation. Staff aware resident screams out during Apollo as "no water, no water".... Be aware resident will scream/yell during transport to bath-staff to provide re-assurance... Prefers shower chair for shower transfer. Resident #11's care plan for Thought Process, Impaired dated 12/24/1997, indicated the following: FYI: frequent pounding/calling out noted during restlessness, also sings aloud which can be confused with yelling secondary to slurred speech, have ritual of bath and packing before leaving for weekend to help calm resident. Resident #11's care plan for Altered Comfort/Pain dated 4/21/1998, indicated the following: Goal: Resident will continue to alert staff to discomfort. Approaches: 4/8/03: Administer medications as ordered. 7/18/03: Be aware resident does have increased agitation when up in wheelchair-increased yelling out, rocking and pounding rail or wall, stamping feet, pulls call light from wall. 4/8/03: Avoid soap and water contact with ears due to infection with use of ear molds to prevent water in ears during bathing and shampoo. 5/13/09: Nursing to assess for pain every shift and as needed with verbal and non-verbal assessment. Resident #11's Pain assessment dated [DATE], noted no indicators of pain. Resident #11's Monthly Behavior Monitoring flow sheets were reviewed for the past 6 months and indicated no record of Resident #11's behavior of yelling out. Resident #11's care card was reviewed with approaches indicating: calls/yells out during cares offer re-assurance and re-approach as needed. Resident #11's interdisciplinary and nursing notes were reviewed and indicated the following: *1/23/13, Annual assessment completed...hard of hearing...[DIAGNOSES REDACTED]. Signed by SW-H (Social Worker). *1/23/13, Quarterly assessment and progress note: Leisure routine includes almost weekly home passes...Resident does yell out at times, reassurance is offered...yelling is often related to showers or transitions... *2/13/13, Interdisciplinary Team: Care plan reviewed, at times resident yells out due to change and transitions. Staff to approach/calm/reassure... *2/18/13, Behavior team meeting: Sensory impairments, yells out. Behaviors reviewed, care plan updated and appropriate. *4/17/13, Resident continue to go out on home pass..Resident is HOH (hard of hearing)..has diagnosis (sic) of [MEDICAL CONDITION] with agitation...Does have a hard time with transitions (change), does yell at times. On 6/19/13 at 12:01 p.m., Surveyor # was seated in the Reflections dining room when loud yelling was heard beyond the nurses' station. Upon investigation, Surveyor # discovered the yelling coming from Resident #11 room. Surveyor # knocked on Resident #11's room door, requested to enter and observed Resident #11 in her room in bed yelling. CNA-B (Certified Nursing Assistant) and LPN-C (Licensed Practical Nurse) had just finished incontinence care for Resident #11. Resident #11 stopped yelling shortly after the cares were completed and returned to a conversational tone and volume of voice. Surveyor # asked LPN-C about the observation and what was heard from the dining room. LPN-C replied, "That's just her, doesn't matter the approached used." LPN-C stated Resident #11 doesn't like to be changed, "You can explain and reassure but this is the response." LPN-C explained changing her incontinence brief, showering and medication administration "makes her yell." On 6/19/13 at 2:18 p.m., Surveyor # spoke with CNA-B regarding the observation. CNA-B indicated she had worked at the facility for 6 years as a CNA and is Resident #11's primary caregiver. Surveyor # asked CNA-B about the observation with Resident #11. CNA-B indicated Resident #11 yells a lot with cares, with movement, when upset about her husband, with showering and when she can't hear. CNA-B explained the yelling occurs daily. Surveyor # asked CNA-B what approach works to calm Resident #11. CNA-B stated being calm, knowing what her "quirks are," she likes certain things, like being shaved and using a wash cloth to cover her eyes in the shower. Surveyor # asked CNA-B if these approaches were in Resident #11's care plan. CNA-B referenced her care card and responded, "No." Surveyor # asked CNA-B about Resident #11's care plan approaches. CNA-B indicated she was not familiar with any other care plan other than her care cards. On 6/19/13 at 2:34 p.m., Surveyor # spoke with LPN-C regarding the observation with Resident #11. LPN-C explained Resident #11 yells with each brief change, during showers, and will put her hand up and yell with medication administration. LPN-C indicated Resident #11 will cooperate with medication administration if given cold water, lemon pudding and medications are crushed. Surveyor # asked LPN-C if the facility has ruled out medical reasons as the cause of Resident #11's yelling. LPN-C responded, "I don't think it's pain," and expressed she was unaware of any trials being done regarding pain medication administration prior to movement. Surveyor # asked LPN-C if Resident #11's care plan addressed the yelling out. LPN-C indicated the behavior is not addressed on the care plan and behavior monitoring data is not collected. Surveyor # asked LPN-C if she had received any dementia specific training. LPN-C expressed she had not received any training from the facility regarding dementia. On 6/19/13 at 2:57 p.m., Surveyor # met with RN-D (Registered Nurse) who is the Clinical Manager for Resident #11. Surveyor # asked RN-D about the process for assessment, care planning and data collection when resident behaviors occur. RN-D indicated upon admission if a resident is on [MEDICAL CONDITION] medication, data collection for their behaviors is initiated, utilizing resident history and family interview. Surveyor # asked if behavioral data is collected for a person demonstrating behaviors that may not be on [MEDICAL CONDITION]. RN-D responded, "We used to." RN-D further explained for a resident on [MEDICAL CONDITION] medication the team reviews the behavior, looks at medications and approaches. Surveyor # asked RN-D if Resident #11's MDS addressed Resident #11's behaviors. RN-D indicated she was not sure and directed Surveyor # to speak with the MDS coordinator. Surveyor # asked RN-D if care plans or care cards address resident behaviors. RN-D responded, "It depends on the person." On 6/20/13 at 6:10 a.m., Surveyor # knocked and requested permission to enter Resident #11's room. Surveyor # observed CNA-A and CNA-B assist Resident #11 with morning cares. Surveyor # observed Resident #11 point to her ear. Surveyor # asked CNA-A if she was familiar with Resident #11. CNA-A responded she had worked at the facility for 2 1/2 years and was familiar with Resident #11. Surveyor # observed staff put Resident #11's socks on and sit Resident #11 on the edge of her bed. Resident #11 stated "heavy" and again pointed to her ear. Surveyor # asked staff if Resident #11 can hear without her hearing aids as Surveyor # wanted to obtain permission from Resident #11 to observe her cares. Staff retrieved Resident #11's hearing aids and placed them in her ears. Resident #11 stated, "I can hear a little bit." Surveyor # asked Resident #11's permission to observe cares. Resident #11 had no objections. Staff prepared Resident #11 for transfer. Resident #11 stated, "I'm scared, hot water, too hot, not too long, a little bit." Staff placed a gait belt on Resident #11 and again Resident #11 stated, "I'm scared." Staff did not respond to Resident #11's fears. CNA-A stated, "We're going to stand you up" and transferred Resident #11 to a shower chair. Resident #11 began to loudly vocalize "too hot, soap in my eyes." Staff again did not respond to Resident #11 fears. Resident #11 stated,"Not too long," and staff did not respond. Resident #11 was covered with a bath blanket then stated, "I want to go home." CNA-B discussed Resident #11's family with her and Resident #11's voice lowered when discussing her family. Staff did not stop the shower preparation process and no other staff intervened on Resident #11's behalf. CNA-B took Resident #11 down the hall to shower. Resident #11 stated, "Don't hurt my legs, hot water, don't hurt me, don't burn me." Resident #11's voice tone and volume increased. CNA-B did not respond. Once in the shower, CNA-E joined and explained 2 staff are required to shower Resident #11 as she has slid out of her shower chair once. CNA-B removed Resident #11's footwear, turned on the water and uncovered Resident #11. CNA-B provided Resident #11 with a wash cloth to cover her eyes. Resident #11 asked, "Gonna take out my hearing aids?" CNA-B removed the hearing aids. When water sprayed onto Resident #11's head she yelled out loudly. CNA-B began washing and Resident #11 stated, "Don't lose my ring." Resident #11 again yelled out loudly when soap was applied to wash cloth stating, "Don't get it in my eyes!" As staff were rinsing the soap off Resident #11, Resident #11 yelled, "Ow! Don't hurt me!" Staff did not stop the shower and no other staff intervened on Resident #11's behalf. CNA-B told Resident #11 she was going to wash her bottom and Resident #11 stated, "Ow! That hurts!" Staff did not respond. CNA-B told Resident #11 she was going to wash her hair. Resident #11 stated, "Don't want!" Staff did not honor Resident #11's request and continued to wash her hair. Resident #11 called out, "Too long! Not too long! Ohhhh! Too long! Ow! Ow! Too long!" Resident #11's voice got louder and higher pitched with each verbalization of "too long!" Resident #11 told staff, "Shave my whiskers and under my arms." Resident #11 again called out, "Too long! Too long! Too long! Got it in my ears!" in a loud tone of voice with high pitch. CNA-B told Resident #11 she is going to dry her off and CNA-E put Resident #11's hearing aids in her ears. Resident #11 stated, "I can't hear, I got water in my ear." Staff did not respond and did not offer Resident #11 any assistance. Resident #11 then loudly stated, "Don't break my arm! Don't break my leg!" when staff were drying her off. Staff placed gripper socks on Resident #11 to which she stated, "Don't break my leg, I don't want to fall down and get hurt." Again staff did not respond. Staff covered Resident #11 and transported her back to her room. Once in her room, staff proceeded to dress Resident #11. Resident #11 stated, "Water in my ear, I can't hear!" and cried out "It hurts!" Resident #11 stated, "Don't comb my hair, want curly hair. Don't comb my hair." CNA-E raised Resident #11's arms and applied deodorant and Resident #11 stated, "Not too much, hurts my shoulder." Staff placed a gait belt on Resident #11 and communicated they were going to transfer her. Resident #11 stated, "Can't hear with this one," and pointed to her right ear, again stating, "Can't hear nothing, my ears are wet." Staff did not respond or make any attempt to communicate what they were going to do and continued with transfer. Once seated in the recliner Resident #11 stated, "Feels better." Resident #11 again stated, "Can't hear" pointing to her right ear, "Sounds like water in it." CNA-B removed Resident #11's hearing aid and Resident #11 cried out, "Can't hear!" 3 times, with her voice getting louder and higher pitched with each repetition of the statement. Staff removed the second hearing aid and dried her ears. Resident #11 repeated, "Can't hear nothing!" 6 times, each time getting louder and louder, and crying. CNA-B got close to Resident #11's ear and explained they were going to take her hearing aids to be checked. Resident #11 stated, "I heard you talk, go home, you're no good, can't hear nothing." As staff exited the room, Surveyor # asked if there was anything else they needed to do. CNA-B responded, "Shave and brush teeth." Despite Resident #11's crying out during cares, staff did not stop. In addition, no other staff intervened. On 6/20/13 at 6:50 a.m., Surveyor # spoke with RN-F regarding the MDS assessment process. RN-F indicated Social Services completes the sections related to mood and behavior on the MDS, and develops care plan approaches based on the assessment. Nurse's notes, progress notes, staff interviews and behavior logs are used as part of the assessment. RN-F also explained if a resident is not on [MEDICAL CONDITION] medications, there may not be a behavior log. Surveyor # asked if Resident #11's MDS captures her behavior of yelling out with cares. RN-F responded, "No." Surveyor # asked RN-F if Resident #11's care plan addresses her behavior of yelling out during cares. RN-F responded, "No" and added the activity portion addresses an approach of staff placing their arm on her shoulder to reassure her, and redirecting her to her room if upset. Surveyor # asked RN-F if the Interdisciplinary Team had discussed Resident #11's behavior of yelling out during cares. RN-F responded she could not see evidence of team discussions per the Social Services notes. RN-F directed Surveyor # to speak with the Social Services Director and Reflections Program Coordinator. On 06/20/13 at 8:21 a.m., while sitting in the Reflections Dining Room, Surveyor # again heard yelling coming from down the hall past the nurses' station. Upon responding to investigate, Surveyor # observed RN-K with her medication cart outside of Resident #11's room and CNA-A sitting next to Resident #11 in her room assisting with breakfast. From outside the door, Surveyor # asked RN-K and CNA-A where the yelling was from. CNA-A indicated Resident #11 was yelling due to medication administration. RN-K stated, "She (Resident #11) doesn't like chunks, bad medicine or crushed medication, so what do you do? I prefer chunks." Resident #11 stopped yelling after she swallowed the medication. CNA-A continued to assist Resident #11 with breakfast. On 6/20/13 at 9:10 a.m., Surveyor # met with RPC-G (Reflections Program Coordinator) and asked about the assessment process that is used on the unit. RPC-G explained she completes an assessment prior to admission and develops approaches based on her assessment. RPC-G indicated Resident #11's assessment resulted in Resident #11 being defined as "Red," or middle stage of dementia. (The facility uses a program called "Colorscapes" to assess and define a resident's progression with dementias.) RPC-G stated Resident #11's care plan for activities addresses coping with activity approaches such as music, family visits and touching base with Resident #11 before and after home visits on weekends. Surveyor # asked RPC-G if the care plan addresses approaches for Resident #11's activities of daily living. RPC-G responded she does not assess activities of daily living and would have to check. On 6/20/13 at 10:10 a.m., Surveyor # spoke with SW-H regarding the assessment and care planning processes for Resident #11's mood and behavior. SW-H explained she is responsible for completion of sections C, D and E on the MDS which deal with mood and behavior. SW-H indicated she completes the sections based on staff interview, review of the chart, observation and family interview. SW-H explained she is aware Resident #11 is more vocal during transitional times before and after home visits. SW-H stated she is not aware of any other mood or behavioral issues and no behavior monitoring data is being collected. SW-H indicated she is not aware if the MDS captures Resident #11's behaviors during activities of daily living such as incontinence care, medication administration and showering or if the care plan addresses those behaviors. SW-H stated she would check to see if this information is addressed and get back to Surveyor # . On 6/20/13 at 12:37 p.m., SW-H informed Surveyor # she had been surprised to hear Resident #11 has been yelling out. SW-H indicated she spoke with staff regarding the behavior. SW-H further explained staff indicated the yelling out is "routine" for Resident #11. The facility informed Surveyor # that Resident #11's spouse is deaf and only communicates via TTY phone. Surveyor # made several attempts to reach Resident #11's spouse, who is also Resident #11's guardian. On 06/21/13 at 9:40 a.m. Surveyor # interviewed Family-V (Resident #11's family member) via phone. Family-V explained Resident #11's spouse is deaf and communicates via a TTY phone only. Surveyor # asked Family-V how often she is able to see Resident #11. Family-V stated she sees Resident #11 each weekend when Resident #11 is on a home visit. Family-V informed Surveyor # that Resident #11 has had a long time fear of showers as water in her ear impedes her hearing and function of her hearing aids. Family-V expressed this information has been shared with the facility on numerous occasions. Family-V further explained Resident #11 used to receive baths at the facility. Surveyor # asked Family-V why the baths stopped. Family-V responded, "I think for ease and convenience for staff." Family-V informed Surveyor # that Resident #11's hearing aids have needed to be sent in for repair several times while at the facility. Surveyor # asked how reliant Resident #11 is on her hearing aids. Family-V responded Resident #11 relies on her hearing aids or she cannot hear. Surveyor # asked Family-V if she was aware of Resident #11 having any pain with movement or episodes of yelling with showers. Family-V responded with Resident #11 is not showered when on home visits. Family-V further explained Resident #11 had a [MEDICAL CONDITION] which affected her left side causing paralysis and hyper sensitivity resulting with her yelling out when someone bumps her left leg. Family-V expressed, "It feels like pins and needles." Surveyor # asked Family-V if Resident #11's voice is any different when she is upset. Family-V explained Resident #11's voice gets louder, more emotional, more agitated, with higher pitch when she is upset. On 06/21/13 at 12:55 p.m., Surveyor # was provided additional information from the facility. RN-D presented a care plan for Resident #11 with a goal dated 06/23/06: Resident will allow staff to complete bathing, dressing, grooming tasks daily and PRN (as needed) approaches: 10-19-04: Weekly bath: total assist. Apollo bath 1 time a week, bed bath attempts and patient has more agitation. Staff aware resident screams out during Apollo as "no water, no water." Additionally, RN-D provided Surveyor # with General Education record dated 06-11-13: Identified Behavior: Bathing Without a Battle training. Intervention #1: Video, will begin training staff, start with Drake Hall (Resident #11 resides on Drake Hall). Surveyor # asked RN-D if training regarding Bathing Without a Battle has been provided to staff. RN-D responded training is planned but has not yet occurred.

Based on observation, record review, and interview, the facility did not ensure that 1 of 9 sampled residents reviewed for incontinence, received appropriate treatment and services to restore as much normal bladder function as possible and to prevent urinary tract infections. The facility completed 3 days of data collection of Resident #5's bladder pattern. The data shows Resident #5 has the ability to improve/maintain continence, however, an individualized care plan was not developed to promote bladder continence. Resident #5 was placed on a "Dignity Management Toileting Plan." Staff interviews indicated this program is for residents who are totally incontinent of bladder and staff check and change/offer toileting every 2 hours. In addition, following an episode of incontinence, Resident #5 was not provided with appropriate perineal cleansing to prevent/decrease the likelihood of urinary tract infections. This is evidenced by: According to the WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. This individualized schedule should be used rather than the facility's incontinence management toileting schedule currently being used for all cognitively impaired and incontinent residents who are unable to communicate with staff that they have to go to the bathroom. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. Surveyor # requested the facility policy and procedure for incontinence/perineal care which indicated, "Cleanliness of the perineum helps to prevent infection, skin breakdown and odor by removing irritating and odorous secretions that collect on the inner surface of the labia...Perineal care is provided to the patient who needs assistance to maintain perineal cleanliness...Gently wash the pubic area. a. For women- use one gloved hand to stabilize and separate the labia and use the other hand to wash from front to back..." Resident #5 was readmitted to the facility with a [DIAGNOSES REDACTED]. Resident #5's quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #5 is frequently incontinent of bladder and requires assistance of 2 staff for transfers and toilet use. Resident #5's annual MDS assessment dated [DATE], indicated Resident #5 was frequently incontinent of bladder and required assistance of 2 staff for toilet use. Staff completed Bladder Voiding Pattern record for Resident #5 on 11/10/12, 11/11/12 and 11/12/12. Surveyor # reviewed these and noted the following: *11/10/13, incontinent at 2:00 a.m., 8:00 a.m., 11:00 a.m., and 6:00 p.m. *11/11/13, incontinent at 2:00 a.m., 7:00 a.m., 1:00 p.m. and 6:00 p.m. *11/12/13, incontinent at 5:00 a.m., and 4:00 p.m. All other hourly checks indicated Resident #5 was dry. The Bladder Status Evaluation indicated Resident #5 has "Functional Incontinence," and is "cognitively unaware of toileting needs." Physical causes checked include, "Physical Weakness, Poor Mobility, Confusion, needs extensive assistance with toileting." The program selected by the evaluator was "Incontinence Care." The summary stated, "Decrease in cognition to alert staff when needs to use BR (bathroom). Multiple incontinent episodes throughout 24 hours." Resident #5's care plan included a problem of Toileting Deficit dated 2/1/10. Approaches include, "Staff to toilet resident per Dignity Mgmt (management) Toileting Program...Provide incontinence protection and provide cares as needed." There was no goal or approaches to assist Resident #5 in decreasing or eliminating incontinent episodes. Review of the CNA Care Plan under Toileting Schedule (TS), indicated Dignity Management (DM). On 6/20/13 at 9:48 a.m., Surveyor # asked the Unit Manager, RN-M (Registered Nurse) what the facility's Dignity Management means. RN-M stated that is a program where someone who is totally incontinent is checked and changed or toileted every 2 hours. Resident #5 demonstrated the ability to remain continent, however an individualized care plan was not developed or implemented to improve bladder continence. On 6/20/13 at 7:12 a.m., Surveyor # observed Resident #5 sitting in her wheelchair yelling out, "I got to go bad!" LPN-L (Licensed Practical Nurse) went into her room and informed Resident #5 that as soon as the CNAs were done giving someone a shower, they would toilet her. Resident #5 recognized the need to use the bathroom, however did not receive assistance. At 7:18 a.m., Surveyor # spoke with Resident #5 who stated, "I've been waiting, can't hold it any longer." CNA-I and CNA-R then came into the room to toilet her. Surveyor # noted Resident #5's brief was very wet. Resident #5 voided into the toilet and had bowel movement. CNA-I and CNA-R stood Resident #5 up with difficulty, using a gait belt. CNA-I used a wipe to provide cleansing. From behind, CNA-I wiped from front to back, then used another wipe to clean the rectal area. No frontal peri care was completed even though Resident #5 had been incontinent. Whenever a female voids, especially in the brief, the urine will flow upward, sideways and/or downward, thus increasing the chance of bacteria remaining on the skin and traveling back up into the bladder, thus increasing the risk for infection. On 6/20/13 at 7:30 a.m., Surveyor # asked CNA-I when peri care should be completed. CNA-I stated peri care is completed with a.m. and p.m. cares. On 6/20/13 at 9:48 a.m., RN-M stated that frontal peri-care should be completed every morning, evening, and with every incontinent episode. On 6/21/13 at 7:40 a.m., Surveyor # asked the Director of Nurses (DON) when peri care should be completed. The DON stated peri care is done with morning and evening cares. Incontinence care is inbetween incontinent episodes using wipes and washing front to back. The DON also stated if a resident had incontinent bowel movement, peri care should be completed. On 6/21/13 at 8:30 a.m., Surveyor # spoke with the Infection Control Preventionist (ICP) who is also the Staff Development Coordinator (SDC) who stated peri care is cleaning all the genital peri area every morning and evening, and every time a resident is incontinent. The ICP stated with the female, urine goes all over when sitting or lying down and peri care is to be done will all incontinent episodes to promote skin integrity and decrease the chance of infection.

Based on observations, interviews, and record reviews, the facility did not protect 1 of 2 sampled residents from physical, verbal, and mental abuse, resulting in a risk of serious psychosocial harm to Resident #2. Resident #1 has a documented history of angry outbursts, including verbal and physical altercations with residents and staff. Resident #1 has targeted Resident #2, who resides next door to Resident #1 with a shared bathroom. Resident #1 reportedly taunts, teases, antagonizes and intimidates Resident #2 repeatedly, as often as daily. Resident #2 reportedly responds by crying, getting upset and yelling "shut up" in response to the teasing from Resident #1. Resident #1 reportedly has threatened other residents including Resident #2's roommate, stating he would kill them and throw them out a window. Resident #1's outbursts continued to escalate. Staff interviews found the ongoing taunting and teasing was reported to management staff. Despite Resident #1's ongoing abuse of Resident #2, the facility took few proactive measures to prevent the abuse from continuing. On 1/20/13, Resident #1 was observed to walk quickly to the area where Resident #2 was seated. Resident #1 struck Resident #2 and began pulling his wheelchair and made "negative verbalizations" to staff. The failure to protect Resident #2 from repeated verbal and mental abuse resulted in a finding of immediate jeopardy, which began on 12/06/12, when Resident #2 was moved next door to Resident #1 with a shared bathroom despite the facility having knowledge of the verbal abuse prior to the move. The Nursing Home Administrator, Director of Nursing and the Regional Director were notified of the immediate jeopardy on 02/13/13 at approximately 11:00 a.m. The immediate jeopardy was removed on 02/12/13, when the facility moved Resident #2 to a different room on a different unit, but noncompliance continues at the lower scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated), as the facility has yet to fully implement and monitor the effectiveness of its actions. This is evidenced by: Review of the records of Resident #1 and Resident #2 and interviews with staff, revealed that they have resided next door to each other with an adjoining bathroom since 12/06/12. Resident #1: Resident #1 was admitted to the facility on [DATE]. Resident #1 is [AGE] years old and walks independently. Resident #1 has [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set assessment (MDS), dated [DATE], indicated: ~Clear Speech, makes self understood; ~Usually understands others; ~BIMS (Brief Interview for Mental Status) score of 7 out of 15 indicating severe cognitively impaired; ~Independent in bed mobility, transfer, walking in room, corridor, and locomotion on and off unit. Resident #1's current care plan dated 11/14/12, includes a problem of coping impaired potential/actual, related to...history of alcohol dependence, unprovoked behaviors in dementia posing a danger to self and others, history of verbal altercations with others, history of becoming upset if negative comments are made to him, gets upset with others entering his room without permission, gets agitated at times without pre-warning signs, will become agitated without known triggers. Approaches are as follows: ~10/26/10: Power of Attorney activated related to help with decisions, 1:1 support and ventilation of feelings, pastoral visits as needed, explore strengths and identify positives in life as appropriate, assist with maintaining contact with family and friends, enjoys joking with staff, if upset prefers to be left alone and 1:1 visits with family and friends, wife is at facility and enjoys speaking with each other frequently, becomes upset at times due to memory loss and placement, provide support. ~08/31/12: If becomes upset make sure he and others are safe, allow to walk to room himself and shut door to calm down, does need time to himself to get over things, does not do well with many staff approaching him. ~12/11/12: when teasing peers redirect and remind teasing is not appropriate, encourage alternate ways to engage with peers. ~01/25/13: When agitated attempt to remove him from perceived agitating stimuli. Surveyor # reviewed Resident #1's CNA (Certified Nursing Assistant) care card and found no information related to Resident #1's behaviors or interventions for staff. Surveyor # reviewed Resident #1's behavior monitoring flow sheets from 04/12 through 02/13 which revealed the following: ~Yelling at peers and staff: 113 episodes; ~Agitation and aggression: 96 episodes; and ~Negative verbalizations: 91 episodes. Examples of Resident #1's behaviors, as documented in Resident #1's nursing notes included the following: ~05/08/12 10:30 p.m., came out of room yelling at staff related to resident opened his door... ~05/10/12, 10:10 p.m., resident verbally aggressive to staff, times 4, related to female resident opened door and entered his room. ~06/05/12, 2:30 p.m., was reported by staff that another resident walked by his room causing him to become agitated and was screaming and cursing...when CNA tried to intervene, he swung at her; when another CNA attempted to assist he punched her. ~06/13/12, 3:00 p.m., another resident went into room...became upset and kicked resident in the buttock and slammed door... ~06/15/12, 10:10 p.m., upset with other resident cursing and yelling..Resident #1 continued to yell and holler and ran down hall, writer tried to redirect...grabbed writer's left side of neck...Resident struck CNA, shoved CNA, yelling would kill them all, threat to staff and female resident, besides pushing, shoving, choking, did spit in writer's face. ~08/13/12, 5:15 p.m., patient exited room in hurried manner headed to male peer, trying to grab peer's arm, grabbing shirt before staff was able to intervene..,'Get that son of a [***] away from me before I bang his f***ing head into the wall'...event was unprovoked, peer was sitting in hall waiting for supper cart. ~9/07/12, (Social Service note) does have a history of verbal altercations, becoming upset easily and becoming verbally and physically aggressive... ~11/13/12, 10:50 p.m., physical contact with agitation toward peers and verbal altercation with staff noted this shift... ~ 11/16/12, Staff moved Resident #1. Intervention #1: "Room change to less confused, less wandering hall." Intervention #2: "Once agitated, bring to low stimulus room (i.e. his room), leave alone and allow time to calm." Intervention #3: "Call spouse to assist to calm if able." ~12/10/12, 7:00 p.m., going out of his way to make fun of another resident at supper. He would loudly ask the resident if he spilled enough juice and tell everyone to look at the other resident drool... ~12/11/12, volunteered (that) another resident was yelling because he (Resident #1) was teasing him (peer) and that probably wasn't very nice... ~1/20/13, 5:30 a.m., writer observed Resident #1 walking rapidly toward rotunda; when he reached the end, struck Resident #2 in left arm, pulled wheelchair and made negative verbalizations, made negative verbalizations to staff, advanced toward CNA and returned to room...Resident #1 was placed on 1-to-1 supervision immediately following the incident. According to the Resident Monitoring Tool, supervision was changed to 15-minute checks beginning at 6:00 a.m. ~1/20/13, 11:00 a.m., Pt (Patient) did have negative verbalizations toward other resident at end of breakfast on way back to his room. Surveyor # reviewed Resident #1's notes to attending physician and noted the following: ~1/21/13, has been increasingly agitated toward other residents and has become involved in resident to resident altercations... On 2/13/13, SW-E provided Surveyor # with the Behavior Team notes. Included was documentation that the team had reviewed Resident #1 on 1/25/13. Identified behavior: "Aggression toward others." Intervention #1: "Once agitation noted, separate him from the perceived agitating stimuli and bring to low stimuli room." Intervention #2: "Attempt aromatherapy with [MEDICATION NAME] for calming." Intervention #3: "Med review/pharmacy consult." There was no other review of Resident #1's aggression toward peers. On 02/13/13 at 8:00 a.m., Surveyor # interviewed Resident #1 regarding the resident who recently moved from next door (Resident #2). Resident #1 was able to identify Resident #2 by name. Resident #1 indicated Resident #2's mind does not work like others. Resident #1 explained Resident #2 moved from the room but he was not sure why. Resident #1 indicated he and another resident liked to tease Resident #2. Surveyor # asked Resident #1 how Resident #2 reacted to the teasing. Resident #1 responded Resident #2 would sometimes get mad and tell him to "shut up." Resident #2: Resident #2 was admitted to the facility on [DATE]. Resident #2 is [AGE] years old and is protectively placed with guardianship. Resident #2 has [DIAGNOSES REDACTED]. Resident #2 requires extensive assistance from staff for bed mobility and transfers. Resident #2 is able to self-propel his wheelchair and uses the handrails for wheelchair mobility. Resident #2 resided in the room next to Resident #1. Resident #2 had to pass Resident #1's room whenever he would leave or come back to his room. Resident #2's most recent Minimum Data Set assessment ((MDS) dated [DATE], indicated the following: ~Moderate cognitive impairments with disorganized thinking and inattention ~Usually understood; ~Usually understands others; ~ Requires extensive staff assistance for bed mobility and transfer; ~Does not ambulate; and ~Mobility service wheelchair. Review of Resident #2 nurse's notes indicate the following: ~01/20/13, 7:00 a.m., was closing resident doors at 3:00 a.m. and headed to fireside to check breakfast menu. Another resident was upset about having his door closed and followed him, struck his left arm, pulled on his wheelchair, making negative verbalizations...Assessment showed slightly reddened deltoid indicated biceps was struck, no redness there... On 2/12/13 at 9:00 a.m., Surveyor # interviewed CNA-A. CNA-A indicated she has worked at the facility for 2 1/2 years and worked with Resident #1 and Resident #2 on the current unit as well as on their previous unit. CNA-A indicated both residents had recently moved. CNA-A explained Resident #1 is like night and day, sometimes pleasant and sometimes rude. CNA-A stated, "Sometimes, there is no turning from being mean." CNA-A indicated Resident #1 sticks his head into Resident #2's room every day and says something inappropriate or mean to Resident #2. CNA-A described one incident where Resident #1 entered Resident #2's room through the adjoining bathroom at 5:30 a.m. CNA-A stated Resident #1 made a lewd comment to Resident #2 which upset Resident #2. CNA-A indicated Resident #2 gets upset and yells which wakes his roommate. CNA-A stated she has reported the teasing and suggested a room change to the unit's clinical manager RN-H. CNA-A stated Resident #1 will push other residents' wheelchairs, chase after residents and staff, causing staff to sometimes having to hide from him. CNA-A indicated sometimes another male resident (Resident #5) will join Resident #1 in teasing Resident #2. CNA-A stated, "They have done so much to Resident #2." CNA-A indicated Resident #2's roommate (Resident #3) and the resident council president (Resident #4) are aware of the incidents. On 02/12/13 at 9:10 a.m., Surveyor # interviewed CNA-C. CNA-C indicated she has worked at the facility for over a year and is familiar with Resident #1 and Resident #2. CNA-C described Resident #1 as intimidating, and stated Resident #1 and Resident #5 pick on Resident #2, and get defensive when staff attempt to intervene and stop them. CNA-C described an incident where Resident #1 became upset with her while she tried to redirect him. Resident #1 threatened CNA-C saying, "Shut your mouth or I will shut it for you." CNA-C stated she hid behind the meal cart out of fear of Resident #1. CNA-C stated Resident #1 is aggressive and confrontational towards other residents and makes fun of Resident #2 almost every day causing Resident #2 to get upset. CNA-C indicated she has reported the behavior and the need for a room change to the unit nurses. On 02/12/13 at 9:20 a.m. Surveyor # interviewed RN-H, the Clinical Manager of the unit where Resident #1 and Resident #2 reside. RN-H indicated Resident #1 gets upsets easily with change in routine, he can be loud, and is redirected to his room to calm down. Surveyor # asked RN-H if anyone in particular is a target for Resident #1. RN-H indicated Resident #2 has repetitive behaviors and speaks differently and likes to shut doors, which is bothersome to Resident #1. RN-H further expressed Resident #1 pokes fun of Resident #2 and staff have reported the teasing behavior to her with one staff telling her Resident #2 should not have to put up with Resident #1's behavior. On 02/12/13 at 9:40 a.m., Surveyor # interviewed CNA-D. CNA-D stated Resident #1 mocks others, teases, makes inappropriate comments and is irritating to Resident #2 causing Resident #2 to get upset. CNA-D indicated Resident #1 will yell at staff and shake his fist at them when staff attempt redirection. CNA-D indicated he had reported the behavior to RN-H. CNA-D expressed the behavior has gotten worse since Resident #2 was moved next door to Resident #1, but incidents had occurred when both Resident #1 and Resident #2 lived on a different unit. On 02/12/13 at 9:50 a.m., Surveyor # interviewed RN-B. RN-B indicated she has worked at the facility 9 years and is familiar with Resident #1 and Resident #2. RN-B explained Resident #2 asks repetitive questions and Resident #1 will "egg him on" until Resident #2 becomes upset and starts yelling "shut up." RN-B stated this occurs a couple times a day. RN-B expressed a room change has been brought up to management so Resident #2 does not have to pass Resident #1's room. On 02/12/13 at 11:10 a.m., Surveyor # spoke with SW-E (Social Worker) regarding Resident #1. SW-E explained she is aware of Resident #1's history of negative comments to others. SW-E expressed the only resident-to-resident altercation she was aware of was the self reported incident occurring in January that was faxed to the state. SW-E stated she was unaware of any specific resident being targeted by Resident #1, was not aware of Resident #1's verbal altercations, and was unaware of Resident #1 entering Resident #2's room via the bathroom or room door to make negative comments. SW-E expressed this was the first she was learning of a problem with Residents #1 and #2 and a room change is in the process. On 02/12/13 at 11:30 a.m., Surveyor # interviewed Resident #4, the Resident Council President. Resident #4 resides on the same unit as Residents #1 and #2. Surveyor # asked Resident #4 if there were any problems with residents on the unit. Resident #4 explained Resident #1 and another male resident tease and laugh at Resident #2, saying things that make Resident #2 start yelling "shut up." Resident #4 indicated this teasing occurred when she, Resident #1, and Resident #2 lived on another unit in the facility. Resident #4 stated Resident #1 says things that are very upsetting to Resident #2. Resident #4 indicated Resident #1 will sometimes fly off the handle if staff say anything. Resident #4 indicated she once heard Resident #1 say, "I will throw you into next week if you don't shut your mouth." Resident #4 further indicated staff are afraid of Resident #1 as he has grabbed them in the past around the neck. Resident #4 stated, "He (Resident #1) is loud, strong and you should be scared of him." On 02/12/13 at 12:05 p.m., Surveyor # observed Resident #1 and Resident # 5 conversing at the dining room table for lunch. Resident #5 told Resident #1 that Resident #2 is no longer in his room. Resident #1 asked where Resident #2 went. Resident #5 told Resident #1 he had moved to another unit. Resident #1 stated, "I am going to look him up...it shouldn't be too hard to find him." On 02/12/13 at 3:00 p.m., Surveyor # interviewed Staff-F (Anonymous). Staff-F indicated she had worked at the facility for several years and was familiar with Residents #1 and #2. Staff-F indicated she had worked with both residents on their previous living unit. Staff-F indicated Resident #1 would tease Resident #2 and grab the back of his wheelchair causing Resident #2 to get upset. Staff-F indicated the behavior occurs on a daily basis and has been occurring since she can remember. Staff-F stated it was not a good idea to move the residents next door to each other as Resident #2 is unable to protect himself from Resident #1. On 02/12/13 at 3:30 p.m., Surveyor # interviewed Staff-G (Anonymous). Staff-G indicated she had worked at the facility for over a year and was familiar with Residents #1 and #2. Staff-G indicated the relationship between Resident #1 and Resident #2 was "not good." Staff-G stated Resident #1 would get upset with staff if they attempted to redirect him. Staff-G expressed Resident #2 would get upset which only caused Resident #1 to do it more. Staff-G indicated she did not report it as she thought everyone knew it was a problem. On 02/13/13 at 8:30 a.m., Surveyor # spoke with the DON (Director of Nursing). Surveyor # asked the DON when and why Resident #1 was moved from his previous living unit to his current room. The DON expressed the facility was developing a dementia care wing and Resident #1 would not benefit from the programing on the unit and did not like other residents wandering in and out of his room. The DON indicated Resident #1 moved to his current room on 11/14/12. On 02/13/13/ at 9:00 a.m., an interview was conducted with Resident #2's spouse and legal representative. Resident #2's spouse indicated she is not able to visit frequently and visits every few months. Resident #2's spouse explained she was not aware of any concerns at the facility until called on 02/12/13. She further explained the facility had told her a couple of gentlemen residents were picking on Resident #2 and the facility would like to make a room change to another unit in the facility. Resident #2's spouse was in agreement to the move. Surveyor # asked Resident #2's spouse if Resident #2 could tell someone if he was having a problem. Resident #2 spouse responded he could not and it would be more beneficial to talk with staff. On 02/13/13 at 9:30 a.m., Surveyor # interviewed Resident #3, Resident #2's roommate. Resident #3 indicated Resident #1 comes into their room through the shared bathroom or the hall door with a look on his face and in his eyes that he "has never seen before." Resident #3 stated Resident #1 teases, antagonizes and threatens Resident #2. Resident #3 indicated Resident #1 had told him (Resident #3) he would kill him and throw him out the window when he was sticking up for Resident #1. Resident #3 explained that Resident #2 would sometimes cry or get angry and yell "shut up" in response to Resident #1's teasing. The roommate indicated Resident #1's intimidation is "uncalled for." The failure to protect Resident #2 from abuse created a finding of immediate jeopardy, which began on 12/6/12. The jeopardy was removed on 2/12/13 when Resident #2 was moved to a different unit in the facility away from Resident #1.

Based on observations, interviews and record reviews, the facility did not operationalize their policies and procedures related to protection from and prevention of instances of verbal, mental, and physical abuse for 1 of 2 sampled residents reviewed, thus allowing resident-to-resident abuse to continue over a period of months. Resident #1 has a documented history of angry outbursts, including verbal and physical altercations with residents and staff. Resident #1 has targeted Resident #2, who resides next door to Resident #1 with a shared bathroom. Resident #1 reportedly taunts, teases, antagonizes and intimidates Resident #2 repeatedly as often as daily. Resident #2 reportedly responds by crying, getting upset and yelling "shut up" in response to the teasing from Resident #1. Resident #1 reportedly has threatened other residents including Resident #2's roommate, stating he would kill them and throw them out a window. Resident #1's outbursts continued to escalate. Staff interviews found the ongoing taunting and teasing was reported to management staff. Despite Resident #1's ongoing abuse of Resident #2, the facility took few proactive measures to prevent the abuse from continuing. On 1/20/13, Resident #1 was observed to walk quickly to the area where Resident #2 was seated. Resident #1 struck Resident #2 and began pulling his wheelchair and made "negative verbalizations" to staff. The facility did not operationalize their policies and procedures to protect Resident #2 and others from abuse. The facility did not develop specific resident care plans with proactive measures for preventing abuse and did not take corrective action to prevent reoccurrence, as directed in their policies and procedures. This resulted in a finding of immediate jeopardy, which began on 12/06/12, when Resident #2 was moved next door to Resident #1 with a shared bathroom despite the facility having knowledge of the verbal abuse prior to the move. The Nursing Home Administrator, Director of Nursing and the Regional Director were notified of the immediate jeopardy on 02/13/13 at approximately 11:00 a.m. The immediate jeopardy was removed on 02/13/13, when the facility moved Resident #2 to a different room on a different unit, but noncompliance continues at the lower scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated), as the facility has yet to fully implement and monitor the effectiveness of its actions. This is evidenced by: The facility policies titled "Abuse" and "Abuse Prevention" were received and reviewed by Surveyor # with the following noted: ~Monitoring residents...to identify inappropriate behaviors... ~The assessment, care planning and monitoring of residents with needs and behaviors that might lead to conflict or neglect. ~Identify resident most at risk of neglect and abuse. ~Develop specific resident care plans and or care cards that identify resident care needs such as aggressive behaviors... ~Reasonably monitor staff, residents and visitors interaction for inappropriate behaviors. ~Identify concerns/problems and take corrective action to assist in preventing re-occurrence. Review of the records of Resident #1 and Resident #2 and interviews with staff, revealed that they have resided next door to each other with an adjoining bathroom since 12/06/12. Resident #1: Resident #1 was admitted to the facility on [DATE]. Resident #1 is [AGE] years old and walks independently. Resident #1 has [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set assessment ((MDS) dated [DATE], indicated: ~Clear Speech, makes self understood; ~Usually understands others; ~BIMS (Brief Interview for Mental Status) score of 7 out of 15 indicating severe cognitively impaired; and ~Independent in bed mobility, transfer, walking in room, corridor, and locomotion on and off unit. Resident #1's current care plan dated 11/14/12, includes a problem of coping impaired potential/actual, related to...history of alcohol dependence, unprovoked behaviors in dementia posing a danger to self and others, history of verbal altercations with others, history of becoming upset if negative comments are made to him, gets upset with others entering his room without permission, gets agitated at times without pre-warning signs, will become agitated without known triggers. Approaches are as follows: ~10/26/10: Power of Attorney activated related to help with decisions, 1:1 support and ventilation of feelings, pastoral visits as needed, explore strengths and identify positives in life as approximate, assist with maintaining contact with family and friends, enjoys joking with staff, if upset prefers to be left alone and 1:1 visits with family and friends, wife is at facility and enjoys speaking with each other frequently, becomes upset at times due to memory loss and placement, provide support. ~08/31/12: If becomes upset make sure he and others are safe, allow to walk to room himself and shut door to calm down, does need time to himself to get over things, does not do well with many staff approaching him. The care plan did not identify specific approaches for protecting Resident #2 from Resident #1's repeated taunts and teasing, which sometimes occurred when Resident #1 entered Resident #2's room through the adjoining bathroom and without staff knowledge. Further, the CNA (Certified Nursing Assistant) care card contained no information related to Resident #1's behaviors or interventions for staff. Surveyor # reviewed Resident #1's behavior monitoring flow sheets from 04/12 through 02/13, which revealed the following: ~Yelling at peers and staff: 113 episodes; ~Agitation and aggression: 96 episodes; and ~Negative verbalizations: 91 episodes. Surveyor # reviewed Resident #1's nursing notes which revealed the following: ~06/05/12, 2:30 p.m., was reported by staff that another resident walked by his room causing him to become agitated and was screaming and cursing...when CNA tried to intervene, he swung at her, when another CNA attempted to assist he punched her. ~06/13/12, 3:00 p.m., another resident went into room...became upset and kicked resident in the buttock and slammed door... There was no evidence that the facility operationalized their policy and procedure to protect residents following this physical altercation. ~06/15/12, 10:10 p.m., upset with other resident cursing and yelling...Resident #1 continued to yell and holler and ran down hall, writer tried to redirect...grabbed writer's left side of neck...Resident struck CNA, shoved CNA, yelling would kill them all, threat to staff and female resident, besides pushing, shoving, choking, did spit in writer's face. ~08/13/12, 5:15 p.m., patient exited room in hurried manner headed to male peer, trying to grab peer's arm, grabbing shirt before staff was able to intervene..,'Get that son of a [***] away from me before I bang his f***ing head into the wall'...event was unprovoked, peer was sitting in hall waiting for supper cart. There was no evidence that the facility operationalized their policy and procedure to protect residents following this physical altercation. ~8/14/12, 1:20 p.m., slightly agitated this a.m. (morning) shaking fist at people... ~9/07/12, (Social Service note) does have a history of verbal altercations, becoming upset easily and becoming verbally and physically aggressive... ~9/07/12, 10:50 p.m., potentially negative interaction with another resident when the other resident attempted to enter his room... ~11/13/12, 10:50 p.m., physical contact with agitation toward peers and verbal altercation with staff noted this shift... There was no evidence that the facility operationalized their policy and procedure to protect residents following this physical altercation until 11/16/12. Notes by the Behavior Team indicate: "Agitation (pt. to pt.) trigger: residents walking into his room." Intervention #1: "Room change to less confused less wandering hall." Intervention #2: "Once agitated, bring to low stimulus room (i.e. his room) leave alone and allow time to calm." Intervention #3: "Call spouse to assist to calm if able." Progress notes continue: ~12/10/12, 7:00 p.m., going out of his way to make fun of another resident at supper. He would loudly ask the resident if he spilled enough juice and tell everyone to look at the other resident drool... ~12/11/12, volunteered (that) another resident was yelling because he (Resident #1) was teasing him (peer) and that probably wasn't very nice... On 12/11/12, Resident #1's care plan was updated with an approach of: when teasing peers redirect and remind teasing is not appropriate, encourage alternate ways to engage with peers. ~1/20/13, 5:30 a.m., writer observed Resident #1 walking rapidly toward rotunda; when he reached the end, struck Resident #2 in left arm, pulled wheelchair and made negative verbalizations, made negative verbalizations to staff, advanced toward CNA and returned to room... Resident #1 was placed on 1-to-1 supervision immediately following the incident. According to the Resident Monitoring Tool, supervision was changed to 15-minute checks beginning at 6:00 a.m. ~1/20/13, 11:00 a.m., Pt (Patient) did have negative verbalizations toward other resident at end of breakfast on way back to his room. Surveyor # reviewed Resident #1's notes to attending physician and noted the following: ~1/21/13, has been increasingly agitated toward other residents and has become involved in resident-to-resident altercations... On 2/13/13, SW-E provided Surveyor # with the Behavior Team notes. Included was documentation that the team had reviewed Resident #1 on 1/25/13. Identified behavior: "Aggression toward others." Intervention #1: "Once agitation noted, separate him from the perceived agitating stimuli and bring to low stimuli room." Intervention #2: "Attempt aromatherapy with [MEDICATION NAME] for calming." Intervention #3: "Med review/pharmacy consult." On 01/25/13, Resident #1's care plan was updated to include: when agitated attempt to remove him from perceived agitating stimuli. (Interviews and observations found that redirection is often times ineffective.) Despite documentation of aggression, the facility made no other changes to Resident #1's care plan in order to prevent further verbal and physical abuse. On 02/13/13 at 8:00 a.m., Surveyor # interviewed Resident #1 regarding the resident who recently moved from next door (Resident #2). Resident #1 was able to identify Resident #2 by name. Resident #1 indicated Resident #2's mind does not work like others. Resident #1 explained Resident #2 moved from the room but he was not sure why. Resident #1 indicated he and another resident liked to tease Resident #2. Surveyor # asked Resident #1 how Resident #2 reacted to the teasing. Resident #1 responded Resident #2 would sometimes get mad and tell him to "shut up." Resident #2: Resident #2 was admitted to the facility on [DATE]. Resident #2 is [AGE] years old and is protectively placed with guardianship. Resident #2 has [DIAGNOSES REDACTED]. Resident #2 requires extensive assistance from staff for bed mobility and transfers. Resident #2 is able to self propel his wheelchair and uses the handrails for wheelchair mobility. Resident #2 resided in the room next to Resident #1. Resident #2 had to pass Resident #1's room whenever he would leave or come back to his room. Resident #2's most recent Minimum Data Set assessment ((MDS) dated [DATE], indicated the following: ~Moderate cognitive impairments with disorganized thinking and inattention ~Usually understood; ~Usually understands others; ~ Requires extensive staff assistance for bed mobility and transfer; ~Does not ambulate; and ~Mobility service wheelchair. Review of Resident #2 nurse's notes indicate the following: ~01/20/13, 7:00 a.m., was closing resident doors at 3:00 a.m. and headed to fireside to check breakfast menu. Another resident was upset about having his door closed and followed him, struck his left arm, pulled on his wheelchair, making negative verbalizations...Assessment showed slightly reddened deltoid indicated biceps was struck, no redness there... On 2/12/13 at 9:00 a.m., Surveyor # interviewed CNA-A. CNA-A indicated she has worked at the facility for 2 1/2 years and worked with Resident #1 and Resident #2 on the current unit as well as on their previous unit. CNA-A indicated both residents had recently moved. CNA-A explained Resident #1 is like night and day, sometimes pleasant and sometimes rude. CNA-A stated, "Sometimes, there is no turning from being mean." CNA-A indicated Resident #1 sticks his head into Resident #2's room every day and says something inappropriate or mean to Resident #2. CNA-A described one incident where Resident #1 entered Resident #2's room through the adjoining bathroom at 5:30 a.m. CNA-A stated Resident #1 made a lewd comment to Resident #2 which upset Resident #2. CNA-A indicated Resident #2 gets upset and yells which wakes his roommate. CNA-A stated she has reported the teasing and suggested a room change to the unit's clinical manager RN-H. CNA-A stated Resident #1 will push other residents' wheelchairs, chase after residents and staff, causing staff to sometimes having to hide from him. CNA-A indicated sometimes another male resident (Resident #5) will join Resident #1 in teasing Resident #2. CNA-A stated, "They have done so much to Resident #2." CNA-A indicated Resident #2's roommate (Resident #3) and the resident council president (Resident #4) are aware of the incidents. On 02/12/13 at 9:10 a.m. Surveyor # interviewed CNA-C. CNA-C indicated she has worked at the facility for over a year and is familiar with Resident #1 and Resident #2. CNA-C described Resident #1 as intimidating, and stated Resident #1 and Resident #5 pick on Resident #2, and get defensive when staff attempt to intervene and stop them. CNA-C described an incident where Resident #1 became upset with her while she tried to redirect him. Resident #1 threatened CNA-C saying, "Shut your mouth or I will shut it for you." CNA-C stated she hid behind the meal cart out of fear of Resident #1. CNA-C stated Resident #1 is aggressive and confrontational toward other residents and makes fun of Resident #2 almost every day causing Resident #2 to get upset. CNA-C indicated she has reported the behavior and the need for a room change to the unit nurses. On 02/12/13 at 9:20 a.m. Surveyor # interviewed RN-H, the Clinical Manager of the unit where Resident #1 and Resident #2 reside. RN-H indicated Resident #1 gets upsets easily with change in routine, he can be loud, and is redirected to his room to calm down. Surveyor # asked RN-H if anyone in particular is a target for Resident #1. RN-H indicated Resident #2 has repetitive behaviors and speaks differently and likes to shut doors which is bothersome to Resident #1. RN-H further expressed Resident #1 pokes fun of Resident #2 and staff have reported the teasing behavior to her with one staff telling her Resident #2 should not have to put up with Resident #1's behavior. On 02/12/13 at 9:40 a.m., Surveyor # interviewed CNA-D. CNA-D stated Resident #1 mocks others, teases, makes inappropriate comments and is irritating to Resident #2 causing Resident #2 to get upset. CNA-D indicated Resident #1 will yell at staff and shake his fist at them when staff attempt redirection. CNA-D indicated he had reported the behavior to RN-H. CNA-D expressed the behavior has gotten worse since Resident #2 was moved next door to Resident #1, but incidents had occurred when both Resident #1 and Resident #2 lived on a different unit. On 02/12/13 at 9:50 a.m., Surveyor # interviewed RN-B. RN-B indicated she has worked at the facility 9 years and is familiar with Resident #1 and Resident #2. RN-B explained Resident #2 asks repetitive questions and Resident #1 will "egg him on" until Resident #2 becomes upset and starts yelling "shut up." RN-B stated this occurs a couple times a day. RN-B expressed a room change has been brought up to management so Resident #2 does not have to pass Resident #1's room. On 02/12/13 at 11:10 a.m., Surveyor # spoke with SW-E (Social Worker) regarding Resident #1. SW-E explained she is aware of Resident #1's history of negative comments to others. SW-E expressed the only resident-to-resident altercation she was aware of was the self reported incident occurring in January that was faxed to the state. SW-E stated she was unaware of any specific resident being targeted by Resident #1, was not aware of Resident #1's verbal altercations, and was unaware of Resident #1 entering Resident #2's room via the bathroom or room door to make negative comments. SW-E expressed this was the first she was learning of a problem with Residents #1 and #2 and a room change is in the process. On 02/12/13 at 11:30 a.m., Surveyor # interviewed Resident #4, the Resident Council President. Resident #4 resides on the same unit as Residents #1 and #2. Surveyor # asked Resident #4 if there were any problems with residents on the unit. Resident #4 explained Resident #1 and another male resident tease and laugh at Resident #2, saying things that make Resident #2 start yelling "shut up." Resident #4 indicated this teasing occurred when she, Resident #1, and Resident #2 lived on another unit in the facility. Resident #4 stated Resident #1 says things that are very upsetting to Resident #2. Resident #4 indicated Resident #1 will sometimes fly off the handle if staff say anything. Resident #4 indicated she once heard Resident #1 say, "I will throw you into next week if you don't shut your mouth." Resident #4 further indicated staff are afraid of Resident #1 as he has grabbed them in the past around the neck. Resident #4 stated, "He (Resident #1) is loud, strong and you should be scared of him." On 02/12/13 at 12:05 p.m., Surveyor # observed Resident #1 and Resident # 5 conversing at the dining room table for lunch. Resident #5 told Resident #1 that Resident #2 is no longer in his room. Resident #1 asked where Resident #2 went. Resident #5 told Resident #1 he had moved to another unit. Resident #1 stated, "I am going to look him up...it shouldn't be too hard to find him." On 02/12/13 at 3:00 p.m., Surveyor # interviewed Staff-F (Anonymous). Staff-F indicated she had worked at the facility for several years and was familiar with Residents #1 and #2. Staff-F indicated she had worked with both residents on their previous living unit. Staff-F indicated Resident #1 would tease Resident #2 and grab the back of his wheelchair causing Resident #2 to get upset. Staff-F indicated the behavior occurs on a daily basis and has been occurring since she can remember. Staff-F stated it was not a good idea to move the residents next door to each other as Resident #2 is unable to protect himself from Resident #1. On 02/12/13 at 3:30 p.m., Surveyor # interviewed Staff-G (Anonymous). Staff-G indicated she had worked at the facility for over a year and was familiar with Residents #1 and #2. Staff-G indicated the relationship between Resident #1 and Resident #2 was "not good." Staff-G stated Resident #1 would get upset with staff if they attempted to redirect him. Staff-G expressed Resident #2 would get upset which only caused Resident #1 to do it more. Staff-G indicated she did not report it as she thought everyone knew it was a problem. On 02/13/13 at 8:30 a.m., Surveyor # spoke with the DON (Director of Nursing). Surveyor # asked the DON when and why Resident #1 was moved from his previous living unit to his current room. The DON expressed the facility was developing a dementia care wing and Resident #1 would not benefit from the programing on the unit and did not like other residents wandering in and out of his room. The DON indicated Resident #1 moved to his current room on 11/14/12. On 02/13/13/ at 9:00 a.m., an interview was conducted with Resident #2's spouse and legal representative. Resident #2's spouse indicated she is not able to visit frequently and visits every few months. Resident #2's spouse explained she was not aware of any concerns at the facility until called on 02/12/13. She further explained the facility had told her a couple of gentlemen residents were picking on Resident #2 and the facility would like to make a room change to another unit in the facility. Resident #2 spouse was in agreement to the move. Surveyor # asked Resident #2's spouse if Resident #2 could tell someone if he was having a problem. Resident #2 spouse responded he could not and it would be more beneficial to talk with staff. On 02/13/13 at 9:30 a.m., Surveyor # interviewed Resident #3, Resident #2's roommate. Resident #3 indicated Resident #1 comes into their room through the shared bathroom or the hall door with a look on his face and in his eyes that he "has never seen before." Resident #3 stated Resident #1 teases, antagonizes and threatens Resident #2. Resident #3 indicated Resident #1 had told him (Resident #3) he would kill him and throw him out the window when he was sticking up for Resident #1. Resident #3 explained that Resident #2 would sometimes cry or get angry and yell "shut up" in response to Resident #1's teasing. The roommate indicated Resident #1's intimidation is "uncalled for." The failure to implement policies and procedures for preventing abuse created a finding of immediate jeopardy, as abuse was allowed to continue. The immediate jeopardy began on 12/6/12 and was removed on 2/13/13 when: ~The facility placed Resident #1 on one-to-one supervision to prevent further occurrences; ~Reviewed other residents to determine if they display behaviors affecting others; ~Re-educated all staff on abuse identification, protection, and prevention; ~Staff not available on 2/13/13 will not be allowed to work until training has been received; ~Developed a Performance Improvement audit tool related-to-resident to resident altercations to be completed with every altercation.