Every finding on record at Aria of Waukesha

Based on interview and record review, the facility did not ensure residents were free from sexual abuse for 1 (R1) of 1 residents reviewed for abuse.On 7/21/26, staff reported seeing R2 touching R1's breasts and thigh. R1 was screaming for R2 to stop. The staff who observed it did not report the incident until the next day. There were no interventions put into place to protect R1 from additional sexual contact. During investigation into the first incident, the facility learned of a second incident where R2 was observed touching R1's breasts and thighs. The exact date of this incident was unknown. The incident was not immediately reported to facility administration. No interventions were put into place to protect R1 from additional sexual contact.The facility's failure to protect R1 from unwanted sexual touching created a finding of immediate jeopardy that began on 7/20/26. Surveyor notified NHA-A (Nursing Home Administrator) and DON-B (Director of Nursing) of the immediate jeopardy on 8/6/26 at 2:33 PM. The immediate jeopardy was removed on 8/7/26 when the facility implemented a removal plan. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan.Findings include:R2 was admitted to the facility on [DATE].R2's Quarterly MDS (Minimum Data Set) assessment dated [DATE] documents R2 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. R2 does not display physical or verbal behaviors toward self or others.The facility reported incident, dated 7/28/26 states the incident was discovered on 7/21/26, however the exact date and time of the incident is unknown. On 7/21/26, staff notified NHA-A and DON-B that R1 was uncomfortable because R2 put their hand on R1's breast and leg over R1's clothes. Police were notified. On 8/5/26 at 3:11 PM, Surveyor asked NHA-A and DON-B when the incident documented in the report and investigation happened. DON-B stated CNA-I informed DON-B and NHA-A shortly after shift started on 7/21/26. DON-B stated that they were told around 4:30 PM and started an investigation right away.On 8/6/26 at 10:45 AM, Surveyor asked why the date and time was not included in the report or investigation. DON-B indicated that they documented in the summary that it was reported on 7/21/26 and that is when they were told that it happened.The facility reported incident included a questionnaire from LPN-C dated 7/23/26. Under the question, Have you ever witnessed a resident touch another resident inappropriately (in an inappropriate location on the resident's body/or in a way that makes the resident uncomfortable)? If so, who? LPN-C documented, Yes. Reported to DON-B. Follow up with DON-B witnessed R2 and R1 touching but R1 denied being uncomfortable or having issue. Surveyor noted that LPN-C did not give a full statement on the questionnaire as to what LPN-C observed or when this touching happened.On 8/5/26 at 11:20 AM and 1:18 PM, Surveyor interviewed LPN-C. LPN-C informed Surveyor that one day, when LPN-C came around the corner from the contingency medication room, LPN-C saw R1 and R2 alone together in the common area. LPN-C observed R2 grabbing at R1's breasts. LPN-C stated that it looked like R1 and R2 were being playful and joking around. LPN-C stated they observed this interaction and saw R2 poking and touching R1's legs. LPN-C stated that after seeing the interaction, LPN-C felt like they needed to check on R1. R2 wheeled away to their unit. LPN-C went up to R1. LPN-C asked R1 if they were ok. R1 stated that R2 was just grabbing at R1's knee. LPN-C asked R1 if they felt safe and R1 replied yes. Surveyor asked LPN-C if this was reported to anyone. LPN-C stated that they did not report it for a couple of days.LPN-C indicated that there was an investigation into this other incident involving R2 touching R1 and that is when LPN-C reported it to DON-B and NHA-A. Surveyor requested any documentation or investigation on R2 grabbing R1's knee, but none was provided. Surveyor noted that the facility did not investigate this incident as reported by LPN-C.The facility reported incident included R1's initial interview dated 7/21/26. R1 stated, [R2 tried] to grab my breasts. I was sitting in the hallway across from the desk outside of [R4's] room. [R2] was coming down the hallway in [their] wheelchair, and I thought [R2] was just going to stop and say hello. [R2] stopped right in front of me, and [R2] reached out and tried to touch my breast. I told [R2] to stop and swatted [their] hands away. After I told him to stop, [R2] didn't do it again.On 8/6/26 at 10:45 AM, Surveyor interviewed DON-B and NHA-A. DON-B stated that during R1's first interview, R1 stated that R2 did not touch R1. After that interview, DON-B and NHA-A continued the investigation and had some follow-up questions for R1. DON-B and NHA-A went to the common dining room where R1 and R4 were sitting. DON-B stated that R1 told DON-B that they needed to talk to R4 because R2 stopped when R4 came out of their room and told them to stop.The facility reported incident documents: R1's second interview dated 7/21/26 documents, [R4] reminded me that when R2 tried to touch my breast, I was swatting [their] hand away and telling [them] to stop and [R2] didn't stop trying to touch me when I asked [them] to. [R4] was in [their] room and [they] heard me telling [R2] to stop. So, [R4] came out of [their] room and [R4] told [R2] to stop. When [R4] told [them] to stop, [R2] did.R4's interview dated 7/21/26 documents: I was in my room and heard [R1] say stop. So, I came out of my room and I saw [R2] sitting in front of [R1's] chair. [R1] was saying don't touch me. I told [R2] not to touch [R1] because [R2] is violating [R1's] personal space. [R2] then stopped doing it. I think [R2] thought it was a joke. Did you see [R2] touch [R1]? [R4 stated], Yes. on [R1's] breast. [R2] reached and taped it. It wasn't a hit or a squeeze.On 8/5/26 at 11:00 AM, Surveyor interviewed R4. Surveyor asked R4 if they witnessed any incident between R1 and R2. R4 stated they saw R2 touch R1's breast with the hand. R4 demonstrated R2 had an open hand and gently tapped R1's breast. R4 stated R2 stopped when R4 told R2 to stop. R4 stated the police were called and talked to R1 and R2. R4 stated R2 had never done that before and R4 and R1 have not seen R2 since that happened.The facility reported incident included R2's interview dated 7/21/26 which states: It was reported that when you were sitting with a female resident, you touched the resident, do you know what we are referring to? [R2 stated] Well, [R4, R1] and I play around a lot, and they touch me too. Where on the body are you referring to? [R2 stated] We all kind of tap or touch each other on the side or arms as a joke. They both do that to me, and I do it to them. We always laugh about it. We all like to joke around. Have you ever tried to touch [the] breast? [R2 stated], It's never been a sexual thing; we all do it. We are all good friends. We play around.On 8/6/26 at 10:45 AM, Surveyor interviewed DON-B and NHA-A. Surveyor asked DON-B if R2 was asked directly if they had touched R1's breast. DON-B stated yes, but R2 would not answer the direct question. DON-B stated that R2 would just say that it (the touching) is not sexual.On 8/5/26 at 10:30 AM, Surveyor asked R2 about the incident with R1 a couple of weeks ago. R2 stated they spent a lot of time with R1 and R4, but they accused R2 of touching R1 inappropriately, which R2 stated R2 did not do. R2 stated R1 and R4 ganged up on R2 and now R2 avoids them by staying mostly in R2's room and keeping to themselves. R2 stated this happened a few weeks ago. R2 stated R1 and R4 were mad at R2 because R2 did not buy Chinese food for them anymore.The facility reported incident indicates the police were called and came to the facility on 7/21/26. DON-B and NHA-A returned to R1 the morning after the police were called and collected a third interview.R1's third interview dated 7/22/26 documents: How many different occasions did [R2] attempt to touch your breasts? [R1 stated], Just the one time that it happened. There were no other times [R2] touched you or tried to touch you on your breasts, or your thighs, or between your legs, or anywhere else that might make you feel uncomfortable? No. [R4, R2] and I are all friends and we play around sometimes. So, sometimes we will poke at each other, or lightly push on each other's arms as a joke but we never touch each other anywhere inappropriately, so I don't know why [R2] suddenly tried to do that. Can you show us with your own hand what [R2] did when [R2] was trying to touch you? [R1] used [their] own hand and placed it on top of [R1's] left breast. [R1 stated], I had my hands crossed in front of me blocking my chest when I realized what [R2] was doing. But I uncrossed my arms to use my hand to swat [R2's] hand away and when I did that, [R2] touched my breast. When [R2] was doing that, I told him to stop and [R2] said, Shut up, shut up. I swatted [R2's] hand away and [R4] told [R2] to stop, [R2] stopped and then [R2] wheeled [themselves] away down the hallway towards the other unit.On 8/6/26 at 10:45 AM, Surveyor interviewed DON-B and NHA-A. DON-B indicated that R1's interviews evolved over time. DON-B stated that R1 does have a history of changing the story but not intentionally. DON-B stated that R4 can steer R1 as well. Surveyor asked if R1 has dementia. DON-B stated yes. Surveyor asked if R1 is forgetful. DON-B stated that R1 is forgetful at times.The facility reported incident included an interview with CNA-I on 7/21/26 which stated: I was on East Unit, and I walked around the corner and saw [R1] sitting in [their] wheelchair across from the nursing station with the back of [the] wheelchair against the wall. [R2] reached to grab [R1's] breast, and I heard [R1] tell [R2] to stop. [R2] wheeled [themselves] away and I took [R1] outside with me. [R1], [R4] and [R2] usually sit together and play around but I have never seen [R2] do anything like that before. Did you see [R2] try to touch [R1] anywhere else? No and [R1] said it was just [the] breast. Was there anyone else around when this happened? No.On 8/5/26 at 12:55 PM, Surveyor interviewed CNA-I. CNA-I stated they heard R1 screaming at the nurse's station. CNA-I went over to the area and saw R2 trying to grab R1's chest and was grabbing R1's thighs. CNA-I separated them and took R1 outside. CNA-I saw R2 touch R1's thighs but not R1's breast. CNA-I stated that they had never seen R2 be like that before. Surveyor asked if any other staff were in the area when this occurred. CNA-I stated that they were not sure. CNA-I stated that later that same evening, R1 told CNA-I that they did not like it and was uncomfortable with what R2 was doing. CNA-I stated that they did not report this right away because they did not know what to do. CNA-I stated that the next day, CNA-I went to DON-B and NHA-A and told them what happened. Later that night, the police came and CNA-I gave a statement to the police. Surveyor asked if the incident occurred on Monday 7/20/26 or Tuesday 7/21/26. CNA-I indicated that R2 touched R1 on Monday 7/20/26 and CNA-I reported it to DON-B, NHA-A and talked to the police on 7/21/26.On 8/6/26 at 10:45 AM, Surveyor interviewed DON-B and NHA-A. DON-B indicated that nothing in the investigation came out that the incident happened on 7/20/26 and not 7/21/26. DON-B stated that staff had recently received abuse training that included when to report allegations of abuse and did not know why CNA-I indicated not knowing what to do. DON-B stated that they did not know why CNA-I stated that they did not know what to do because they had just gotten education.On 8/5/26 at 11:10 AM, Surveyor interviewed R1. R1 informed Surveyor that during the evening a few weeks ago, R1 was sitting in the common area near the nurse's station. R2 rolled up to R1 and was trying to touch R1's breasts. R1 stated that they kept telling R2 to go and telling R2 to stop. R1 stated that R2 kept trying multiple times and would not stop. R1 crossed their arms and tried to cover their breasts. R1 used their arms to swat at R2's hands. R1 stated that R2 touched R1 on their breast. Surveyor asked if R1 could demonstrate how R2 touched them. R1 took their open hand and placed it on R1's right breast. R1 stated that this was witnessed by CNA-I and R4. R1 indicated that R2 stopped after R4 and CNA-I intervened and told R2 to stop. Surveyor asked how R1 felt. R1 stated, I felt violated. R1 stated that they told R2 that they did not like what was happening and told R2 to stop but R2 wouldn't stop. R1 stated that they felt like R2 thought it was a joke. Surveyor asked if R2 had done anything like this in the past. R1 stated they never had concerns like this in the past and that is why they were so shocked that it happened. R1 stated that they have not had any interaction with R2 since this happened.The facility reported incident included a summary stated: Although [R2] states it was not [their] intention to cause [R1] to feel uncomfortable and that [R2] did identify [their] actions caused [R1] to be uncomfortable as [R2] believed [their] actions were a continuation of a running joke between the two, the facility's investigation identified [R1] did not consent to physical contact in that manner. The facility believes that what was described by [R2], [R1] and [R4] as a friendship that involved playing around with each other, evolved and [R1's] boundaries were crossed.On 8/5/26 at 12:48 PM, Surveyor interviewed CNA-H and asked if they had any knowledge of what happened between R1 and R2. CNA-H stated they were working on 7/20/26 and 7/21/26. Surveyor asked if CNA-H saw anything that happened on the night R2 touched R1. CNA-H stated that they could not remember the exact time but knew it was after dinner. CNA-H was charting at the nurse's station. R2 wheeled past and stopped to talk to R1. CNA-H heard R2 and R1 bantering back and forth like they have done in the past. Surveyor asked what bantering meant. CNA-H stated that they would tease and poke fun at each other. CNA-H stated that next they heard R1 telling R2 to stop. CNA-H stood up and saw R2 poking R1's thighs and chest. Another CNA came and took R1 outside.On 8/6/26 at 1:21 PM, Surveyor again spoke with DON-B. DON-B stated CNA-H filled out a staff questionnaire as part of the facility's investigation and answered No to the question of whether they had witnessed a resident touch another resident inappropriately. That is why DON-B and NHA-A did not follow up with CNA-I for further comment or statement.Surveyor reviewed R1's comprehensive care plan and noted that facility staff did not enter resident-centered interventions regarding R1 and R2's touching relationship until after 7/21/26 when the facility added the following to R1's plan of care: History of inappropriate/unwanted physical contact. Interventions: Discuss the resident's situation with the psychiatrist and IDT. Encourage coping skills such as: Deep breathing exercises and taking a break in a quiet area. Encourage participation with psych services and talk therapy. Explain procedures and activities beforehand. Respect requests for personal space. Use calm, supportive communication.Surveyor reviewed R1's electronic medical record and did not find evidence that R1's capacity to consent for sexual touching or relationships was assessed by facility staff after the 7/21/26 investigation began.On 8/6/26 at 10:45 AM, Surveyor interviewed DON-B and NHA-A. Surveyor asked if R1 had been assessed for their capacity to consent to a sexual relationship. DON-B indicated that they do those assessments on residents who are interested and/or residents that want a sexual relationship. At the completion of the assessment, care planning is documented. DON-B stated that R1 was not interested in completing the assessment because R1 did not want a sexual relationship. DON-B indicated that because R1 did not want a sexual relationship, R1 did not have an assessment or care plan completed.On 7/21/26 at 6:15 PM, R2 was placed on one-on-one supervision, which was in place until 7/22/26 at 10:00 AM. In an interview on 8/6/26 at 2:32 PM, DON-B stated R2 was on one-to-one observation overnight until they determined R2 was not a threat to any resident.R2's Behavior of Inappropriate Personal Boundaries Care Plan was initiated on 7/22/26.R1's History of Inappropriate/unwanted physical contact Care Plan was initiated on 7/23/26.Surveyor reviewed R2's Certified Nursing Assistants (CNAs) task section for behavior monitoring. Surveyor noted that R2 did not have any documented sexually inappropriate behaviors at any time while a resident at the facility.On 8/6/26 at 12:37 PM, Surveyor interviewed CNA-N. Surveyor asked if CNA-N had witnessed R1 and R2 interactions in the past. CNA-N stated that CNA-N never saw R2 touch R1 but stated that R2 was sexually inappropriate. CNA-N stated that R2 would make inappropriate and mean comments to R1. Surveyor asked what that meant. CNA-N stated that R2 would be mean and call R1 fat and ugly. CNA-N stated that R2 would be sexually vulgar and talk about sex. When that occurred, R1 would tell R2 to leave R1 alone and tell R2 to get away from R1.Surveyor asked what sexually inappropriate comments were made by R2 to R1. CNA-N stated that R2 talked about how [they'd] do [R1] in bed. Surveyor asked if R2 would direct comments like this to other residents or just to R1. CNA-N stated that it is just R2's personality. R2 thinks it's ok. CNA-N stated that they would redirect R2 when they heard anything like this occur. CNA-N stated that they would constantly have to redirect R2. CNA-N stated that they have a good rapport with R2 and R2 will listen to CNA-N.On 8/6/26 at 10:45 AM, Surveyor informed DON-B and NHA-A that facility staff had informed Surveyor that R2 had a history of making mean and sexually inappropriate comments to R1. DON-B stated that they had never heard R2 make mean or sexually inappropriate comments in the past.On 8/6/26 at 10:45 AM, Surveyor informed DON-B and NHA-A that facility staff had informed Surveyor that R2 had a history of making mean and sexually inappropriate comments to R1. DON-B stated that they had never heard R2 make mean or sexually inappropriate comments in the past.On 8/6/26 at 12:48 PM, Surveyor informed DON-B and NHA-A of the following concerns:1. Facility staff informed Surveyor that R2 had a history of making sexually inappropriate comments to R1.2. LPN-C observed R2 touch R1 inappropriately prior to the allegation of sexual abuse and did not report this until after the investigation into the alleged sexual abuse had already started.3. R1 did not have an assessment or care plan completed on their ability to consent to sexual touching after R2 was first seen touching R1.4. CNA-I and CNA-H worked on both 7/20/26 and 7/21/26. Both CNAs informed Surveyor that on 7/20/26, R2 touched R1. CNA-I saw R2 touch R1's thighs. CNA-H saw R2 poke R1's chest and thighs. CNA-I stated that R1 was screaming for R2 to stop. R1 told CNA-I later in the night that R1 did not like it and was uncomfortable. This was not reported to DON-B, NHA-A or the Police Department immediately. Facility staff did not implement measures to keep R1 safe from R2.5. The next day, on 7/21/26, CNA-I informed DON-B and NHA-A of the alleged sexual abuse and an investigation started. R1 informed DON-B and NHA-A that R2 touched their breast. R4 observed R2 touch R1's breast. R1 informed Surveyor that R2 touched R1's breast and R1 felt violated.DON-B and NHA-A both indicated that they were not aware that the incident happened on 7/20/26.The failure to immediately report an allegation of sexual abuse, failure to protect R1 from unwanted sexual abuse, created a finding of immediate jeopardy that began on 7/20/26. The immediate jeopardy was removed on 8/7/26 when the facility completed the following:Audit conducted to identify any current residents showing signs of desire for intimate expressions.Updated the Assessment for Consent for Physical/Sexual/Intimate expressions for all residents identified with interest of intimate expressions of any kind.Protecting Personal Boundaries agreement has been updated and will be utilized upon admission for all new admissions. Updated care plans to be person centered and specific related to each resident's desire for intimate expressions.Identify residents expressing desire for intimate expressions and ensure person centered care plans are in place with appropriate interventions and documentation of ability to consent to any physical contact.Update the Sexual Physical and Intimacy Expressions Policy to address screening for residents who show an interest in intimate expression.Education will be provided to all staff prior to the start of their next shift on facility policy for Sexual Physical and Intimacy Expressions including what to do when a change in relationship or behavior is identified.Education provided on Abuse, Neglect, and Misappropriation Policy to all staff.Education provided to licensed nursing staff on the Protecting Personal Boundaries agreement.24 hour boards to be reviewed daily by IDT during clinical meeting to identify any new resident behaviors related to intimate expressions or sexual contact.Education provided to all staff on personal relationships among residents and boundaries.Initiated education with all current residents on Respecting Personal Boundaries agreement.Identify residents who show an interest in intimate expressions to identify the resident's ability to consent to this type of contact.Audit to include completion of assessment and care plan updates to reflect resident's ability to consent.IDT will review daily in clinical meeting any new admissions or change in resident behavior to identify those expressing interest in intimate expressions to ensure assessments and care plans are updated.

Based on interview and record review, the facility did not ensure that all alleged violations involving sexual abuse were reported to the State Agency and Local Law Enforcement within the required reporting timeframe for 1 (R1) of 2 residents reviewed.Licensed Practical Nurse (LPN)-C, observed R2 touching R1's breasts and thighs. This was not reported to the Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A or Local Law Enforcement immediately. In a different instance, facility staff heard R1 screaming for R2 to stop. R2 was touching R1's breast and thighs again. This second instance of R2 touching R1 was not reported to DON-B, NHA-A, or Local Law Enforcement immediately. The day after the alleged incident, DON-B and NHA-A were made aware, and the incident was reported to the State Agency and police was contacted.Findings include:The undated facility policy titled, Abuse Prevention Program. Facility Procedures. Training Program and Staff Materials, documents, in part: This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. This will be done by: . orienting and training employees on how. to recognize and report occurrences of abuse. identifying occurrences and patterns of potential mistreatment. Immediately protecting residents involved in identified reports of possible abuse. During orientation of new employees, the facility will cover at least the following topics: . What constitutes abuse. Procedures for reporting incidents of abuse. Dementia management and resident abuse prevention. An employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement. Employees are required to report any incident, allegation or suspicion of potential abuse. they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the required regulatory agencies immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. The facility shall also contact local law enforcement authorities. in the following situations: . Sexual abuse of a resident by a staff member, another resident, or visitor.R1 was admitted to the facility on [DATE] with diagnoses that include dementia, Bipolar disease, Anxiety, and Depression.R1's Quarterly Minimum Data Set assessment dated [DATE] documents R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. R1 does not display physical or verbal behaviors toward self or others. R2 was admitted to the facility on [DATE] after bilateral below-the-knee amputations.R2's Quarterly MDS assessment dated [DATE] documents R2 is cognitively intact with a BIMS score of 13. R2 does not display physical or verbal behaviors toward self or others. Surveyor reviewed the facility map and noted that R1 and R2's rooms are located on the same floor but on different units.On 8/5/26 at 11:10 AM, Surveyor interviewed R1. R1 informed Surveyor that during the evening time a few weeks ago, R1 was sitting in the common area near the nurse's station. R2 rolled up to R1 and was trying to touch R1's breasts. R1 stated that they kept telling R2 to go and telling R2 to stop. R1 stated that R2 kept trying multiple times and would not stop. R1 crossed their arms and tried to cover their breast. R1 used their arms to swat at R2's hands. R1 stated that R2 touched R1 on their breast. Surveyor asked if R1 could demonstrate how R2 touched them. R1 took their open hand and placed it on R1's right breast. R1 stated that this was witnessed by Certified Nursing Assistant (CNA)-I and R4. R1 indicated that R2 stopped after R4 and CNA-I intervened and told R2 to stop. Surveyor asked how R1 felt. R1 stated, I felt violated. R1 stated that they told R2 that they did not like what was happening and told R2 to stop but R2 wouldn't. R1 stated that they felt like R2 thought it was a joke. Surveyor asked if R2 had done anything like this in the past. R1 stated they never had concerns like this in the past and that is why they were so shocked that it happened. R1 stated that they have not had any interaction with R2 since this happened.Surveyor reviewed the facility's self-reported incidents for the last 6 months and was provided with the investigation completed by NHA-A into this allegation of sexual abuse.The facility Self-Report included staff questionnaires.LPN-C's questionnaire dated 7/23/26 documents: Have you ever witnessed a resident touch another resident inappropriately (in an inappropriate location on the resident's body/or in a way that makes the resident uncomfortable)? If so, who? [LPN-C documented] Yes. Reported to [DON-B]. [Follow up with DON-B] witnessed [R2] and [R1] touching but [R1] denied being uncomfortable or having issue.Surveyor noted LPN-C answered the question of whether they had witnessed a resident touch another resident inappropriately as YES. Surveyor noted that LPN-C did not give a full statement on the questionnaire as to what LPN-C observed or when this touching happened.On 8/5/26 at 11:20 AM and 1:18 PM, Surveyor interviewed LPN-C. LPN-C informed Surveyor that one day, when LPN-C came around the corner from the contingency medication room, LPN-C saw R1 and R2 alone together in the common area. LPN-C observed R2 grabbing at R1. Surveyor asked, grabbing at what. LPN-C stated R2 was grabbing at R1's breasts. LPN-C stated that it looked like R1 and R2 were being playful and joking around. LPN-C stated that they observed this interaction and saw R2 poking and touching R1's legs. LPN-C stated that after seeing the interaction, LPN-C felt like they needed to check on R1. R2 wheeled away to their unit. LPN-C went up to R1. LPN-C asked R1 if they were ok. R1 stated that R2 was just grabbing at R1's knee. LPN-C asked R1 if they felt safe and R1 replied yes. Surveyor asked if LPN-C reported this interaction to anyone. LPN-C stated that they did not report it for a couple of days. LPN-C indicated that there was an investigation into another incident of R2 touching R1 and that is when LPN-C reported it to DON-B and NHA-A.On 8/6/26 at 10:45 AM, DON-B confirmed that after LPN-C answered the questionnaire and DON-B followed up with LPN-C. DON-B stated that they were not made aware of this until after the investigation on 7/21/26 began. DON-B stated that LPN-C did not report it because R1 said they were not uncomfortable and R1 said they were fine.Surveyor noted that LPN-C informed Surveyor that they witnessed R2 grabbing R1's breast as well as poking and touching R1's legs. LPN-C did not report this to administration immediately. Surveyor noted that LPN-C stated that this happened a couple of days before LPN-C reported it to facility administration. Surveyor noted that this was observed before R2 was seen touching R1 again on 7/20/26.The Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report (which is the initial report submitted to the State Agency before the full investigation is completed) dated 7/21/26 documents, in part: Is date and time occurred known? No. Date occurred: [BLANK]. Time occurred: [BLANK]. Date discovered 7/21/26. On 7/21/26, staff member notified [NHA-A and DON-B] that [R1] reported. that [R1] was uncomfortable because [R2] put [their] hand on [R1's] breast and leg over [R1's] clothes. [R1] stated they and [R2] have had a friendly relationship for a while and sometimes there is physical contact. [R1] stated when [they feel] uncomfortable, [R1] tells [R2] to stop and [R2] does. [R2] stated that [they] and [R1] have a friendly relationship and does recall occasionally putting [their] hand on [R1] but does not recall [R1] ever expressing being uncomfortable. Investigation immediately initiated. Police contacted.The Misconduct Incident Report dated 7/28/26 (which includes the findings of the investigation) documents, in part: Is date and time when occurred known? No. Date occurred: [BLANK]. Time occurred: [BLANK]. Describe the incident: See Attached. Surveyor noted that both in the initial report and the misconduct incident report, facility staff documented that they did not know the date and time that the incident occurred.On 8/5/26 at 3:11 PM, Surveyor asked NHA-A and DON-B when the incident documented in the report and investigation happened. DON-B stated that the incident occurred on 7/21/26. CNA-I informed DON-B and NHA-A shortly after the shift started. DON-B stated that they were told around 4:30 PM and started an investigation right away. On 8/6/26 at 10:45 AM, Surveyor asked why the date and time was not included in the report or investigation. DON-B indicated that they documented in the summary that it was reported to us by staff on 7/21/26 and that is when they were told that it happened.Included in the facility investigation were interviews completed with R1 and CNA-I.R1 was interviewed 3 times during the course of the investigation.R1's third interview dated 7/22/26 documents, in part: . How many different occasions did [R2] attempt to touch your breasts? [R1 stated], Just the one time that it happened. There were no other times [R2] touched you or tried to touch you on your breasts, or your thighs, or between your legs, or anywhere else that might make you feel uncomfortable? No. R4, R2 and I are all friends and we play around sometimes. So, sometimes we will poke at each other, or lightly push on each other's arms as a joke but we never touch each other anywhere inappropriately, so I don't know why [R2] suddenly tried to do that. Can you show us with your own hand what [R2] did when [R2] was trying to touch you? [R1] used [their] own hand and placed it on top of [R1's] left breast. [R1 stated], I had my hands crossed in front of me blocking my chest when I realized what [R2] was doing. But I uncrossed my arms to use my hand to swat [R2's] hand away and when I did that, [R2] touched my breast. When [R2] was doing that, I told him to stop and [R2] said, Shut up, shut up. I swatted [R2's] hand away and [R4] told [R2] to stop, [R2] stopped and then [R2] wheeled himself away down the hallway towards the other unit.Surveyor noted that in the initial report submitted to the State Agency, NHA-A documented that facility staff reported that R1 was uncomfortable because R2 put their hand on R1's breast and leg. Surveyor noted that in the third interview with R1, R1 again stated to facility staff that R2 put their hand on R1's breast. Surveyor noted that R1 informed Surveyor that R2 put their hand on R1's breast.According to the facility's Self-Reported Incidents, the police were called and came to the facility on 7/21/26.As part of the facility Self-report, DON-B and NHA-A both interviewed CNA-I.CNA-I's interview dated 7/21/26 documents, in part: I was on East Unit, and I walked around the corner and saw [R1] sitting in [their] wheelchair across from the nursing station with the back of [the] wheelchair against the wall. [R2] reached to grab [R1's] breast, and I heard [R1] tell [R2] to stop. [R2] wheeled [themselves] away and I took [R1] outside with me. [R1], [R4] and [R2] usually sit together and play around but I have never seen [R2] do anything like that before. Did you see [R2] try to touch [R1] anywhere else? No and [R1] said it was just [the] breast. Was there anyone else around when this happened? No.On 8/5/26 at 12:55 PM, Surveyor interviewed CNA-I. CNA-I stated that they heard R1 screaming at the nurse's station. CNA-I went over to the area and saw R2 trying to grab R1's chest and was grabbing R1's thighs. CNA-I separated them and took R1 outside. CNA-I saw R2 touch R1's thighs but not R1's breast. CNA-I stated that they had never seen R2 be like that before. Surveyor asked if any other staff were in the area when this occurred. CNA-I stated that they were not sure. CNA-I stated that later that same evening, R1 told CNA-I that they did not like it and was uncomfortable with what R2 was doing. CNA-I stated that they did not report this right away because they did not know what to do. CNA-I stated that the next day, CNA-I went to DON-B and NHA-A and told them what happened. Later that night, the police came and CNA-I gave a statement to the police. Surveyor asked if the incident occurred on Monday 7/20/26 or Tuesday 7/21/26. CNA-I indicated that R2 touched R1 on Monday 7/20/26 and CNA-I reported it to DON-B, NHA-A and talked to the police on 7/21/26.Surveyor noted that CNA-I informed Surveyor that they observed R2 touching R1 in a way that R1 did not want. Surveyor noted that CNA-I did not report this touching right away to DON-B, NHA-A or the police department. Surveyor noted that this was not reported to facility administration and the police until the next day, 7/21/26.On 8/5/26 at 12:48 PM, Surveyor interviewed CNA-H. Surveyor asked if they had any knowledge of what happened between R1 and R2. CNA-H stated that they were there both nights. Surveyor asked for clarification on what both nights meant. CNA-H stated that they were working the night that R2 touched R1 and the night that the police were called and came to the facility. Surveyor asked if CNA-H saw anything that happened on the night R2 touched R1. CNA-H stated that they could not remember the exact time but knew it was after dinner. CNA-H was charting at the nurse's station. R2 wheeled past and stopped to talk to R1. CNA-H heard R2 and R1 bantering back and forth like they have done in the past. Surveyor asked what bantering meant. CNA-H stated that they would tease and poke fun at each other. CNA-H stated that next they heard R1 telling R2 to stop. CNA-H stood up and saw R2 poking R1's thighs and chest. Another CNA came and took R1 outside.Surveyor noted that through the investigation and interview, DON-B and NHA-A did not identify that the unwanted touching happened on 7/20/26 but was not reported to the State Agency or Local Law Enforcement until 7/21/26. Surveyor noted that R2 was observed by two different facility staff members touching R1 in a way that R1 did not want. Surveyor noted that facility staff did not report this touching right away to DON-B, NHA-A or the Police Department.On 8/6/26 at 10:45 AM, Surveyor interviewed DON-B and NHA-A. DON-B indicated that nothing in the investigation came out that the incident happened the night before. DON-B stated that staff had recently received abuse training that included when to report allegations of abuse. DON-B stated that they did not know why CNA-I stated that they did not know what to do because they had just gotten education. At 1:21 PM, DON-B returned to Surveyor. DON-B stated that CNA-H filled out a staff questionnaire after the alleged abuse and answered No to the question of whether they had witnessed a resident touch another resident inappropriately. That is why DON-B and NHA-A did not follow up with CNA-I for further comment or statement.On 8/6/26 at 12:48 PM, Surveyor informed DON-B and NHA-A of the following concerns: LPN-C observed R2 touch R1 inappropriately and did not immediately report this to DON-B and NHA-A. CNA-I and CNA-H worked on both 7/20/26 and 7/21/26. Both CNAs informed Surveyor that on 7/20/26, R2 touched R1. CNA-I saw R2 touch R1's thighs. CNA-H saw R2 poke R1's chest and thighs. CNA-I stated that R1 was screaming for R2 to stop. R1 told CNA-I later in the night that R1 did not like it and was uncomfortable. This was not reported to DON-B, NHA-A or the Police Department immediately. The next day, on 7/21/26, CNA-I informed DON-B and NHA-A of the alleged sexual abuse. NHA-A then reported it to the State Agency and the Police Department.DON-B and NHA-A both indicated that they were not aware of when the incident occurred but that it was reported to them on 7/21/26.

Based on interviews and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 1 (R1) of 2 residents reviewed. Facility staff observed R2 touching R1's thighs and chest, and R4 observed R2 touch R1's breast. R1 was screaming for R2 to stop. This allegation of sexual abuse was not thoroughly investigated.Findings include:The undated facility policy titled, Abuse Prevention Program. Facility Procedures. Training Program and Staff Materials, documents, in part: This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. Internal Investigation: All incidents will be documented, whether or not abuse. occurred, was alleged or suspected. Any incident or allegation involving abuse. will result in an investigation.R1 was admitted to the facility on [DATE] with diagnoses that include dementia, Bipolar disease, Anxiety, and Depression.R1's Quarterly Minimum Data Set assessment dated [DATE] documents R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. R1 does not display physical or verbal behaviors toward self or others. R1's Patient Health Questionnaire-9 (PHQ9) assessment to measure the severity of depression documents a score of 1, indicating minimal or no depression. RR2 was admitted to the facility on [DATE] after bilateral below-the-knee amputations. R2's Quarterly MDS assessment dated [DATE] documents R2 is cognitively intact with a BIMS score of 13. R2 does not display physical or verbal behaviors toward self or others. Surveyor reviewed the facility map and noted that R1 and R2's rooms are located on the same floor but on different units.On 8/5/26 at 11:10 AM, Surveyor interviewed R1. R1 informed Surveyor that during the evening time a few weeks ago, R1 was sitting in the common area near the nurse's station. R2 rolled up to R1 and was trying to touch R1's breasts. R1 stated that they kept telling R2 to go and telling R2 to stop. R1 stated that R2 kept trying multiple times and would not stop. R1 crossed their arms and tried to cover their breast. R1 used their arms to swat at R2's hands. R1 stated that R2 touched R1 on their breast. Surveyor asked if R1 could demonstrate how R2 touched them. R1 took their open hand and placed it on R1's right breast. R1 stated that this was witnessed by Certified Nursing Assistant (CNA)-I and R4. R1 indicated that R2 stopped after R4 and CNA-I intervened and told R2 to stop. Surveyor asked how R1 felt. R1 stated, I felt violated. R1 stated that they told R2 that they did not like what was happening and told R2 to stop but R2 wouldn't. R1 stated that they felt like R2 thought it was a joke. Surveyor asked if R2 had done anything like this in the past. R1 stated they never had concerns like this in the past and that is why they were so shocked that it happened. R1 stated that they have not had any interaction with R2 since this happened.Surveyor reviewed the facility's self-reported incidents for the last 6 months and was provided with the investigation completed by NHA-A into this allegation of sexual abuse.The Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report (which is the initial report submitted to the State Agency before the full investigation is completed) dated 7/21/26 documents, in part: Is date and time occurred known? No. Date occurred: [BLANK]. Time occurred: [BLANK]. Date discovered 7/21/26. On 7/21/26, staff member notified [NHA-A and DON-B] that [R1] reported. that [R1] was uncomfortable because [R2] put [their] hand on [R1's] breast and leg over [R1's] clothes. [R1] stated [they] and [R2] have had a friendly relationship for a while and sometimes there is physical contact. [R1] stated when [they feel] uncomfortable, [R1] tells [R2] to stop and [R2] does. [R2] stated that [they] and [R1] have a friendly relationship and does recall occasionally putting [their] hand on [R1] but does not recall [R1] ever expressing being uncomfortable. Investigation immediately initiated. Police contacted.Surveyor noted that NHA-A documented that facility staff reported to them that R1 was uncomfortable because R2 put their hand on R1's breast and leg.The Misconduct Incident Report dated 7/28/26 (which includes the findings of the investigation) documents, in part: Is date and time when occurred known? No. Date occurred: [BLANK]. Time occurred: [BLANK]. Describe the incident: See Attached.Surveyor noted that both in the initial report and the misconduct incident report, facility staff documented that they did not know the date and time that the incident occurred.On 8/5/26 at 3:11 PM, Surveyor asked NHA-A and DON-B when the incident documented in the report and investigation happened. DON-B stated that the incident occurred on 7/21/26. CNA-I informed DON-B and NHA-A shortly after CNA-I's shift started. DON-B stated that they were told around 4:30 PM and started an investigation right away.On 8/6/26 at 10:45 AM, Surveyor asked why the date and time was not included in the report or investigation. DON-B indicated that they documented in the summary that it was reported to DON-B by staff on 7/21/26 and that is when they were told the incident occurred.The facility's Self-Report Incident included a Summary which documents, in part: . Although [R2] states it was not [their] intention to cause [R1] to feel uncomfortable and that [R2] did identify [their] actions caused [R1] to be uncomfortable as [R2] believed [their] actions were a continuation of a running joke between the two, the facility's investigation identified [R1] did not consent to physical contact in that manner. The facility believes that what was described by [R2], [R1] and [R4] as a friendship that involved playing around with each other, evolved and [R1's] boundaries were crossed.Surveyor noted that the facility investigation concluded that R1's boundaries were crossed when R2 touched R1.As part of the facility's Self-Reported Incident, DON-B and NHA-A both interviewed CNA-I.CNA-I's interview dated 7/21/26 documents, in part: I was on East Unit, and I walked around the corner and saw [R1] sitting in [their] wheelchair across from the nursing station with the back of [the] wheelchair against the wall. [R2] reached to grab [R1's] breast, and I heard [R1] tell [R2] to stop. [R2] wheeled [themselves] away and I took [R1] outside with me. [R1], [R4] and [R2] usually sit together and play around but I have never seen [R2] do anything like that before. Did you see [R2] try to touch [R1] anywhere else? No and [R1] said it was just [the] breast. Was there anyone else around when this happened? No.On 8/5/26 at 12:55 PM, Surveyor interviewed CNA-I. CNA-I stated that they heard R1 screaming at the nurse's station. CNA-I went over to the area and saw R2 trying to grab R1's chest and was grabbing R1's thighs. CNA-I separated them and took R1 outside. CNA-I saw R2 touch R1's thighs but not R1's breast. CNA-I stated that they had never seen R2 be like that before. Surveyor asked if any other staff were in the area when this occurred. CNA-I stated that they were not sure. CNA-I stated that later that same evening, R1 told CNA-I that they did not like it and was uncomfortable with what R2 was doing. CNA-I stated that they did not report this right away because they did not know what to do. CNA-I stated that the next day, CNA-I went to DON-B and NHA-A and told them what happened. Later that night, the police came and CNA-I gave a statement to the police. Surveyor asked if the incident occurred on Monday 7/20/26 or Tuesday 7/21/26. CNA-I indicated that R2 touched R1 on Monday 7/20/26 and CNA-I reported it to DON-B, NHA-A and talked to the police on 7/21/26.Surveyor noted that the incident per CNA-I's statement did not occur on 7/21/26 as reported by the facility. Surveyor noted that CNA-I informed Surveyor that they observed R2 touching R1 in a way that R1 did not want. Surveyor noted that CNA-I did not report this touching right away to DON-B, NHA-A or the police department. Surveyor noted that this was not reported to facility administration and police until the next day, 7/21/26.On 8/5/26 at 12:48 PM, Surveyor interviewed CNA-H. Surveyor asked if they had any knowledge of what happened between R1 and R2. CNA-H stated that they were there both nights. Surveyor asked for clarification on what both nights meant. CNA-H stated that they were working the night that R2 touched R1 and the night that the police were called and came to the facility. Surveyor asked if CNA-H saw anything that happened on the night R2 touched R1. CNA-H stated that they could not remember the exact time but knew it was after dinner. CNA-H was charting at the nurse's station. R2 wheeled past and stopped to talk to R1. CNA-H heard R2 and R1 bantering back and forth like they have done in the past. Surveyor asked what bantering meant. CNA-H stated that they would tease and poke fun at each other. CNA-H stated that next they heard R1 telling R2 to stop. CNA-H stood up and saw R2 poking R1's thighs and chest. Another CNA came and took R1 outside.Surveyor noted that through investigation and interview, DON-B and NHA-A reported the alleged incident until 7/21/26 despite staff statements stating the incident occurred the day before. Surveyor noted that R2 was observed by two different facility staff touching R1 in a way that R1 did not want.On 8/6/26 at 10:45 AM, Surveyor interviewed DON-B and NHA-A. DON-B indicated that nothing in the investigation came out that the incident happened the night before. DON-B stated that staff had recently received abuse training that included when to report allegations of abuse. DON-B stated that they did not know why CNA-I stated that they did not know what to do because they had just gotten education.On 8/6/26 at 1:21 PM, DON-B returned to Surveyor. DON-B stated that CNA-H filled out a staff questionnaire after the alleged abuse and answered No to the question of if they had witnessed a resident touch another resident inappropriately. That is why DON-B and NHA-A did not follow up with CNA-I for further comment or statement.On 8/6/26 at 12:48 PM, Surveyor informed DON-B and NHA-A of the concern that the unwanted touching of R1 was not thoroughly investigated. The facility did not document the date and time that the incident occurred. The facility did not identify when exactly the incident occurred as the incident was not reported to DON-B and NHA-A until 7/21/26. DON-B and NHA-A both indicated that they were not aware that the incident did not occur on 7/21/26.

Based on record review, observation and interview, the facility did not ensure a resident with a pressure injury was comprehensively assessed. This was observed with 1(R47) of 4 residents reviewed with pressure injury. * R47 was re-admitted into the facility from the hospital on 1/5/26. The medical record documents a stage 2 wound on the coccyx, with only a measurement, on 1/5/26. On 1/8/26, the wound consult assessment assesses stage 3 pressure injury with treatment. The medical record does not have documentation of treatment implementation until 1/8/26, along with a revised plan of care not initiated until 1/29/26. This resulted in actual harm to R47.Findings include:The facility policy and procedure Wound Management-Wound Prevention and Treatment dated 10/11/24. The Provision and Procedure:1.b.) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.;2. Upon admission, the resident will receive a head-to-toe check to identify any skin issues. And RN will assess any noted pressure injuries and complete an initial comprehensive assessment.;7. When the resident is admitted with a pressure ulcer, the admitting nurse will document the size, location, appearance, odor if any, drainage if any, and current treatment ordered.8. Interventions will be implemented in the resonance care plan to prevent deterioration and promote the pressure ulcers healing.9. The admitting nurse will notify the attending physician of the condition of the pressure ulcer.R47 was readmitted to the facility on [DATE] with diagnoses that include morbid obesity and diabetes mellitus.R47's initial admission Minimum Data Set (MDS) assessment was completed on 7/18/25 and documents a BIMS (Brief Interview for Mental Status) score of 13, indicating that R47 is cognitively intact. The MDS documents that R47 is at risk for the development of pressure injuries and has had no pressure injury at the time of the MDS assessment. Section GG (Functional Abilities) documents that R47 has impairment to one side of R47's lower extremities and is independent when rolling left and right in bed but requires partial to moderate assistance to transition from laying to sitting on the side of the bed. R47's Hospital Discharge summary dated [DATE]. This Hospital Discharge Summary does not document the presence of a coccyx wound or treatment orders for a coccyx wound.On 2/09/2026, at 9:27 AM, Surveyor observed R47 in their bed. R47 was lying on their side. R47 stated to Surveyor they have a wound on their back with a band-aid on it. R47 medical record nurses note dated 1/5/26 documents a Stage 2 to coccyx approximately 3 centimeters (cm) by 3 cm. This was documented by Registered Nurse (RN)-H.There is no documentation on 1/5/26 that includes characteristics of the wound, drainage, odor or treatment. R47's next assessment of the coccyx is by an outside wound consultation on 1/8/26. This consultation assesses stage 3 pressure injury on the coccyx. Noted to be present upon admission. The wound measures 6.3 cm by 4.6 cm by 0.1 cm; light sero-sanguinous drainage; 20% slough; 50% granulation tissue; 30% intact normal color. The treatment that was ordered was Leptospermum honey apply once daily and as needed.R47's Plan of Care (POC) includes Impaired skin integrity related to stage 3 pressure injury to coccyx. The date initiated is 1/29/26. The goal date is 4/28/26. The Interventions are:- Administer a dietary supplement as ordered.-Encourage and assist resident to elevate heels off surface of bed.- Encourage Resident to frequently shift weight.-Encourage the use of lifting devices while in bed.- Monitor for signs and symptoms of skin infection.- Monitor nutritional status.- Monitor resonant for wound related pain, notify Medical Doctor (MD) if pain is unmanaged with current pain regimen and non-pharmacological interventions.- Monitor residence nutritional intake.- Monitor skin for redness, specifically over bony promises.- Pressure relieving cushion to wheelchair.- Provide skin care per facility guidelines and PRN as needed.- Update MD with signs or symptoms of infection or changes in wound status.- Utilize pressure relieving devices on appropriate surfaces.- Wound assessment conducted weekly.Surveyor noted that R47's plan of care was not initiated with the new onset of the pressure injury upon readmission on [DATE].R47's plan of care prior to 1/29/26 for skin, date initiated 7/22/25, documents that R47 is at risk for impaired skin integrity and pressure injury Related to muscle weakness with impaired mobility, functional limitations and range of motion, newly admitted after prolonged hospitalization, active orders for antidepressant medications, and diagnosis of diabetes mellitus, congested heart failure, asthma, heart disease, depression, and depression, at risk of malnutrition. The goal date is 4/28/2026. The Interventions are:- Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. - educate resident family caregivers of causative factors and measures to prevent skin injury.- encourage good nutrition and hydration in order to promote healthier skin.- implement pressure-reducing devices example: wheelchair cushion, air mattress, offloading heels, etc.- keep skin clean and dry. use lotion on dry skin.- use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. This was initiated on 1/22/26.R47's plan of care was not revised with the onset of a new pressure injury on 1/5/26.R47 Treatment Administration Record documentation for January 2026 documents a coccyx treatment starting on 1/9/2026. There is no documentation of a treatment being administered to R4's coccyx from 1/5/26 to 1/9/26.On 2/10/2026, at 1:15 PM, Surveyor interviewed the facility's Wound Nurse Licensed Practical Nurse (LPN)- G. LPN- G stated they thought there was a Meplix dressing on the coccyx upon R4's readmission 1/5/26. LPN-G stated that the Wound Nurse Practitioner (NP) Consult changed the staging to a 3 on 1/8/26 due to necrosis coming off the wound. LPN-G reviewed R47's medical record during the interview. R47's medical record did not have a treatment order starting on 1/5/26, not a comprehensive assessment of R47's coccyx pressure injury. LPN-G stated the previous Assistant Director of Nursing (ADON) did the care plans and that R47's pressure injury is almost healed now. On 2/10/2026, at 2:33 PM, LPN-G spoke with Surveyor. LPN-G stated they placed a Meplix dressing on R47's coccyx when R47 was readmitted and that it was the same type of dressing as the hospital. LPN-G stated they had staged it differently and LPN-G did not provide documentation of an comprehensive wound assessment for R47's coccyx pressure injury on 1/5/26 or treatment order or hospital orders for the care of R47's coccyx pressure injury.On 2/10/2026, at 3:18 PM, at the facility exit meeting with the Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor shared the concerns with R47's wound assessment, treatment and plan of care. At the time, no additional information was provided. On 2/11/2026, at 10:07 AM, Surveyor interviewed the DON-B and NHA-A. The harm concerns for R47 were reviewed, and again there was no additional information provided. On 2/11/2026, at 10:39 AM, Surveyor interviewed RN-H. RN-H stated they spoke to the hospital via telephone and that the hospital stated they were using a foam dressing on the coccyx 3 times a week. RN-H applied a Meplix (foam type) dressing on the area upon readmission and that RN-H told Wound LPN-G about the area. RN-H stated they just take the measurements of the wound and roughly what stage it is when a resident is readmitted . RN-H stated Wound LPN-G does comprehensive assessment and gets the treatment order for any pressure injuries. On 2/11/2026, at 10:48 AM, Surveyor interviewed DON-B. DON-B stated the RN on the floor would be expected to complete a comprehensive wound assessment. Surveyor informed DON-B that R47 was readmitted with a pressure injury on the coccyx on 1/5/26 and at the time the pressure injury was not comprehensively assessed and not provided with treatment until 1/8/26. Surveyor informed DON-B that R47's plan of care was not revised with the new onset of a pressure injury on 1/5/26.No additional information was provided.

Based in interview and record review the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers of Medicare and Medicaid Services (CMS).Staffing information for Fiscal Year Quarter 4 2025 (July 1st, 2025 - September 30th, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.This deficient practice has the potential to affect all 56 residents residing in the facility.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, documents: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 October 1-December 31, (quarter) 2 January 1-March 31, (quarter) 3 April 1-June 30, (quarter) 4 July 1-September 30.Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal Year Quarter 4 2025 (July 1st, 2025 - September 30th, 2025; run date 1/21/2026), documents the facility had excessively low weekend staffing, one star staffing rating, and no registered nurse (RN) hours for the following dates:- 7/5/2025, 7/6/2025, 7/20/2025, 7/2025.- 8/2/2025, 8/3/2025, 8/16/2025, 8/17/2025, 8/30/2025, 8/31/2025.- 9/13/2025, 9/14/2025, 9/27/2025, 9/28/2025.On 2/11/2026, at 9:06 AM, Surveyor requested facility weekend schedules with nurse postings for Quarter 4 2025 (July- September 2025). Director of nursing (DON)-B provided Surveyor an email from Corporate Director of Recruitment (DoR)-Q that documented DoR-Q was inputting information incorrectly into the PBJ Staffing report to CMS and resulted in inappropriate staffing levels being reported. DON-B stated the RN (registered nurse) hours were not reported accurately. Surveyor requested to review the email and look at the requested schedules.Surveyor reviewed the facility's assessment and noted staffing ratios, compared them to the schedules provided. No discrepancies were found between the schedules or RN hours during quarter 4 for 2025. Surveyor noted licensed nurses and certified nursing assistants on each shift and unit per facility assessment. Surveyor noted schedules included call ins and showed the staff that picked up the shift. Surveyor reviewed the email provided that was sent to CMS from DoR-Q on 2/5/2026. The email documents: . (DoR-Q) just confirmed what caused the 1- star in staffing. (DoR-Q) neglected to report the manual updates the facility made to the days that were missing RN hours. Steps have been added to the reporting process to ensure the issue does not happen again. Multiple steps:1. Upload all time clock . data to SimplePBJ.2. Submit that data to CMS3. (DoR-Q) executed and analyzed the report to identify potential missing or inaccurate information, including low or missing RN hours.- If that report identifies missing or inaccurate information, the facility is alerted for accuracy:- If the facility uncovers missing hours from the time clock . the facility manually enters the hours into SimplePBJ.- Once the facility makes the updates, (DoR-Q) is updated. - (DoR-Q) reruns the analyzation report to ensure the manual facility updates were made and taken into effect.- (DoR-Q) resubmits the hours to CMS (THIS WAS THE PART DoR-Q DID NOT COMPLETE. The facility made the manual updates timely on 11/4/2025. On 11/7/2025 the facility confirmed with DoR- Q the manual updates were made. (DoR-Q) did not resubmit the hours to CMS.On 2/11/2026, at 10:17 AM, Surveyor interviewed DoR-Q who stated DoR-Q recalls receiving the information for the facility for the 1-start staffing and no RN hours for selected dates. DoR-Q notified the facility and DOR-B sent the corrects back to DoR-Q. DoR-Q stated, just forgot to resubmit the corrections to CMS, unable to determine why the step was missed, however a step has been added to ensure it does not happen again. DoR-Q stated has been submitting the hours to CMS for about 3 years now and only missed once. Surveyor asked DoR-Q if there was a response from CMS. DoR-Q state did not receive and official email back from CMS, but CMS acknowledged the response with a 'Thumbs up emoji. On 2/11/2026, at 12:54 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B. DON-B stated when the facility was notified of the low weekend staffing and no RN hours, the facility reviewed the schedule and nurse postings. DOB-B stated during that time the facility did not have many weekend RN's and the facility does not do agency help. DON-B and the previous assistant DON (ADON) would alternate the weekends that did not have an RN on duty. Surveyor reviewed the schedules with DON-B and the dates of concern on the PBJ staffing report. DOB-B or the previous ADON were in the facility on those dates, however because DON-B and the previous ADON are/ were salaried and not paid hourly, they do not get reported like the other workers for PBJ staffing report. DON-B resubmitted the corrections to DoR-Q. DON-B stated the corrections were not submitted to CMS from what DON-B understands. DON-B stated currently the facility has weekend RNs, so it is no longer an issue for reporting the hours or RN coverage. Surveyor shared concern even though the error was noted for submitting hours and has since been corrected, there is still concern that hours were not accurately reported at the time for quarter 4 2025. NHA-A understood the concern and no additional information was provided.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not have documentation that it implemented an effective water management plan. This deficient practice had the ability to affect all 56 of 56 residents residing at the facility at the time of this recertification survey. * The facility could not provide documentation of weekly temperature testing, weekly flushing logs for the vacant second floor rooms or rooms that were tested on first floor, the infection preventionist was not part of the water management team, and the water management plan did not include diagrams of the analysis of the building water system, control measures and monitoring, and was not included in the Facility Assessment. * Surveyor made observations on 2/9/2026 of staff not wearing appropriate personal protective equipment (PPE) in rooms with signs posted for droplet precautions. Findings include: The facility policy titled Water and Waste Management authorized 4/1/2025 documents: Water Management Plans to Reduce Legionella Growth; Policy- The water management program at [Facility name] will help identify at-risk areas with our water system and help us take the steps needed to minimize the growth and spread of Legionella and other pathogens. Developing and maintaining a water management program is a multi-step process that requires continuous review. [Facility name] is establishing a water management team to work together to identify ways to reduce legionella growth, conduct routine checks and control measures, and to take action if an issue is found. Our water management program includes:- Describing the building water systems using flow diagrams and a written description.- Identifying areas where legionella could grow and spread.- Deciding where control measures should be applied and how to monitor them.- Establishing ways to intervene when control measures are not met.- Ensuring the program is running as designed and is effective.- Documenting and communicating all activities.Several different types of control measures used to control growth of legionella:- Using the correct amount of disinfectant.- Keeping our water at the recommended temperatures.- Operating and maintaining equipment to reduce biofilm and debris.- Preventing stagnation by keeping water flowing.- Awareness of external factors around (such as construction and water main breaks).Our water management team shall regularly monitor water control parameters such as disinfectants, pH, and temperature levels. Surveyor reviewed the Facility's Water Management Program (WMP) Manual that documents: . per the facility's manual the water management program team consists of the director of nursing (DON)-B, maintenance director-D, and nursing home administrator (NHA)-A. The water management program will be championed by maintenance director-D. NHA-A will be responsible to ensure the WMP is maintained and will report at the facility's Quality Assurance and Performance Improvement (QAPI) meeting any findings. DON-B will be responsible for all clinical aspects of the plan . Surveyor noted the infection preventionist was not included as a team member of the facility water management program team. Surveyor noted the WMP manual facility diagram included the path of water flow throughout the facility, however the diagrams do not indicate any points with potential for legionella or other waterborne pathogens to grow, does not include a risk assessment of the water system or analysis of control measures or what the facility is to do in event control measures have not been met. Surveyor noted the facility water flow diagram indicated the second floor is a closed unit. Surveyor reviewed the facility map of their floor plan. Surveyor noted 2nd floor was not included in the facility floor plan. On 2/10/2026, at 10:05 AM, Surveyor walked around the 2nd floor of the facility and noted the following:1. Emergency eye washing station room- - Tape across the toilet seat with writing that documented: No water- DO NOT USE- A little water noted in the toilet bowl with an orange rust stain in the toilet bowl- in the corner of the room was an open shower with calcium build-up around the floor drain. The shower pipe did not have a shower head on it. 2. Rooms 203, 205, 207:- Bathrooms are blocked with walkers, wheelchairs, and other equipment. Surveyors were unable to get into bathroom; bathroom doors were closed. 3. room [ROOM NUMBER] and 210 connecting bathroom:- Water in the toilet bowl with rust stains noted around the toilet bowl. 4. room [ROOM NUMBER]- Sign on toilet documenting: DO not use water, toilet shut off 10/9/2023.- No water in the toilet bowl.- Rust stain noted around the toilet bowl. 5. room [ROOM NUMBER] and 215 connecting bathroom:- Small amount of water in the toilet bowl with rust stains noted around the toilet bowl. 6. room [ROOM NUMBER]:- Toilet bowl dry with rust stains around the toilet bowl.- Sink dry with calcium deposits and rust stains around the sink bowl. On 2/11/2026, at 9:18 AM, Surveyor interviewed Maintenance- D who stated Maintenance-D has been employed with the facility since November 2025 and NHA-A who has been employed with the facility since September 2025. Surveyor asked to review logs for temperatures and flushing. Maintenance-D stated the facility does not keep logs, Maintenance-D just knows what has been flushed and tested. Surveyor asked how often rooms get flushed. Maintenance-D stated on 2nd floor, every sink gets turned on for 2-3 minutes and toilets get flushed 2-3 times biweekly and 1st floor bedrooms get flushed if a resident is not in the bedroom which is discussed at morning meetings so made aware of what rooms are not occupied. Surveyor asked maintenance-D if every room upstairs is flushed. Maintenance-D stated every room on 2nd floor is flushed except the toilets that have tape on them. Maintenance-D and NHA-A were not sure if the water to the toilets was turned off or what was happening with the 2nd floor. NHA-A and Maintenance-D were not sure how long the 2nd floor units have been shut down. NHA-A stated the previous maintenance director threw away all the logs whether they were temperature logs or flushing logs, NHA-A was not sure. Maintenance-D stated there has not been a water management team meeting to go over the facility water management plan and was not sure what parameters to go off of regarding water temperatures or what to do in the instance a control measure was out of range. Maintenance-D stated would bring any concerns to the attention of NHA-A. Surveyor reviewed the water management plan with Maintenance-D, and Maintenance-D was not able to walk Surveyor through the facility water flow diagram or indicate where potential areas on the water flow diagram where potential areas of legionella and other waterborne pathogens growth could occur. Maintenance-D started finding a sheet from 2021 and started using that as a guide to log water temps until Maintenance-D could come up with a more up to date form, as of right now, maintenance-D does not log water temps or room flushes to indicate they are being completed. NHA-A provided a water specimen sheet that indicated the facility was tested for legionella and other waterborne pathogens on 9/8/2025 and results were negative, with some of those locations tested included second floor rooms. The next water testing for the facility will be March 2026. Surveyor shared concerns with NHA-A and Maintenance-D that the facility could not provide documentation of weekly temperature testing, weekly flushing logs for the vacant second floor rooms or rooms that were tested on first floor, the infection preventionist was not part of the water management team, and the water management plan did not include diagrams of the analysis of the building water system, control measures and monitoring. Surveyor shared when reviewing the facility assessment, the water management plan was not included. NHA-A and Maintenance-D understood the concerns. No additional information was provided at the time of this write up. 2.) The facility policy titled Management of Covid-19, Influenza and other ARI (Active Respiratory Infection) Outbreak revised 11/11/25 documents (in part): It is the policy of this facility that influenza or respiratory outbreak measures are instituted whenever there is an incidence above what would normally be expected, considering seasonal variations. Outbreak measures are used to reduce the potential spread of influenza or respiratory virus. Procedure: 3. Guidelines to prevent the spread of the infection: d. Caregivers and visitors should adhere to the appropriate precautions when in the presence of a resident with suspected or confirmed respiratory illness. Transmission-based precautions may be recommended, depending on the type of respiratory virus detected. For Covid-19 outbreak: For confirmed or suspected influenza, residents should remain on droplet and contact precautions for at least ten days after onset of illness or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. On 2/9/26 at 10:13 AM, during the initial pool review, Surveyor observed a sign outside of R37's room that documented: Droplet precautions. Everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. Surveyor noted that there was not a Personal Protective Equipment (PPE) cart outside or inside of R37's room. Surveyor noted that R37 has a roommate (R16). Surveyor observed a staff member inside of the room next to R37's bed. The staff member was wearing only a surgical mask and no other PPE and was placing dirty laundry in a bag. The staff member said to R37 I'll be back later picked up the bag of laundry, left the room and did not wash her hands. Surveyor later identified the staff member as Hospice Aide-K. On 2/9/26 at 10:17 AM, Surveyor observed Hospice Aide-K entering R37's room wearing a surgical mask, but no other PPE. She brought a Styrofoam cup of water, placed it on the bedside table and then put gloves on. After gathering garbage in a bag, she went into the bathroom and Surveyor heard water running. The aide then left the room with the garbage bag tied up. On 2/9/26 at 10:23 AM, Surveyor asked Hospice Aide-K about the sign on the door and asked which resident was on precautions. Hospice aide-K reported she did not know, stating, I don't think it's (R37) because she's my resident and I think I would know. On 2/9/2026 at 10:32 AM, Surveyor asked Certified Nursing Assistant (CNA)-E which resident is on droplet precautions and why. CNA-E reported she did not know. Surveyor advised there is not a PPE cart outside of the room. CNA-E stated, Yeah, I don't see one, I don't know which one is on the precautions or why. Surveyor asked CNA-E if she wears PPE when she enters the room. CNA-E stated, I usually do for (R16) because she sits on the side of the bed and pees or poops. On 2/9/26 at 12:31 PM, Surveyor noted the sign outside of R37's room had been removed. On 2/9/26 at 10:59 AM, Surveyor observed a sign outside of R52's room that documented: Special Droplet/Contact precautions. In addition to standard precautions only essential personnel should enter this room. Everyone must, including visitors, doctors and staff: Clean hands when entering and leaving the room. Wear mask (fit tested N-95 or higher recommended when performing aerosol-generating procedures), wear eye protection (face shield or goggles), gown and glove at the door. Surveyor observed a PPE cart outside the room. Surveyor observed Hospice aide-K, CNA-E and CNA-F inside the room, none of whom were wearing any PPE except for Hospice aide-K, who was wearing only a surgical mask. All 3 staff members left the room and were observed standing outside of the room talking to a woman/visitor (unknown name). Surveyor heard the woman ask, Does someone in this room have covid? Hospice Aide-K and CNA-E responded, I don't know. The woman asked, Why do they have this sign on the door? CNA-E stated, I don't know which one the precautions are for. Hospice Aide-K stated, I've been wearing a mask just to be safe. Surveyor heard one of the CNA's (unsure which one) say, When you find out if one of them has Covid would you let us know. On 2/9/26 at 11:07 AM, Surveyor noted the sign outside of R52's room had been removed. Surveyor observed Hospice Aide-K inside the room talking to R52. Upon leaving the room, Surveyor asked Hospice aide-K if she knew the woman who was earlier asking about the sign and precautions. Hospice aide-K reported the woman was from Hospice but was not sure if she is the music person or someone else and could not remember her name. Hospice Aide-K reported the woman was asking if one of the residents in the room have Covid or something. Hospice Aide-K stated, I was like I don't know, no one told me anything. On 2/9/26 at 12:34 PM, Surveyor noted the PPE cart was no longer outside of R52's room and a sign was posted for Enhanced Barrier Precautions. On 2/10/26 at 9:57 AM, Surveyor reviewed R37's medical record and found no evidence of Covid or respiratory infection. A rapid Covid test done on 12/22/25 was negative. Review of R37's roommate (R16) revealed a rapid Covid test done on 12/22/25 was positive. Review of R52's medical record documented a rapid Covid test done on 12/22/25 was positive. On 2/11/26 at 11:12 AM, Surveyor advised Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-C of observations and concern staff not wearing appropriate PPE in rooms with sign posted for droplet precautions. DON-B reported the residents were not in precautions anymore and the signs should have been removed. Surveyor advised DON-B of concern staff was not aware, signs were still posted for droplet precautions, and observations of staff not following PPE precautions. DON-B reported she understood the concern. No additional information was provided.

Based Observation and interview, the facility did not ensure that 1 (R6) of 16 residents reviewed had clean, comfortable and a homelike environment. *R6 was observed to have mold on the ceiling in R6's room.Findings:The Facility's policy, titled Housekeeping Policy- Safe, Clean, Comfortable Homelike Environment dated 1/2/2026, states PROCEDURE: II. The facility must provide: . b. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; . On 02/09/2026, at 11:12 AM, Surveyor observed mold on the ceiling tiles around the light in R6's room. R6 indicated the facility is aware and said they will be fixing it.On 02/10/2026, at 10:23 AM, Surveyor interviewed Maintenance- D. Maintenance-D informed Surveyor that Maintenance-D was made aware of the issue in R6's room about 1 week ago but does not have any tiles to replace it and would need to go to the store to buy new tiles. Maintenance-D indicated he would be addressing the mold immediately.On 02/10/2026, at 10:26 AM, Chief Innovation Officer-K informed Surveyor that Chief Innovation Officer-K saw it yesterday and Maintenance-D is getting new tiles. Chief Innovation Officer-K indicated mold should immediately be corrected. A work ticket would be put in and addressed immediately.The facility then immediately began fixing the mold issue in R6's room. No additional information was provided.

Based on interview and record review, the facility did not ensure that discharge planning included documented coordination of services, resident participation, and verification of a safe and appropriate transition for 1 (R32) of 2 residents reviewed.* R32's medical record did not contain documentation of a completed discharge summary, documented care conference discharge meeting and confirmation that the post-discharge needs and services for R32 were fully addressed prior to discharge. Findings:The Facility's policy, titled Discharge Planning, dated 7/17/2024 states the following, . 13. Document, complete on a timely basis on the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. 14. A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. 15.The post-discharge plan of care will indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. R32 was admitted to the facility on [DATE] with diagnoses which include respiratory failure (the lungs cannot properly provide oxygen to the blood or remove carbon dioxide), cognitive communication deficit, heart failure and muscle weakness.R32's admission Minimum Data Set (MDS), dated [DATE], indicates R32 has a Brief Interview for Mental Status (BIMS) score of 14 indicating R32 is cognitively intact. R32 does not use an assistive devices, has functional limitation in upper extremities on one side, has impairment on both side of lower extremities, requires substantial/maximal assistance with sit to stand, requires substantial/maximal assistance with chair/bed to chair transfer, dependent with car transfer and dependent on staff with walking 10 feet.R32's discharge MDS, dated [DATE], indicates R32 was discharged to home/community, has a BIMS score of 13 indicating intact cognition, requires partial/moderate assistance with sit to stand, partial/moderate assistance to chair/bed to chair transfer, car transfer was not attempted due to medical condition or safety concerns, walk 10 feet was not attempted due to medical or safety concerns.The Facility's provided document titled Care Plan Report, indicates R32 would like to discharge home or community, initiate on 12/29/2025. Interventions include encouraging R32 to discuss feelings and concerns with impending discharge, evaluate R32's motivation and ability to safely return to the community and evaluate/record R32's abilities and strengths and determine gaps in abilities which will affect discharge.Surveyor reviewed the Facility provided progress note, dated 1/22/2026 at 9:16 AM, which indicates R32 was discharged home with all paperwork provided by social services and medications sent by the social worker, nursing gave R32 all remaining medications and all belongings. Van transport arrived at the Facility and R32's family member is waiting at destination.On 02/10/2026, at 11:13 AM, Surveyor interviewed Social Services-M who indicated has worked at the Facility for about 7 months. Social Services-M recalled working with R32 and R32's brother regarding discharge and the initial plan when admitted , was to go back to R32's brother's home after rehab. R32's insurance ran out and R32 did not qualify for assistance and did not want to pay privately. R32 is their own person but would include R32's brother in care conferences. Social Services-M indicated R32's first care conference was on 12/31/2025 and the next care conference was 1/6/2026. Surveyor asked Social Services-M if Social Services-M documented the care conferences in R32's medical record or had any documentation of the meetings with R32 regarding discharge planning. Social Services-M informed Surveyor that he usually takes notes in one note and if needed, will reference those notes and deletes them. Social Services-M indicated the notes are only seen by Social Services-M and if any other staff have questions or need the information the staff will come to Social Services-M.On 02/10/2026, at 11:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-N regarding the discharge process and progress note for R32. LPN-N indicated the discharge process is managed by the discharge team which includes the social worker, therapy and management (Assistant Director of Nursing (ADON), Director of Nursing (DON), department heads). The Social Worker manages all home health care if needed, doctors' orders and the medications available to the residents. Nursing has little involvement in the discharge process, just making sure belongings are together and sent along with medication management and being available to answer questions. LPN-N indicated there is a discharge check off list which is done on a piece of paper and is not part of medical record. The nurse is responsible for documenting what time the resident is leaving and what is with them. The discharge assessment is done by the team; nursing can do also. Surveyor asked LPN-N how LPN-N knew R32's brother would be waiting for R32 at the homes, LPN-N indicated R32 was on the phone with R32's brother and they were talking. LPN-N did not go over any discharge instructions with R32 and informed Surveyor that the social worker would have gone over discharge instructions and the secretary would go over appointments. LPN-N indicated R32 was given a discharge summary given as well as a copy of medications. LPN-N stated R32's discharge was really fast and abrupt once insurance ran out. LPN-N indicated LPN-N was not working the floor that day but wanted to document what was going on because there was nothing in the chart.Surveyor noted that R32's discharge occurred without documented evidence that R32's discharge goals were met or that R32's ability to safely transition to the community was fully evaluated and verified.On 02/10/2026, at 12:01 PM, Surveyor interviewed Occupational Therapist (OTR)-O. OTR-O indicated R32's goals were for basic Activities of Daily Living (ADL)'s lower body dressing and toilet transfers (was an assist of 1 w/ 2ww). R32 used a wheelchair on the unit for mobility and there was no change at time of discharge. OTR-O indicated based on R32's evaluation, R32 at time of discharge was not appropriate to live alone and was cut off by insurance. Therapy recommended home health services after discharge from the Facility. Surveyor noted that therapy recommendations for home health services were not implemented prior to R32's discharge. There was no documented evidence that the facility ensured referrals for home health services were completed, confirmed or declined by R32. There was no documentation that R32 was fully informed of the risks and benefits of accepting or declining home health services.OTR-O informed Surveyor R32's brother got R32 an apartment and that therapy gave recommendations to R32 and the social worker. OTR-O informed Surveyor that the Social Worker follows up and will do home health referrals. Surveyor noted that R32's medical record did not contain any documentation that home health referrals were initiated or formally declined by R32. There was no documentation that R32 was informed of therapy's recommendations for home health services or the potential risks of discharging without the services On 02/10/2026, at 1:06 PM, Surveyor interviewed Social Services-M regarding therapy recommendations for R32 at time of discharge. Social Services-M indicated R32's brother was reluctant to allow anyone to come to the home and said he did not want anyone in his home, which was discussed over the phone the day prior day to discharge. Social Services-M indicated R32's brother said 2 family members would be at the residence to assist R32 and set up a time. Social Services-M indicates he was never told R32 has own apartment and the plan was to stay with R32's brother. Social Services-M informed Surveyor that the home services referral was never sent due to conversation with R32's brother but Social Services-M has nothing documented. Surveyor noted that the facility relied on information provided by R32's brother without informing and verifying it with R32, despite R32 having a BIMS score indicating that he was cognitively intact and was identified to be his own person and decision maker. There was no documentation that R32 was informed of therapy's recommendation for home health services or that R32 declined such services after education regarding potential risks. Surveyor noted that the facility failed to verify that adequate support was in place at the discharge location prior to R32's discharge from the facility. The was no documentation confirming the number of caregivers available, their ability to provide the required assistance with transfer and mobility or that the environment was safe and appropriate for R32's functional status.On 02/10/2026, at 3:20 PM, Surveyor interviewed DON-B and NHA-A regarding the discharge process. DON-B informed Surveyor that Social Worker will open the discharge summary in the electronic health record and nursing will review before the resident leaves. Therapy referrals should be followed through and should be documented why it would not have been submitted. NHA-A indicated the Social Worker should be documenting the care conferences and would expect the Social Worker to document all aspects of clinical team discussed in the care conference in the resident's record. DON-B did not provide any information as to why R32's discharge planning failed to ensure that the recommended home health services were arranged or formally declined by R32 or why the facility did not verify that the discharge environment of R32's destination met R32's identified care needs.On 02/11/2026, at 12:16 PM, NHA-A informed Surveyor that the Facility does not have the records regarding R32's discharge summary or recapitulation of stay.No additional information was provided as to why the facility did not ensure that R32's discharge was safe, informed and consistent with R32's assessed needs and discharge goals.

Based on observation, interviews and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for 1 of 16 (R23) residents reviewed for ADLs.R23 did not receive showers as requested.Findings include:R23 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, neuralgia and neuritis.The facility policy titled Bathing Policy revised 7/28/25 documents (in part) . It is the policy of this facility to provide residents with a bath or shower in order to cleanse the skin, observe the skin, increase circulation, and prevent infection.1. All residents are offered a bath or shower at least once a week or per resident's preference.4. Documentation of the resident's shower or bath must be completed. If the resident refuses the shower/bath, the nurse needs to be informed for reapproach. If the resident continues to refuse, the refusal must be documented by the licensed nurse.R23's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment.Section GG0130 Self-Care Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair) - Dependent.R23's Care Plan documents: The resident has an ADL self-care performance deficit related to impaired mobility with physical limitations, muscle weakness, recent hospitalization - dated 3/18/25. Interventions include Bathing/Showering: The resident requires assistance by 1 staff with bathing/showering twice a week and as necessary dated 11/3/25. Requires assistance by 2 staff with bathing/showering twice a week and as necessary - Revised 1/27/26.R23's Kardex documents bathing/showering: The resident requires assistance by 2 staff with bathing/showering twice a week and as necessary.On 2/9/26 at 9:43 AM, while interviewing R23, she reported she needs assistance with ADLs. R23 stated. I don't ask a lot, just a diaper change, and get me washed and dressed. I used to get a shower every Monday, but now I don't anymore - I don't know why. R23 reported she thinks her last shower was maybe 2 weeks ago. R23 reported she wants her shower early in the morning, before 10:00 AM.On 2/9/26 at 10:00 AM, Surveyor advised Assistant Director of Nursing (ADON)-C R23's call light was not working for at least an hour, was crying and needed to be changed and she would like some ice water.On 2/9/26 at 10:19 AM, Surveyor observed staff wheeling R23 into her room in the shower chair. Surveyor spoke with R23 after she was dressed and in her wheelchair. R23 reported she received a shower, if that's what you want to call it. It was like 2 minutes; they just rinsed me with water and that was it.Surveyor asked Registered Nurse (RN)-J how the Certified Nursing Assistants (CNAs) know when residents' shower days are. RN-J provided Surveyor a form titled [NAME] Census which listed each resident's name, room number and shower day highlighted in yellow. Surveyor noted the form documents R23's shower day on Monday and Thursday AM.On 2/9/26 at 2:00 PM, Surveyor reviewed the Point of Care (POC) tasks documentation of R23's bathing/showers for the past 30 days (1/12/26 through 2/9/26). The documentation revealed the following:1/12/26, 1/15/26, 1/26/26 and 2/5/26 - Type of Bathing Received: A check mark under not applicable. There was no documentation R23 received a shower on these dates.1/19/26 - a check mark under refused.1/22/26 - a check mark under bed bath. Surveyor found no documentation of why a bed bath was given instead of a shower.1/29/26 and 2/2/26 - there was no documentation on these dates indicating a shower was given.2/9/26 - a check mark under shower. (When Surveyor was in building).On 2/11/26 at 10:32 AM, Surveyor requested and was provided with a printed copy of R23's POC task/shower documentation. Upon reviewing printed copy, Surveyor noted it differed from what surveyor previously viewed in the computer POC. Surveyor viewed documentation in POC again and noted check marks under shower on dates that were not previously there when viewed on 2/9/26. On 2/11/26 at 10:37 AM, Nursing Home Administrator (NHA)-A was advised of concern regarding R23 not receiving showers. Surveyor advised NHA-A that the task/shower documentation on the printed copy provided is different than what surveyor viewed on 2/9/26 and asked why it would have been changed. NHA-A reported her boss printed the form and has no knowledge if or why the documentation is different than previously viewed. On 2/13/26 at 5:08 PM, DON-B emailed the state agency additional information regarding R23's showers. The email documented: Documentation attached shows Resident received showers (within last 30 days as reviewed during survey):1/12/20261/15/2026- Refused1/19/20261/22/2026- Refused shower but allowed bed bath1/23/20261/24/20261/26/2026- Refused1/29/2026- Refused2/7/20262/9/2026Surveyor noted that per R23's plan of care, where it documents R23 is supposed to receive showers on Monday and Thursday AM, R23 was supposed to have a total of 9 scheduled shower opportunities between 1/12/26 and 2/9/26. The documentation provided by the facility does not provide evidence that R23 received showers per R23's care plan on 2/2/26 and 2/5/26 nor does it provide an explanation as to why the documentation provided was not the same as the documentation viewed by surveyor during the on site survey. No additional information was provided as to why R23, who is unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene.

Based on record review and interview, the facility did not ensure that based on the comprehensive assessment of a resident, 1 (R4) of 5 residents reviewed, received treatment and care in accordance with professional standards of practice.*R4 has diabetes mellitus and receives scheduled insulin. R4's blood glucose was being obtained 3 times a day without any parameters and without order for treatment for variances in R4's blood glucose. Findings include:R4 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. R4 receives scheduled insulin 3 times a day.R4's physician orders documents: Insulin Lispro inject 5 units subcutaneously three times a day. Do not give if R4 doesn't eat.R4's Medication Administration Record since 10/3/25 documents that blood sugars were obtained three times a day while R4 was administered scheduled insulin.R4's physician order summary does not document blood glucose orders with parameters nor does it give any hyperglycemia or hypoglycemia protocols if R4 experiences variances in blood glucose levels.On 2/10/2026, at 3:44 PM, Surveyor interviewed the Director of Nursing (DON)-B. DON-B is covering the nursing units. Surveyor requested blood glucose orders and parameters for R4.On 2/11/2026, at 7:24 AM, DON-B informed Surveyor that the facility does not have blood glucose orders with parameters for R4. DON-B provided physician blood sugar orders with parameters for R4 dated 2/10/26. The physician orders include parameters for blood sugars with interventions for hypoglycemia and hyperglycemia.No additional information was provided.

Based on interview and record review, the facility did not ensure the accurate and safe administration of medication for 1 Resident (R5) of 16 reviewed.R5 returned from the hospital with an order for an antibiotic on 12/16/25 and it was not available until 12/18/25, three doses were not provided. Findings include:The Facility Policy titled Unavailable Medications revised January 2018 documents (in part): Policy: Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure that medications are available to meet the needs of each resident.Procedures.B. Nursing staff shall:1) Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available.a. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction.2) Obtain a new order and cancel/discontinue the order for the non-available medication.3) Notify the pharmacy of the replacement order.R5 was admitted to the facility on [DATE] with pertinent diagnoses that include end stage renal disease (your kidneys no longer work as they should to meet your body's needs), type 1 diabetes mellitus with diabetic chronic kidney disease (high blood sugar causes damage to the kidney's nephrons, impairing their ability to filter blood and potentially leading to end-stage renal disease), and dependence on renal dialysis (refers to the mandatory, long-term reliance on artificial blood filtration, hemodialysis or peritoneal dialysis, because the kidneys have permanently failed, usually due to end-stage renal disease).R5's Annual/Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 12/19/25, documents a Brief Interview for Mental Status (BIMS) score of 13 indicating R5 is cognitively intact. The MDS documents R5 was assessed to have no behaviors exhibited during the look back period and can make self understood and understands others. The MDS documents that an antibiotic was given.R5's physician order dated 12/16/25 documents Vancomycin HCl Oral Suspension 50 MG/ML, Give 2.5 ml by mouth every morning and at bedtime for c diff (Clostridioides difficile)(C. diff) is a bacterium causing severe, watery diarrhea, fever, and abdominal pain, usually following antibiotic use that disrupts healthy gut flora) prophylaxis for 14 Days.R5's Medication Administration Record (MAR) documents that the bedtime dose was not given on 12/16/25, and the morning and bedtime doses were not given on 12/17/25. Surveyor noted this is three doses missed.R5's progress note written on 12/16/2025, at 8:19pm, documents: Administration Note Text: Vancomycin HCl Oral Suspension 50 MG/ML.on order.R5's progress note written on 12/17/2025, at 02:14am, documents Resident Vancomycin was temporary out of stock and will send as soon as available per pharmacy no ETA date given.R5's progress note written on 12/17/2025 at 1:55pm, documents Administration Note Text: Vancomycin HCl Oral Suspension 50 MG/ML.Medication on order.On 02/10/2026, at 1:24 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-L and asked why the vancomycin was not available, LPN-L replied per notes it was temporarily out of stock at the pharmacy, and they sent it when available. Surveyor asked if R5's physician was contacted, LPN-L replied that they did not see a note indicating that.On 02/10/2026, at 3:40 PM, and on 02/11/2026, at 7:56 AM, Surveyor asked if Director of Nursing (DON)-B had any information about the vancomycin and was told they were looking at documentation.On 02/11/2026, at 10:05 AM, Surveyor interviewed DON-B regarding the concern that the prescription was started late, not given for 14 days, and no documentation was provided that the physician was contacted.On 02/11/2026, at 11:55 AM, DON-B provided an email dated 2/11/2026, at 11:04am, documenting that the Nurse Practitioner (NP) wrote I was in the building on 12/17/25 and was made aware that R5's Vancomycin was not available from the pharmacy. He was returned from the hospital on 12/16 and was placed on vancomycin prophylaxis for a hx (history) of C-diff. No signs of symptoms of C-diff was reported from nursing. Therefore his vancomycin course was not extended.On 2/13/26 at 5:08 PM, DON-B emailed the state agency providing additional information regarding R5's Vancomycin availability. The email documents: Order for prophylactic vancomycin was obtained on 12/16/2025Pharmacy informed facility that medication was out of stock, but was delivered to the facility at 0200 on 12/18Medication was administered 12/18Facility nurse practitioner was in facility morning of 12/17 and was notified of vancomycin not being available in facility (see attached email from nurse practitioner).Nurse practitioner did not wish to extend vancomycin course since medication was prophylactic and resident had no signs or symptoms of infection (as described in email attached)Surveyor informed DON-B there is still a concern that the pharmacy did not provide a physician ordered medication on time, as the NP was not consulted until the next day and documentation of the consultation was obtained during the survey. There was no evidence provided that R5's bedtime dose was given on 12/16/25, and the morning and bedtime doses were given on 12/17/25. Surveyor noted that despite the additional documentation that was provided, R5 still missed three doses missed of Vancomycin as originally ordered. No additional information was provided regarding the antibiotic not being available for administration as ordered.

Based on record review and interviews, the facility did not ensure pharmacy irregularity reports were maintained in the medical record, and acted upon promptly, by the primary care provider. This was observed with 2 (R10 and R42) of 5 resident pharmacy record reviews. * R10 and R42, had a Medication Regimen Review (MMR) completed by the pharmacist and a separate recommendation report was written for R10 and R42. The recommendation reports were not discovered in the medical record, nor acted upon promptly by the primary care provider. Findings include: The facility policy and procedure Consultant Pharmacist Reports undated. The Procedures section documents:G. Recommendations are acted upon and documented by the facility staff and/or the prescriber.G.1) Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Findings include: 1.) R10 medical record was reviewed for Medication Regimen Review (MMR) by the Pharmacist. On 12/6/25 there was a Pharmacist MMR completed by the Pharmacist-I. This document stated: Pharmacist Statement: Medication regimen review completed. Recommendations are documented in a separate, written report. R10's medical record did not contain the written report that was completed by the pharmacist. On 2/10/2026, at 12:18 PM, Surveyor interviewed the Director of Nurses (DON)-B and Nursing Home Administrator (NHA)-A. DON-B stated they are unable to locate the written reports by the pharmacist and that the reports were not sent and that the facility does not have them. On 2/10/2026, at 3:18 PM, at the exit meeting with NHA-A and DON-B, NHA-A stated the old NHA would print off the written reports by the pharmacist and that DON-B was getting a duplicate copy but that the pharmacy written report for R10 could not be located. On 2/10/2026, at 1:48 PM, Surveyor interviewed Pharmacist -I. Pharmacist-I stated they send written reports to the facility management and that pharmacy sends them electronically. They were not aware that the facility could not locate the reports and Pharmacist-I stated they will find out. O 2/11/2026, at 8:46 AM, The DON-B provided Surveyor with R10 written pharmacist report from 12/6/25. This recommendation was implemented on 2/9/26 due to survey query. The recommendation for the written report is: Midodrine 5 mg (milligram) by mouth every 8 hours as needed for systolic blood pressure (SBP) less than 100 PRN (as needed). Metoprolol tartrate 12.5 mg by mouth twice daily for atrial fibrillation [ give midodrine if SBP is less than 100].Please consider clarification of metoprolol administration parameters: metoprolol tartrate 12.5 mg by mouth twice daily related to history of atrial fibrillation [hold if SBP less than 120 and pulse less than 60. Surveyor noted that the pharmacy recommendation was not followed up on promptly for R10 by the medical care provider. No additional information was provided. 2.) R42 was admitted to the facility on [DATE] with pertinent diagnoses that include chronic diastolic (congestive) heart failure (occurs when the heart's left ventricle becomes stiff and doesn't relax properly, hindering its ability to fill with blood), cognitive communication deficit (difficulty with communication that stems from impaired thinking skills, such as memory, attention, and problem-solving, rather than from physical speech problems), dementia, with anxiety, and hallucinations. R42's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/4/25, documents a Brief Interview for Mental Status (BIMS) score of 03, indicating that R42 has severe cognitive impairment. The MDS documents R42 is understood and understands others. R42 exhibited no behaviors during the look back period of the MDS assessment. R42's Pharmacy Review progress notes, dated 12/6/25, 11/5/25, 10/1/25, 9/3/25, 8/6/25, document a recommendation was made to the facility regarding medications. On 02/11/2026, at 11:55 AM, Surveyor interviewed Director of Nursing (DON)-B who provided a Prescriber Recommendations Pending a Response form from the pharmacy. Per DON-B, the same recommendation had been made for all of the above mentioned dates. On 2/9/26, the Nurse Practitioner signed off to discontinue the two PRN medications the pharmacy was recommending due to lack of utilization. Per DON-B, nothing was done about the prior pharmacy recommendations until 2/9/26. No additional information regarding R42's repeated pharmacy recommendations not being acted upon in a prompt matter was provided.

Based on observation, interview and record review, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts reviewed.Insulin pens and vials were not dated when opened.Findings include:The facility policy titled Storage of Medications (which is not dated) documents (in part): Medications and biologicals are stored safely, securely and properly, following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Expiration Dating (Beyond-use dating)A. Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing.C. Certain medications or package types, such as multiple dose injectable vials, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency.D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date or expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.On 2/10/26 at 9:30 AM, Surveyor observed the medication cart on the west unit. The bottom drawer of the medication cart contained a plastic bin containing residents insulin pens and vials. Surveyor review of the insulin pens and vials revealed the following:A Lispro insulin Kwik pen belonging to R4 which was open and used but not dated when opened. The label documented: Discard after 28 days.A Lantus vial belonging to R26 which was open and used but used not dated when opened. The label documented: Discard after 28 days.A Glargine insulin pen belonging to R39 which was open and used but not dated when opened. The label documented: Discard after 28 days.A Lispro insulin vial belonging to R39 which was open and used but not dated when opened. The label documented: Discard after 28 days. On 2/10/26 at 9:45 AM, Surveyor informed Registered Nurse (RN)-J of the observed resident insulins that were opened and used but not dated of when they were opened.On 2/10/26 at 11:11 AM, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were advised of the above insulins that were open and used but not dated of when they were opened. DON-B expressed frustration stating, Pharmacy just did an audit like 2 weeks ago.No additional information was provided.

Based on observation and interview, the facility did not ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 16 (R23) rooms observed.R23 needed to be changed for incontinence and her bedside call light was not functioning.Findings include:R23 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, neuralgia and neuritis.R23's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment.Section GG0130 Self-Care Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement - Dependent.R23's Care Plan documents: The resident has bladder incontinence r/t (related to) activity intolerance, muscle weakness - revised 3/18/25. Interventions include clean peri-area with each incontinent episode.The resident has an ADL (Activity of Daily Living) self-care performance deficit related to impaired mobility with physical limitations, muscle weakness, recent hospitalization - revised 3/18/25. Interventions include: The resident requires assistance by 1 staff to turn and reposition in bed as necessary with right sided bed rail - revised 11/3/25. The resident is dependent on staff for toileting. Bed pan/check and change - revised 1/27/26. Encourage the resident to use bell to call for assistance - revised 4/9/25.On 2/9/26 at 9:00 AM, Surveyor observed R23 lying in bed on her back. Surveyor observed her call light next to her bed was on (illuminated), but was not on above the door outside of the room.On 2/9/26 at 9:43 AM, Surveyor observed R23's call light remained on next to her bed but was not on outside of her room. Surveyor noted the call board at the nurse's station was illuminated for R23's room to indicate her call light was on. Surveyor interviewed R23 who reported she needs assistance with ADLs. R23 stated, I don't ask a lot, just a diaper change, and get me washed and dressed. R23 reported her call light has been on for 45 minutes because she needs to be changed for incontinence. R23 began crying and tried to reposition herself. R23 appeared frustrated and stated, I can't, I just need someone. Can I please have some ice water?On 2/9/26 at 10:00 AM, Surveyor left the room to look for assistance for ice water. Surveyor noted the call light was still not on outside of her room. Surveyor asked Assistant Director of Nursing (ADON)-C, who was in the hall outside of R23's room if she could get R23 some ice water. ADON-C entered R23's room and R23 asked her for ice water. Upon leaving the room, Surveyor asked ADON-C how staff would know if the residents' call light were on. ADON-C looked up at the light above R23's door and reported it should light up. Surveyor advised R23's call light is illuminated on the wall next to her bed, but not outside the room. ADON-C stated, I noticed that; I don't know why it's not on. Surveyor asked R23's roommate (R40) to put her call light on to see if it was working. R40 pushed the button, which lit up on the wall next to her bed, but did not light up outside of the room. ADON-C reported she will let maintenance know. On 2/9/26 at 10:19 AM, Surveyor observed Maintenance-D standing on a ladder outside of R23's room reaching for the light above the door.On 2/9/26 at 12:14 PM, Surveyor tested R23's call light, which now turned on both the wall and outside of the room. On 2/11/26 at 9:18 AM, Surveyor spoke with Maintenance-D about R23's call light. Maintenance-D reported it was the bulb, it was out, and he replaced it.On 2/11/26 at 11:30 AM, Surveyor advised Nursing Home Administrator (NHA)-A of concern R23 needed to be changed for incontinence, turned her call light on, however it was not functioning outside the room for at least 1 hour until Surveyor advised ADON-C. NHA-A reported R23 was provided a bell to ring for assistance and the call light has since been fixed. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for accidents/supervision. The facility did not correctly assess R1's risk for elopement and, thus, did not implement interventions to monitor and supervise R1 to prevent R1 from eloping from the facility. The facility had gaps in the monitoring of the main entrance of the building once the alarm system was turned off and before the area was staffed for the day, allowing R1 to leave the facility unnoticed by staff. R1 was returned to the facility 8 hours later when his family found him 20 miles away from the facility. The facility's failure to provide adequate supervision allowed for R1 to elope from the facility, which created a finding of immediate jeopardy that began on 8/25/25. Surveyor notified Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A, Regional Chief Innovations Officer-C, Regional Director of Quality Assurance-E, and Regional Director of Operations-D of the immediate jeopardy on 10/9/25 at 12:15 pm. The immediate jeopardy was removed on 9/26/25. The deficient practice continues at a scope and severity of D as the facility continues to implement its action plan. Findings include:The facility's policy and procedure titled Elopement Prevention and Missing Resident Policy last revised 8/8/2025, documents in part: Procedure:A. Elopement PreventionThe following section outlines the facility approach for elopement risk assessments, strategies for the prevention of elopement, staff training and education, and the Quality Assurance process:Assessments and Plan of Care:-Upon admission or re-admission, all residents will be assessed for elopement risk utilizing the Elopement Risk Assessment form.-A comprehensive elopement prevention plan of care will be developed for each resident identified as at risk for elopement.-Residents at risk for elopement will be reassessed quarterly and with a significant change of condition in conjunction with the MDS (Minimum Data Set) schedule.Routine Procedures: .-Should an exit alarm sound, staff shall immediately respond and determine the cause of the alarm. If no reason can be found, the Supervisor shall be notified, and an account of all residents identified to be at risk for elopement shall be performed.R1 was admitted to the facility on [DATE] with diagnoses that include:Encephalopathy (a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form), cognitive communication deficit (difficulty with communication that stems from impaired thinking skills, such as memory, attention, and problem-solving, rather than from physical speech problems), Vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), and Psychotic disturbance, mood disturbance, and anxiety (distinct but often co-occurring mental health issues that can include a loss of reality, emotional dysregulation, and excessive worry.)R1's 5-day Minimum Data Set (MDS) with an assessment reference date of 6/9/25, documents a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS documents R1 was assessed to have no behavioral concerns exhibited during the look back period.R1's hospital admission paperwork dated 5/29/25, documents: PMH (Primary Medical History) of multi-infarct dementia, . has been living with his daughter for the last few months. Here with encephalopathy, was found crawling on the floor. Per ED (Emergency Department) Daughter cannot care for him anymore asking for higher level of care. Called patient's ex-wife to corroborate history: stated daughter was taking care of patient. Patient had a stroke around Christmas and has dementia now. Daughter is POA. Ex-wife stated patient had been yelling, falling off the bed, wanted to leave home, said it was difficult to work with patient. Called daughter (POA): patient has been acting up, had not been taking medication. Had been agitating, yelling at the door, jumps off the bed, broke the bed guard, bruises from crawling, worse at night. Tantrum every morning. This has started about March. Argues with daughter and family. At baseline is disoriented, fluctuating.Surveyor notes R1 was agitated while living in the community and wanted to leave home. This information was provided to the facility upon R1's admission and demonstrated R1's potential for increased agitation and elopement risk when transferred to a new environment at the facility.On 6/2/25, upon admission, R1's Elopement Risk Evaluation was completed. The facility form documents a score of 4 or more requires action unless the resident is not ambulatory.R1 was assessed to receive a score of 2.0, indicating not at risk for elopement. Two points were assessed related to: Relevant diagnosis/impaired cognition - Alzheimer's, Dementia, Schizophrenia, Traumatic Brain Injury, short-term or long-term memory problems, impaired decision-making skills.Surveyor notes R1 should have also been marked yes for Mobility Status - independently mobile via ambulation, w/c (wheelchair) or with assistive device which would be one point, as well as yes to New to Facility - admitted to facility within 60 days. This would have given R1 an assessed risk score of 4 which would indicate R1 is at risk for elopement and more action from the facility would have been required.Surveyor notes R1's initial care plan does not address concern for elopement risk. R1 did not have a Wanderguard bracelet.R1's care plan dated 6/2/25 documents: R1 would like to discharge home or community.Interventions include: -Encourage resident to discuss feelings and concerns with impending discharge. Monitor for and address episode of anxiety, fear, distress. Dated initiated: 6/2/2025. -Evaluate the resident's motivation and ability to safely return to the community. Dated initiated: 6/2/2025.-Evaluate/record [R1's] abilities and strength, with family/caregivers/IDT (interdisciplinary team). Determine gaps in abilities which will affect discharge. Address gaps by making community referral, pre-discharge PT (physical therapy)/OT (occupational therapy)/ or internal referral. Date initiated: 6/2/25, Revision on 6/13/25. On 6/6/25, Activity Director-J documented: Resident is alert and oriented. Resident makes needs known. Resident is ready to discharge.On 6/10/25, R1 was seen by the MD (Medical Doctor), who documented: Improved over course of hospitalization remained weak decondition now transferred to [name of skilled nursing facility] for ongoing care. Was very restless and tremulous. Very weak, monitoring to know when he can go home, no other nursing concerns.On 6/18/25, R1's MD progress notes document: Up in w/c (wheelchair) asking do I go home today?On 7/31/25, R1's MD progress notes document: seen up in w/c propelling self in hall, asking about discharge plan and when can I get out of here? Spoke with SS (Social Services) who confirmed patient will be LTC (Long Term Care) resident at facility. Patient confused at baseline. Surveyor notes R1's care plan was not revised to address R1's continued desire to discharge vs. Social Services' understanding R1 is going to be staying long term at the facility.On 8/6/25, R1 had a psychiatric consultation via Telehealth which documents the HPI (history of present illness): The resident presents with chronic moderate-to-severe depressed mood and hopelessness, impairing motivation, future planning, and daily functioning. He demonstrates persistent decreased motivation and low energy, which affects his ability to initiate and complete activities. Cognitive deficits involving concentration and short-term memory are noted, moderately compromising recall and following instructions, thus impairing daily functioning. The patient experiences episodic irritability, anger and occasional agitation/restlessness, primarily impacting interpersonal interactions. [RH1] [SM2] Surveyor notes R1's care plan does not address R1's irritability, anger, agitation, restlessness, hopelessness, impaired motivation, low energy, or depression or the recommendation by psychiatric services to start escitalopram. On 10/9/25 at 9:02 AM, Surveyor interviewed DON-B. Surveyor asked about the elopement risk assessment being completed incorrectly upon R1's admission to the facility. DON-B stated R1 should have been assessed as an elopement risk and had a Wanderguard ordered. On 8/24/25, R1's medical record documents: res (resident) siblings here and wanting information regarding a plan for discharge closer to their home, directed to reattempt to contact social worker for this information and or administrator and they will call during business day, res is alert and oriented to self, is very forgetful and is not completely aware of surroundings.Surveyor notes R1 has expressed desire to leave the facility and R1's extended family was at the facility requesting information related to R1's discharge plans and a desire to move R1 closer to their home. The next morning R1 could not be located at the facility. Surveyor notes the facility's investigation into R1's elopement from the facility documents R1's son stated he and his brother are going to speak with the Resident's siblings about being cautious when it comes to what they discuss with the Resident during their visits with him at the facility. Son stated he has attempted to provide these family members with updates on the Resident's status and plan of care on several occasions but despite this they continue to ask the Resident about leaving the facility and they feel the Resident's siblings discussing this with the Resident or in front of him likely causes him increased confusion.On 8/25/25, R1 eloped from the facility, and a silver alert was initiated. R1 was found 20 miles away from the facility by his family who were assisting in the search. Timeline of R1's Elopement on 8/25/25:R1 was last seen at 6:50 AM by a CNA (Certified Nursing Assistant) who stated R1 was sitting in his w/c holding a red pair of shoes.At 7:50 AM, a CNA attempted to locate R1 for breakfast and noted he was not in his room and was not present on the unit; a facility search began.At 7:45 AM, a police officer was flagged down by R1 on Cleveland and [NAME] Avenue and R1 asked for directions to Waukesha Hope Center.At 8:00 AM, NHA-A was alerted of resident missing, an internal code silver was communicated, and another facility sweep was conducted.At 8:20 AM, staff dispersed and searched the neighborhood.At 8:30 AM, NHA-A placed calls to daughter and second contact in medical record, there was no answer.At 9:07 AM, 911 dispatch was called by NHA-A.At 10:05 AM, police reported R1 was spotted on 95th and Bluemound and had been on a city bus. (Per NHA-A bus driver gave R1 ride for free.)At 1:45 PM, a Silver Alert was officially issued for R1.At 3:00 PM, R1's sons found R1 on 49th and [NAME] in Milwaukee, R1 was self-propelling down the sidewalk.At 4:00 PM, R1's sons returned R1 to the facility.At 4:05 PM, a body check was performed by facility staff and R1 had superficial abrasions to back of left forearm. R1 was sent to emergency room (ED) as seems to have fallen. ED report states: medical workup to evaluate for any toxic metabolic or traumatic injuries. CT head negative. Metabolic workup unremarkable. No signs of infection. [NAME] count normal, no significant anemia. Electrolytes normal. Urine Negative. Patient at Baseline.Surveyor noted R1 was found 8 hours after last seen at the facility and was located 20 miles away.On 10/6/25 at 11:06 AM, Surveyor interviewed Receptionist-F. Surveyor asked how Receptionist-F knows which residents are at risk for wandering/elopement. Receptionist-F stated, there is a binder located at the receptionist desk with information on all residents who have a Wanderguard. Receptionist-F stated they have a personal relationship with all the residents and watches out for all the residents when leaving the building. Receptionist-F makes sure each resident leaves with a responsible party or is scheduled to be picked up by medical transport. If not, Receptionist-F stops the resident trying to leave and redirects. Surveyor asked how often it occurs that a resident is trying to leave unsupervised and/or with a Wanderguard. Receptionist-F stated, rarely, only a couple of times and each time residents were redirected. Receptionist-F stated the alarm by the front door lobby will sound if residents wearing a Wanderguard attempt to leave. Receptionist-F stated residents who have a Wanderguard cannot even be outside in the front of the building without supervision.Surveyor asked Receptionist-F, what are the hours the reception area is supervised/manned. Receptionist-F stated, during the week the reception area is covered first shift, 7:30 AM to 4:00 PM and a second shift, 4:00 PM to 8:00 PM, weekends the reception area is covered 8:00 AM to 4:00 PM. Surveyor asked a clarifying question to Receptionist-F, so there is no receptionist monitoring the front area after 8:00 PM and until 7:30 AM during the weekdays and no receptionist monitoring the front area on weekends from 4:00 PM to 8:00 AM and Receptionist-F stated, Correct, the doors automatically lock between 7:30 PM and 8:00 PM and automatically unlock between 5:30 AM and 6:00 AM every day. Receptionist-F stated a code must be entered in order to get outside during the times the doors are locked.Surveyor noted the doors are unlocked between 5:30-6:30 AM daily and there is no receptionist coverage until 7:30 AM during the weekdays and until 8:00 AM on weekends, leaving no active or passive monitoring (code to enter) to open doors as doors are unlocked during this time.On 10/8/25 at 2:09 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who stated night shift got R1 up before 6 AM on 8/25/25. A CNA reported R1 missing so staff went to look. R1 left before reception arrived for the day. At 6 AM the doors unlock, before that you need a code to open the doors.On 10/9/25 at 6:10 AM, Surveyor walked into the facility, the front doors were unlocked. No one was working at the reception desk. Surveyor observed NHA-A walking around the reception area.On 10/9/25 at 6:15 AM, Surveyor observed NHA-A standing by the reception desk while housekeeping cleaned the area. On 10/9/25 at 6:27AM, Surveyor observed the reception area empty of facility staff. Surveyor walked out the front doors and no alarms sounded, no one witnessed Surveyor exit. Surveyor noted there is no way for staff to be aware of residents exiting the building unsupervised once the front entrance doors are unalarmed prior to the receptionist starting their shift.On 10/9/25 at 6:28 AM, Surveyor interviewed CNA-H who stated getting R1 up on NOC (night) shift was not the regular routine. R1 was restless so they got R1 up early and R1 wanted to remain in his room and watch TV. Later R1 came out and talked to CNA-H while they were charting at the desk, then went to talk to the nurse passing meds. When asked if R1 expressed a desire to leave, CNA-H stated R1 was talking about shoes and a haircut that morning. CNA-H stated R1 was only up that early a couple of times and never expressed a desire to leave.On 10/9/25 at 6:28 AM, Surveyor observed R1 in bed sleeping.On 10/9/25 at 6:29 AM, Surveyor interviewed Registered Nurse (RN)-I who stated R1 was always looking for the Social Worker and talking to him.On 10/9/25 at 6:36 AM, Surveyor observed NHA-A and a housekeeper talking in the reception area.On 10/9/25 at 7:24 AM, Surveyor interviewed Activities Director-J who stated R1 stated being ready to discharge from the beginning, giving all the answers that R1 is ready to go home. Over time R1 was withdrawing and not coming to activities that R1 used to go and watch.On 10/9/25 at 7:27 AM, Surveyor interviewed Social Services Director-K who has been at the facility 3 months. Social Service Director-K stated R1 stops by the office every day and tells Social Services Director-K R1 is here temporarily for a cousin. In actuality, R1 is here because family could no longer care for R1. Social Services Director-K felt R1 was content and only expressed wanting to leave after family visited. The POA wants R1 placed in a facility, other family wants R1 closer to their homes.On 10/9/25 at 9:01 AM, Surveyor interviewed NHA-A and DON-B. Surveyor asked how the front entrance to the facility is monitored. DON-B stated there are two alarm systems. One alarm is for the Wanderguard system and if a resident is wearing a Wanderguard and tries to exit the front of the building, an alarm will sound 24/7. The second alarm is sounded when the doors are locked, and anyone opens the doors without disarming the alarm with a code. Surveyor asked when the doors are locked. DON-B stated, the doors are locked at 8:00 PM, and unlocked at 6:30 AM, seven days a week. Surveyor asked what the receptionist coverage is. DON-B stated the reception area is staffed 7:30 AM to 8:00 PM during the week and 8:00 AM to 4:00 PM on the weekends. Surveyor asked if residents without Wanderguards would be able to leave the facility without an alarm sounding between the hours of 6:30 AM and 7:30 AM during the week or 6:30 AM and 8:00 AM on the weekends or between 4:00 PM and 8:00 PM and weekends. DON-B stated, This is not a prison and residents who have not been identified of having risk for elopement have the right to leave when they want to. Surveyor acknowledged understanding but questioned how the facility would know if residents who are not at risk were leaving without an alarm nor anyone at the reception area to observe. DON-B stated, the residents will sign in and out. DON-B stated, the facility installed cameras following R1's elopement on 9/26/25 and both DON-B and NHA-A receive notifications on their cell phone whenever anyone enters or leaves the facility.On 10/9/25 at 9:25 AM, Surveyor informed DON-B and NHA-A of the serious concern related to R1 eloping and the need for adequate supervision for all residents including R1.On 10/9/25 at 11:09 AM, NHA-A followed up with Surveyor and stated due to concerns brought up during survey, doors will now lock at 8pm and unlock at 8am.The facility's failure to provide adequate supervision for R1 allowed R1 to elope from the facility; R1 was found 20 miles away by his family. The failure created a reasonable likelihood for serious harm or injury thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 9/26/25 when the facility implemented the following: -All facility residents were re-assessed to identify risk for elopement and ensure proper interventions were implemented.-Identified residents at risk for elopement and ensure person centered care plans are in place with preventative measures to include the specified level of supervision for residents at risk for elopement.-Reviewed elopement/missing resident policy to address the timing of searching for/reporting a missing resident to help ensure an expedited search.-Education was provided to all staff on following the facility's updated elopement policy, accuracy of elopement assessments, monitoring resident's at risk for elopement and timely response to door alarms.-Elopement risk assessments completed will be reviewed during clinical meeting to verify accuracy and ensure appropriate interventions were put in place.-New elopement risk assessments were completed for all facility residents.-Facility implemented cameras at facility entrance.-Reviewed updated facility policy and procedure on elopement and coordination with medical director. Including updated elopement assessments, and addition of cameras at the facility entrance to ensure adequate resident supervision is in place to identify residents exiting the facility and to ensure facility policy and procedure meets current standard of practice.-Facility Maintenance will complete audits to ensure door alarms are properly functioning. Audits will be completed weekly on all shifts.-IDT will review daily in clinical meeting any new admissions elopement assessments, incidents regarding changes in residents' behaviors, and document on eagle board to ensure proper assessments have been obtained and appropriate interventions have been implemented. Audits will be conducted twice a week for 3 weeks, weekly for 3 weeks, every 2 weeks and x2 monthly x3. (sic) Results will be reviewed by QAPI Committee to determine compliance or additional follow up required.-An Ad Hoc QAPI completed 08/29/25.

Based on interview, record review, and facility document review, the facility failed to employ a qualified Dietary Manager (DM) or clinically qualified nutritional professional on a full-time basis to carry out the functions of overseeing the menus. 4 (R25, R9, R11 and R49) of 4 residents interviewed regarding menus and food selection expressed concerns regarding kitchen management. Findings include: Review of the facility's undated job description and responsibilities for the Dietary Manager (DM) revealed that the primary purpose of the job is to . assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner . During the initial kitchen tour on 10/08/24 at 9:45 AM, the menus for the week of 10/06/24 through 10/12/24 were reviewed. The breakfast menu revealed hot or cold cereal and eggs were served daily. Meat was listed as the protein source on 10/08/24 (sausage gravy) and 10/12/24 (sausage links). During an interview on 10/08/24 at 11:00 AM, the DM confirmed that she has been at the facility for over [AGE] years and had been the DM for about two years. The DM confirmed she was not a Certified Dietary Manager. She stated she believed the facility had a full-time registered dietitian (RD). The DM stated the RD was responsible for completing resident assessments, and the DM was responsible for the menus, ordering, and maintaining inventory. During an interview on 10/08/24 at 12:59 PM, Resident (R) 25, who had been at the facility since 08/03/14, stated that they received the same items for breakfast each morning. R25 stated the residents received eggs every day and no meat. During a Resident Council meeting on 10/09/24 at 11:00 AM, R9, R11, and R49 confirmed that they rarely receive meat during the breakfast meal. The residents stated they had talked with staff about the lack of meat at breakfast. During an interview with the DM on 10/10/24 at 7:06 AM, the DM stated she was unaware of residents' complaints regarding the lack of meat during the breakfast meal. She stated the RD was responsible for creating the menus and ensuring they met each resident's nutritional needs. The DM stated she was responsible for ordering all kitchen inventory. She stated that she would advise the RD of the residents' concerns and would attempt to adjust the menu and purchase orders. A phone interview was conducted with a representative of the facility's consultant registered dietitian (RD) group on 10/10/24 at 10:06 AM, and she advised that she and her team provided three to four hours of remote consultative work per week, which consisted of updating charts and attending weekly interdisciplinary meetings. When asked if she was aware of any food or menu complaints or concerns, the RD stated that would be the responsibility of the DM, as she was responsible for the menu and the ordering of stock. The RD stated the DM was also responsible for compiling and responding to resident requests and suggestions. During an interview on 10/10/24 at 12:52 PM with the Director of Nursing (DON) and the Administrator, they confirmed that the dietitian was a consultant that was not full-time. They confirmed that they were working with the current DM to get her certified. When asked who was responsible for planning the menu, they confirmed that the DM was, with assistance from an automated menu planning program. They stated they were unaware the residents were unhappy with the lack of meat protein served for breakfast.

Based on interview, observation, record review, policy review, and review of the United States Department of Agriculture (USDA) website, the facility failed to store food and snacks in a sanitary manner in one of two resident refrigerators (East unit refrigerator). The facility did not ensure items stored in the East unit refrigerator were labeled, dated, and removed, when necessary. This had the potential to cause food-borne illness for residents who utilized the East unit refrigerator. Findings include: Review of R25's Face Sheet, found under the Census tab of the electronic medical record (EMR), revealed R25 was admitted to the facility on [DATE] for rehabilitation services following a fall at home. Review of R15's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/24 and located under the MDS tab of the EMR, revealed R25 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated she was cognitively intact. During an interview on 10/08/24 at 12:59 PM, R25 stated that the refrigerator/freezer located at the East nurses' station was unclean and needed to be defrosted. During an observation on 10/11/24 at 10:48 AM, Certified Nurse Aide (CNA) 2 was seen removing a can of an energy drink from the freezer portion of the refrigerator located at the East nurses' station. She opened the beverage and began to sip. A sign on the door of the refrigerator recorded that the refrigerator was for resident foods, and all items needed to be labeled, dated, and discarded after three days. Observation of the interior of the freezer portion of the refrigerator revealed a buildup of ice and frost. The ice was approximately two and one-half inches thick. There were two plastic soda bottles stored in the freezer area, and they took up most of the free space in the freezer. The bottles were not labeled or dated. There were leftover fast-food containers, leftover individually packaged beverages, and other unknown items in the refrigerator that were not labeled or dated. In the door of the refrigerator, there were multiple opened containers of condiments, including salad dressing and mustard, and none of the items were labeled or dated. During an interview on 10/11/24 at 11:18 AM, the DON was asked about the refrigerator located at the East nurses' station and who was responsible for cleaning and ensuring its' contents were labeled, dated, and properly stored and/or discarded. The DON stated that the refrigerator in question was specifically used for the residents, and it was the responsibility of the dietary staff to clean it and for the nursing staff to ensure any item placed inside the refrigerator was labeled with resident information and the date the item was placed in the refrigerator. During an interview on 10/11/24 at 3:03 PM, the Administrator provided an infection control cleaning policy and a housekeeping (HK) responsibility checklist. Review of the checklist revealed no documentation of whose responsibility it was to clean the residents' refrigerators. The Administrator stated she felt the facility had missed assigning responsibility for cleaning the resident refrigerators to a particular department, and no one took responsibility for it. The Administrator advised that the refrigerator would be cleaned immediately, and items would be discarded as needed. Review of the facility policy titled, Infection Control-Cleaning and disinfection/non-critical and shared equipment, revised 07/07/23, revealed that the facility is to . ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations . Review of the USDA website at https://ask.usda.gov/s/ revealed opened salad dressings can be safely stored in refrigeration for two months and opened mustard for 12 months.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) when providing direct care to one of 13 residents (Resident (R) 313) on Enhanced Barrier Precautions (EBP) out of a total sample of 25. This failure could promote the spread of multi-drug-resistant organisms throughout the facility. Findings include: A review of the facility's document titled, Enhanced Barrier Precautions, dated 03/25/24 reads in part, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities . An order for enhanced barrier precautions (by physician-approved 'standing orders') will be initiated for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with an MDRO. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply . Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing an activity with a risk of splash or spray (i.e., wound irrigation, tracheostomy care). PPE for enhanced barrier precautions is only necessary when performing high-contact care activities (described below) and may not need to be donned before entering the resident's room. Ensure access to alcohol-based hand rub . A review of Resident 313's Admission Record, located in the resident's electronic medical record (EMR) tab titled, Profile, documented the resident was admitted to the facility on [DATE] with diagnoses that included stage IV sacral pressure ulcer, vascular dementia, hemiplegia, hemiparesis, bacteremia, urinary retention, and gastrostomy tube. A review of R 313's Physicians' Orders, located in the resident's EMR tab titled Orders, documented the resident was on Enhanced Barrier precautions related to having an indwelling urinary catheter and wounds. An observation on 10/09/24 at 3:26 PM revealed that R313's room door had signage posted that read, Enhanced Barrier Precautions. The signage directed staff to perform hand hygiene and don gowns and gloves when providing direct care for R313. An observation on 10/09/24 at 3:37 PM revealed Registered Nurse (RN) 1 performed hand hygiene, donned a pair of gloves, and then entered R313's room. The nurse failed to don a gown. RN1 performed wound care on R313's heel ulcer without wearing a gown. An interview on 10/09/24 at 4:10 PM with RN1 revealed that she was unaware the resident was on EBP but agreed that since the resident did have an indwelling urinary catheter, received wound care, and had a feeding tube, the resident should be on EBP and acknowledged that she failed to follow the directions on the signage posted on the resident's door. An interview was conducted on 10/11/24 at 10:06 AM with the Director of Nursing (DON). The DON stated that it was an expectation that staff providing direct care to residents on Enhanced Barrier Precautions would perform hand hygiene when entering and exiting the resident's room and that staff were to wear gowns and gloves when providing direct care. The DON stated the staff were recently instructed on EBP precautions. A review of the facility's in-service records for Enhanced Barrier Precautions training revealed that RN1 attended a training session on 10/10/24.

Based on staff interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse for 2 of 8 staff reviewed for caregiver background checks. The facility did not ensure thorough and timely caregiver background checks were completed for Laundry Aide (LA)-C and Certified Nursing Assistant (CNA)-D. Findings include: The facility's undated Abuse Prevention Program indicates: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment .This will be done by: conducting pre-employment screening of employees and pre-admission screening of residents .This facility will not knowingly employ any staff convicted of any of the offenses affecting caregiver eligibility under the WI Caregiver Program .Prior to a new employee starting a work schedule, this facility will: .Obtain a Wisconsin Criminal History Record from the Wisconsin Department of Justice, Division of Law Enforcement Services for the individual being hired; and obtain a caregiver background check from the Department of Health Services for the individual being hired. The Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility For Chapter 50 Programs, dated 4/2020, indicates: This document lists Wisconsin crimes and other offenses that the Wisconsin State Legislature, under the Caregiver Law, Wis. Stat. S 50.065, has determined require rehabilitation review approval before a person may receive regulatory approval, work as a caregiver, reside as a non-client resident at, or contract with an entity .Additional information must be obtained when: .The Background Information Disclosure (BID) or Department of Justice (DOJ) response indicates a conviction of any of the following, where the conviction occurred five years or less from the date on which the information was obtained .6. Disorderly Conduct Wis. Stat. S 947.01 .Note: These seven convictions do not prohibit employment, but do require the entity to obtain the criminal complaint and judgment of conviction from the Clerk of Courts office in the county where the person was convicted. On 6/7/24, Surveyor reviewed background check documents for 8 staff members, including LA-C and CNA-D and noted the following: ~ LA-C's hire date was listed as 2/15/24. LA-C's BID form was dated 2/20/24. LA-C's DOJ and Integrated Background Information System (IBIS) letters were dated 2/20/24. LA-C's BID form indicated LA-C previously resided in Florida. A Florida criminal background check was not provided. LA-C's Wisconsin DOJ letter indicated LA-C was convicted of Disorderly Conduct Wis. Stat. S 947.01 in 2023. ~ CNA-D's hire date was listed as 11/6/23. CNA-D's BID form was dated 3/29/24. CNA-D's DOJ and IBIS letters were dated 6/7/24. On 6/7/24 at 11:41 AM, Surveyor interviewed Human Resources Director (HRD)-E who stated the facility's process is to obtain a BID form and DOJ and IBIS letters prior to a new employee's first shift. When asked if the facility conducts out-of-state criminal background checks, HRD-E stated, I think we do national background checks. Don't get too many applicants out of state. I started here mid-March (2024). I would go to the state they were in (to obtain that state's criminal background check). Following a discussion of the above information related to LA-C, HRD-E reviewed LA-C's employee file. HRD-E stated LA-C's file did not contain a criminal background check from Florida and verified there was no additional information related to LA-C's disorderly conduct conviction. Following a discussion of the above information related to CNA-D, HRD-E stated HRD-E obtained CNA-D's DOJ and IBIS letters on 6/7/24 because HRD-E did not see current DOJ and IBIS letters in CNA-D's employee file. HRD-E stated CNA-D transferred from a sister facility and verified CNA-D started at the facility on 11/6/23. HRD-E verified the facility should have obtained a new BID form and DOJ and IBIS letters when CNA-D started employment. Upon request, HRD-E provided Surveyor with LA-C's punch details for 2/15/24 through 2/20/24. HRD-E verified LA-C worked shifts during that timeframe. On 6/7/24, Surveyor reviewed punch details for LA-C for 2/15/24 through 2/21/24 which indicated LA-C worked 11:00 AM to 3:30 PM on 2/15/24, 8:00 AM to 3:30 PM on 2/16/24, 8:00 AM to 3:30 PM on 2/19/24, and 8:00 AM to 3:30 PM on 2/20/24. Surveyor reviewed the Background Request Payment document attached to LA-C's DOJ and IBIS letters which indicated the request was made and paid for on 2/20/24 at 1:35 PM. On 6/7/24 at 12:12 PM, Surveyor interviewed Regional Director of Clinical Operations (RDCO)-F who verified background checks should be completed at a new facility when an employee switches facilities within the corporation. RDCO-F verified background checks should to be done upon hire prior to the employee's first shift. Following a discussion about the facility's policy that does not address out-of-state criminal background checks, RDCO-F indicated a national criminal background check is performed on all employees. On 6/7/24 at 12:25 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility did not have proof that a national criminal background check was obtained for LA-C. NHA-A stated the national criminal background check should have been run and printed for LA-C's file.

Based on record review and interview, the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for one of three sampled residents (Resident (R) 1). The facility assessed R1 as an elopement risk and placed a wanderguard device on the resident; however, on 10/01/23 the resident exited the backdoor of the facility and the facility's wanderguard system failed to alarm. Findings include: Review of R1's electronic medical record (EMR) under the Diagnosis tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included encephalopathy, Alzheimer's disease, dementia, and cerebral amyloid angiopathy. Review of R1's Physician's Orders located it the resident's EMR under the Orders tab revealed an order for Namenda oral tablet 10 milligrams (MG) (active date on 11/21/23), Depakote Sprinkles oral capsule delayed release sprinkle 125 MG (active date 11/20/23), Seroquel oral tablet 50 MG (active date on 11/20/23), monitor for behaviors (active date 10/19/23), sertraline HCl oral tablet 50 MG (active date 10/11/23), monitor antipsychotic use (active date 09/25/23), Wanderguard: check placement, location and function QD [every day] (active date 09/25/23) and apply Wanderguard on resident identified for elopement ( active date 09/25/23). All physician's orders identified were current through 11/21/23. Review of R1's admission modification Minimum Data Set (MDS) with Assessment Reference Date (ARD) date of 10/01/23, located in the resident's EMR under the MDS tab revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated resident was severely cognitively impaired. Continued review of the MDS revealed the facility assessed R1 to have no impairment in functional limitation of range on upper/lower extremity, did not require the use of mobility devices, required supervision/touching assistance for sit to stand, and partial/moderate assist for walking. Review of R1's Care Plan located in the resident's EMR under the Care Plan tab revealed problems dated initiated 09/26/23 and revised on 10/02/23 indicated R1 was an elopement risk related to cognitive deficit and diagnoses of dementia and Alzheimer's disease. Review of R1's Elopement Assessment, dated 09/25/23, provided by the facility revealed the resident was at risk for elopement. Review of the facility's undated investigation titled, [R1's Name] Investigation Summary, revealed R1 left the facility unsupervised on 10/01/23. Continued review revealed the resident exited through a back door of the facility and the resident's wanderguard did not alarm as it was supposed to once the resident reached the door. During an interview on 11/21/23 at 11:20 AM, the Administrator confirmed R1 exited a back door of the facility alone on 10/01/23. The Administrator stated no one heard the wanderguard alarm that should have alarmed once the resident reached the back door. Interview on 11/21/23 at 1:48 PM with Licensed Practical Nurse (LPN 1) confirmed R1 eloped from the facility on 10/01/23. LPN1 stated R1 was able to walk out the back door without the alarm sounding. During a subsequent interview on 11/21/23 at 1:58 PM, the Administrator stated R1 was found on the sidewalk in front of the facility on 10/01/23. The Administrator stated it was determined the wanderguard alarm switch did not alarm as intended and was immediately replaced. Review of facility's policy titled Elopement Prevention and Missing Resident Policy, dated 01/05/21, provided by the Director of Nursing (DON) revealed Residents who are at risk for elopement shall be provided at least one of the following safety precautions. 1. A WanderGuard device that will notify facility staff when the resident has left the building without supervision; 2. Door alarms on facility exits; 3. Staff supervision, either by visual contact or closed-circuit television of facility exits.

Based on observation, interviews, and record reviews, the facility did not ensure quality of care was provided to 3 (R3, R19, and R18) of 24 residents reviewed. *R3 had diagnoses of irritable bowel syndrome and constipation. From 12/19/22 to 12/21/22 R3 experienced severe constipation and was hospitalized due to an obstructed bowel. The facility did not have a comprehensive care plan in place to address R3's bowel management and diagnoses of irritable bowel syndrome and constipation. *R19 had a skin condition that was not comprehensively assessed by the facility or addressed with a comprehensive skin integrity care plan. R19 was admitted on [DATE] with an open wound to the right thigh per facility staff that was not comprehensively assessed until 4/10/2023, no treatment was in place until 4/10/2023, and no Skin Integrity Care Plan was initiated until 4/10/2023. R19 was admitted with documentation of a fluid-filled pocket to the left scalp that was never documented on after that initial assessment. *The facility did not provide R18 with tubigrip stockings per MD order. Findings Include: 1. R3 was admitted to the facility on [DATE] with diagnoses of cardiomyopathy, malnutrition, irritable bowel syndrome, and constipation. Surveyor reviewed R3's comprehensive care plan. Surveyor did not locate a comprehensive care plan to address R3's diagnosis of irritable bowel syndrome, constipation, or bowel management. Surveyor reviewed R3's physician orders. Upon admission to facility (on 11/29/22) R3 was receiving scheduled Lomotil (an anti-diarrheal medication) three times a day. On 12/7/22, R3's physician discontinued the scheduled Lomotil due to drug induced constipation. Surveyor noted R3's physician orders included as needed orders for laxatives including miralax powder daily as needed, milk of magnesia 30 milliliters daily as needed, and bisacodyl suppository daily as needed for constipation. Surveyor noted that R3 had been receiving Miralax powder daily since 12/19/22 and a dosage of milk of magnesia and a bisacodyl suppository on 12/19/22. R3 had a medium soft stool documented on 12/19/22. On 12/21/22 at 10:27 AM, Nursing progress note reads c/o (complains of) abdominal discomfort and feeling urge to have bowel movement nausea .bowel sounds present x (times) 4 (quadrants), bowel sounds hypoactive, ABD (abdomen) tender to palpation, firm. STAT KUB (abdominal X-ray), simethicone ordered for gas pain. On 12/21/22 at 10:44 AM, a STAT KUB abdominal X-ray order was placed with the facility's contracted diagnostic imaging company. On 12/21/22 at 2:43 PM, nursing progress notes indicated STAT KUB abdominal X-ray was completed. On 12/22/22 at 4:26 AM, Nursing progress note reads Resident large dark emesis x (times) 2, called obtained KUB results. Mild colonic ileus, updated NP (Nurse Practitioner) on results and resident having emesis. Resident being his own person and wants to go to the hospital . Surveyor reviewed the STAT KUB X-ray report that had been faxed to the facility at an unknown time or date. The result time of the X-ray was documented by the radiologist on 12/21/22 at 1:49 PM. The facility called an ambulance and R3 was transferred to the hospital. R3 was admitted to the hospital with severe sepsis, a perforated bladder, and small bowel obstruction. On 4/18/23 at 7:14 AM, an interview was conducted with LPN (Licensed Practical Nurse)-U. Surveyor asked LPN-U if they had recalled monitoring R3's bowel management while they were residing at the facility. LPN-U told Surveyor they remembered getting called into R3's room by a Certified Nursing Assistant (CNA) who is no longer employed at the facility who reported R3's large emesis. LPN-U remembers listening to R3's abdomen and their bowel sounds were hard to auscultate and hypoactive. LPN-U remembers updating the acting Director of Nursing (DON) at the time, calling for the KUB results and sending R3 out of the facility by ambulance. Surveyor asked what time R3 was transported to the hospital. LPN-U told Surveyor they thought it was about 3:30 AM when the ambulance left the facility. Surveyor asked LPN-U if they were given report about R3's gastrointestinal status by the previous shift staff on 12/21/22. LPN-U told Surveyor they did not recall whether or not R3's status was reported to them prior to the night shift on 12/22/23. Surveyor asked LPN-U why facility staff did not obtain R3's STAT KUB results until the night shift on 12/22/22. LPN-U did not provide any additional information related to R3's STAT KUB results. On 4/18/23 at 2:30 PM, Surveyor conducted an interview with DON-B. DON-B was not employed at the time R3 was residing at the facility. Surveyor asked DON-B what their expectation would be for ordering and obtaining STAT diagnostic results? DON-B told Surveyor that they would expect that a STAT diagnostic order would be completed and given results within 4 to 6 hours. Surveyor asked DON-B if abnormal diagnostic results are noted by the facility when should the results be reported to a physician? DON-B responded that the results should be reported as soon as possible. Surveyor asked if residents should have a bowel and bladder evaluation completed upon admission to the facility. DON-B responded that all residents should be evaluated for bowel and bladder status on admission. On 4/18/23 at 3:00 PM, Surveyor met with NHA (Nursing Home Administrator)-A. Surveyor informed NHA-A of concerns related to R3's lack of bowel monitoring and patterning upon admission to the facility and lack of care plan to address R3's diagnoses of irritable bowel syndrome and constipation. Surveyor also informed NHA-A of concerns related to R3's STAT KUB x-ray results not being reported to their physician until the night shift of 12/22/23 when the diagnostic results were read by a radiologist on 12/21/22 at 1:49 PM. NHA-A did not provide any additional information at this time. 38253 The facility policy and procedure entitled Wound Management - Wound Prevention and Treatment dated 2/24/2021 states: POLICY: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as no-pressure-related wounds. PROVISION AND PROCEDURE: . 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. A licensed nurse will assess any noted pressure injuries. 7. When the resident is admitted with a pressure ulcer(s), the admitting nurse will document the size, location, appearance, odor (if any), drainage (if any), and current treatment ordered. 8. Interventions will be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing. 9. The admitting nurse will notify the attending physician of the condition of the pressure ulcer. 2. R19 was admitted to the facility on [DATE] with diagnoses of hydrocephalus, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, a Stage 4 pressure injury to the sacrum, coronary artery disease, congestive heart failure, and peripheral vascular disease. R19 did not have a Minimum Data Set (MDS) assessment completed at the time of the survey. R19 had a court appointed Guardian. R19 was dependent on staff for all activities of daily living (ADL) per R19's ADL Care Plan. On 4/7/2023 at 5:41 PM in the progress notes, Director of Nursing (DON)-B charted R19 was admitted from a neuro rehab facility and has had ongoing coccyx wound since 2022. Surveyor noted no other wounds were described in the progress note. On 4/7/2023 on the Admission Data Collection and Baseline Care Plan Tool in the Skin Condition Section of the form, nursing charted R19 had a fluid filled pocket on the left side of the scalp. The form was signed by DON-B on 4/10/2023, three days after admission. Surveyor noted no measurements or wound characteristics were documented for the area on the scalp. No treatment orders were in place. No Skin Integrity Care Plan was initiated. On 4/8/2023 on the Body Check Form, nursing circled the sacral area on the body diagram and charted the dressing was clean, dry, and intact. No other areas on the body diagram were circled indicating a wound was present. On 4/9/2023 on the Body Check Form, nursing circled the sacral area on the body diagram and documented the on-call physician or Nurse Practitioner (NP) was called for treatment orders. Hand-written on the side of the form were measurements of the wound: 3.6 cm x 4 cm x 0.5 cm and per the NP was the treatment order to cleanse the wound with normal saline, pack the wound with hydrofera blue followed by gauze and a 6x6 dressing. Surveyor noted no other areas on the body diagram were circled indicating a wound was present. On 4/10/2023 on the Skin Impairment/Wound Form, Registered Nurse (RN)-K documented the trauma wound to the right thigh measured 2.5 cm x 2.0 cm x 0.1 cm with 100% granulation. RN-K documented the wound was caused from an indwelling urinary catheter digging into R19's skin to the right upper thigh causing the open wound and there was no change in the wound. R19 was seen by the NP with RN-K on that date for the weekly scheduled wound rounds. Surveyor noted the statement there was no change in the wound indicated the wound had been assessed prior to 4/10/2023 and no documentation of an assessment was found. No further documentation was found of the left scalp wound that was noted on admission. On 4/10/2023 on the Treatment Administration Record (TAR), the treatment was initiated for the right thigh opened wound due to trauma: cleanse with wound cleanser and cover with bordered foam dressing every Monday, Wednesday, and Friday and as needed if dressing falls off, is removed, or becomes saturated. On 4/10/2023, R19's Skin Integrity Care Plan was initiated with the following interventions: -Bariatric alternating pressure mattress with foot extender applied to bed due to alternating pressure mattress too small for resident. -Avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short. -Encourage food nutrition and hydration to promote healthier skin. -Facility podiatrist to see resident to trim toenails to bilateral feet. -Follow facility protocols for treatment of injury. -Monitor/document location, size, and treatment of skin injury; report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to physician. -Perform catheter care as ordered, preventing catheter tubing from digging into resident's skin to thighs. Provide pressure relieving devices: bariatric alternating pressure mattress with foot extender to bed, wheelchair cushion, off-loading using prevalon heel boots and pillows when in bed. -Turn and position as necessary. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. -Wound care NP to consult, evaluate, and treat all skin issues with weekly scheduled wound rounds. On 4/17/2023 on the Skin Impairment/Wound Form, Registered Nurse (RN)-K documented the trauma wound to the right thigh had healed. On 4/17/2023 at 2:22 PM, Surveyor observed R19 in bed on a bariatric alternating pressure air mattress with an extended foot piece. R19 was being seen by Speech Therapy at the time of the observation. At 3:27 PM, Surveyor talked with R19 and R19's family member at bedside. R19 did not have any concerns regarding the care that was being provided. In an interview on 4/18/2023 at 11:18 AM, RN-K stated R19's right thigh wound had healed the previous day and Surveyor did not observe a wound on the right thigh. DON-B stated R19 had the right thigh wound on admission. Surveyor noted no documentation was found regarding the right thigh wound until 4/10/2023, three days after admission. In an interview on 4/18/2023 at 11:45 AM, RN-K stated RN-K is responsible for the wounds in the facility and works Monday through Friday. RN-K stated if a new resident is admitted during the time when RN-K is in the facility, then RN-K would do the initial skin assessment. RN-K stated if it is after hours or on a weekend, then the RN in the building or the RN supervisor would be responsible for doing the initial skin assessment and RN-K would see the resident the next time RN-K was in the building. Surveyor asked RN-K if RN-K saw R19 on the day of admission, Friday, 4/7/2023. RN-K stated R19 came in after RN-K had left for the day so RN-K would have seen R19 on wound rounds the following Monday, 4/10/2023. Surveyor asked RN-K what the expectation was for a nurse that was doing the admission skin assessment on a resident. RN-K stated if the resident had any open areas, a skin impairment form should be completed with measurements and a description of the wound tissue. RN-K stated some nurses are not comfortable staging pressure injuries, but they should be able to describe what the wound looked like and the color or type of tissue that was in the wound bed. Surveyor shared the concern with RN-K that R19 was admitted to the facility on [DATE] and no documentation was found of an assessment being completed and no treatment in place until 4/10/2023 when RN-K saw the wound to the right thigh. RN-K stated Surveyor needed to talk to DON-B about the situation because DON-B was the nurse that did the admission assessment of R19 on 4/7/2023. RN-K stated RN-K would expect to see documentation of measurements and wound or tissue description on the day of admission and if treatment orders were not in place, the nurse should call the physician or NP and get treatment orders. In an interview on 4/18/2023 at 1:26 PM, DON-B stated the supervisor or RN in charge at the time a new admission comes in would be responsible for doing the skin assessment of that resident and then RN-K would follow up with any wounds that were discovered at that time. Surveyor asked DON-B what the expectation was of the nurse doing the skin assessment. DON-B stated the RN assessment should include measurement of the wound and a description of the wound. DON-B stated a treatment for the wound should be entered into the Treatment Administration Record (TAR) and if there was no treatment order with the discharge orders, then the nurse should call the physician and get treatment orders. Surveyor shared the concern with DON-B that on admission on 4/7/2023, R19 had a fluid-filled pocket to the left scalp on the admission assessment that was never assessed and a non-pressure injury to the right thigh that was not comprehensively assessed until RN-K saw R19 on 4/10/2023, three days after admission. DON-B stated DON-B would look to see if DON-B had any documentation of the skin and would get back to Surveyor. DON-B stated DON-B knows If it's not written, it's not done. On 4/18/2023 at 3:15 PM, Surveyor shared with Nursing Home Administrator-A and DON-B the concerns R19 was admitted on [DATE] with an open wound to the right thigh per facility staff that was not comprehensively assessed until 4/10/2023, no treatment was in place until 4/10/2023, and no Skin Integrity Care Plan was initiated until 4/10/2023. On the Admission Data Collection and Baseline Care Plan Tool on 4/7/2023 there was documentation of a fluid-filled pocket to the left scalp that was never documented on after that initial assessment. No further information was provided at that time. 20483 3. R18's diagnoses includes metabolic enceophalopathy, chronic kidney disease, & hypertension. The potential/actual impairment to skin integrity care plan initiated 3/29/23 & revised 4/17/23 includes an intervention of Apply tubi-grip stockings to BLEs (bilateral lower extremities) daily in AM (morning) & remove daily at HS (hour sleep) for edema management. Initiated 4/13/23. The physician orders with an order date of 4/13/23 documents Apply tubi-grip stockings to BLEs daily in AM & remove daily at HS. every day and night shift for edema management to BLEs. Apply tubi-grip stockings daily in AM and remove daily at HS. On 4/17/23 at 11:59 a.m. Surveyor observed R18 in bed with an air mattress on the bed. R18 is on her right side with a pillow under R18's upper left side. R18 informed Surveyor her knees hurt. Surveyor observed R18 is wearing bilateral pressure relieving boots and is not wearing tubi grips. On 4/17/23 at 1:01 p.m. Surveyor observed R18 continues to be in bed on her right side. Surveyor observed R18 is still not wearing tubi grips. On 4/17/23 at 3:23 p.m. Surveyor observed R18 continues to be in bed wearing bilateral boots with a pillow under R18's lower legs. Surveyor observed R18 is not wearing tubi grips. Surveyor observed a pair of tubi grips on R18's dresser. On 4/18/23 at 8:20 a.m. Surveyor observed R18 in bed on her right side with a pillow under R18's upper left side. Surveyor observed R18 is wearing bilateral pressure relieving boots and is not wearing tubi grips. On 4/18/23 at 10:31 a.m. Surveyor observed R18's coccyx pressure injury treatment with RN (Registered Nurse)/Wound Nurse-K and DON (Director of Nursing)-B. Surveyor observed R18 is not wearing tubi grips and noted the tubi grips on the dresser. At 11:05 a.m. upon completion of R18's treatment, RN/Wound Nurse-K & DON-B placed R18's tubi grips on. On 4/18/23 at 1:47 p.m. Surveyor asked DON-B when staff are doing morning cares for R18 should they place R18's tubi grips on. DON-B indicated they should. Surveyor informed DON-B of the observations of R18 not wearing tubi grips.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R2 & R19) of 5 Residents reviewed for pressure injuries. * R2 was admitted to the facility on [DATE] without any pressure injuries. The admission assessment dated [DATE] documents R2 was admitted with Mepilex on his right & left trochanter and sacrum, there was no redness or open areas. On 1/27/23 R2 was identified with a DTI (deep tissue injury) on his left upper posterior thigh & left posterior hip. There was no revision in R2's care plan until R2 was identified as having a DTI to left ischium, an unstageable pressure injury to right Achilles, and DTI to the right buttock on 1/30/23. The diabetes mellitus care plan initiated 1/23/23 has an intervention documented of inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness initiated 1/23/23. There is no evidence in R2's medical record the facility implemented this intervention either prior to the development of R2's unstageable right Achilles pressure injury or after the development. * R19 was admitted to the facility on [DATE] with a Stage 4 pressure injury to the coccyx. The facility did not comprehensively assess and a treatment was not put in place until 4/10/23. Findings include: The Wound Management Wound Prevention and treatment policy & procedure with an effective date of 2/24/21 under provision and policy includes documentation of 1. The facility will ensure that based on the comprehensive assessment of a resident: a) A resident receives care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they are were unavoidable; and b) a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. For Etiology and Risk Factors for Pressure Injury under accurate documentation documents Accurate documentation is needed to ensure continuity of care. The plan of care should address efforts to stabilize, reduce or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate. The care plan should specifically address risk factors, pressure points, under nutrition and hydration deficits and moisture and its impact. 1.) R2 was admitted to the facility on [DATE] and discharged to the hospital on 2/1/23. R2 has an activated power of attorney for healthcare. R2's diagnoses includes multiple sclerosis, diabetes mellitus, moderate protein calorie malnutrition, depressive disorder, anxiety disorder, and dementia. R2 has a suprapubic urinary catheter and a colostomy. The ADL (activities of daily living) self care performance deficit care plan initiated 1/23/23 under interventions documents: * Bed Mobility: The resident requires max assist by 2 staff to turn and reposition in bed Q2H (every two hours) and as necessary. Initiated 1/23/23. The potential/actual impairment to skin integrity care plan initiated 1/23/23 & revised on 1/30/23 has the following interventions: * Encourage good nutrition and hydration in order to promote healthier skin. Initiated 1/23/23. * Follow facility protocols for treatment of injury. Initiated 1/23/23. * Provide pressure relieving device(s): APM (alternating pressure mattress) scoop mattress, w/c (wheelchair) cushion, off-loading heels with pillows when in bed. Initiated 1/23/23 & revised 1/26/23. * Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated 1/25/23. * Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration, etc to MD (medical doctor). Initiated 1/25/23. * Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated 1/25/23. * WC (wound care) to consult, evaluate, and treat all skin issues with weekly scheduled wound rounds. Initiated 1/25/23. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated 1/25/23. * 1/26/23: Requested maintenance to apply APM scoop mattress to bed to prevent skin breakdown d/t (due to) decreased mobility. Initiated 1/26/23. * Prevalon heel lift boots to be applied to bilateral feet when resident is in bed. Initiated 1/30/23. * Resident to not have any briefs/depends on at all times. Initiated 1/30/23. The admission data collection and baseline care plan tool dated 1/23/23 for section H documents for site 25) Right trochanter (hip) and for description documents: Has Mepilex on and has no redness or open areas. For site 26) Left trochanter (hip) and for description documents: Has Mepilex on and has no redness or open areas. For site 53) Sacrum and for description documents: Has Mepilex on, skin is without redness and no open areas. Under admission summary progress note documents: Awake, alert to self. Lung sounds clear anterior, abdomen soft, flat with bowel sounds positive in all four quads. Has Foley patent with clear yellow urine and colostomy with soft unformed stool to right abdomen. Lower abd (abdomen) quads have few scattered injection sites with ecchymosis. Right inner wrist and anticub with ecchymosis from IV (intravenous) sites also left anticub with ecchymosis from IV sites. Has Mepilex to bil (bilateral) hips and coccyx. All three sites do not have redness, no pink, no open areas noted. Has his own teeth and upper front teeth in poor shape, no hearing aides, no glasses. Feet good conditions [sic], will put on list for podiatry to see has a few long toe nails. Pleasant and cooperative at this time, tired, has call light within reach and understands usage. VS (vital signs): 109/57, 66, 18, 98.7, 97% RA (room air). Likes to be called [Name]. This assessment data collection was completed by UM (Unit Manager)-X. Surveyor was unable to interview UM-X as UM-X is no longer employed at the facility. The nurses note dated 1/23/23 documents, Resident arrived into room [number] via ambulance. Awake and alert to self only. VS (vital signs): 109/57, 66, 18, 98.7, 97% on room air. Has Foley catheter draining clear yellow order and colostomy to right abdomen. Right hand and right antecubital with status post IV sites, band aides removed. Has Mepilex to both hips and coccyx, all are without redness and no open areas noted. Does have a few scattered injection sited from anticoagulant therapy noted to lower quadrants. Has own teeth in poor shape, does not have glasses does not have hearing aides. The Braden assessment dated [DATE] has a score of 12 which indicates high risk for pressure injuries. The nurses note dated 1/25/23 documents: Writer was called to room by CNA (Certified Nursing Assistant) stated that the resident had an OA (open area) on the left shoulder, rear, over bone. Area is 1 cm (centimeter) x (times) 1 cm x 0.1 cm. No s/s (signs/symptoms) of infection. No drainage noted. Resident was unaware of it being there. No pain or s/s of pain. Appears to be a skin tear likely caused by shearing. Area was cleaned, medihoney applied to wound bed, gauze island bandage placed to cover the wound. Called and updated POA (power of attorney), wife at 2212 (10:12 p.m.). Called and updated on call at [name of medical group] at 2217 (10:17 p.m.). Surveyor reviewed under the task tab - skin care/monitoring. No is answered for the question Barrier cream applied after cleansing with each incontinent episode and as needed during the shift on 1/25/23 at 3:19 a.m., 1/26/23 at 3:21 a.m., 1/27/23 at 3:32 a.m., 1/28/23 at 4:23 a.m., 1/29/23 at 4:15 a.m., 1/30/23 at 4:36 a.m., 1/31/23 at 3:54 a.m., 2/1/23 at 5:11 a.m. and not applicable on 2/1/23 at 11:37 a.m. There are no other dates or times documented. Yes is answered for the question, Resident repositioned self or was assisted with repositioning every 2 hours and as needed during shift on 1/25/23 at 3:19 a.m., 1/26/23 at 3:21 a.m., 1/27/23 at 3:32 a.m., 1/28/23 at 4:23 a.m., 1/29/23 at 4:15 a.m., 1/30/23 at 4:36 a.m., 1/31/23 at 3:54 a.m., 2/1/23 at 5:11 a.m. and at 11:37 a.m. There are no other dates or times documented. The skin/wound note dated 1/26/23 documents Wound care RN assessed new skin issue on 1/26/23. New skin issue occurred on 1/25/23 on PM (evening) shift. New opened wound to left posterior shoulder d/t (due to) shearing. Wound to left posterior shoulder measures: L (length) = (equals) 1.0 cm, W (width) = 1.0 cm, D (depth) = 0.1 cm. Wound bed to opened wound to left posterior shoulder with 100% red/granulation tissue to wound bed, small amount of serosanguinous drainage, no s/s infection, and skin surrounding opened wound to left posterior shoulder WNL (within normal limits)/intact. Resident denies any pain to opened wound to left posterior shoulder, pain level = 0/10 per resident report. new wound treatment orders obtained as follows: Cleanse NS (normal saline), pat dry, apply skin prep to peri-wound, Cover with bordered gauze dressing or bordered island dressing, change dressing every Mon/Wed/Fri (Monday/Wednesday/Friday) & PRN (as needed). Wound care performed to left posterior shoulder as ordered, resident tolerated wound care well with no complications noted. On 1/26/23 APM scoop mattress to be applied to bed to prevent areas of skin breakdown d/t decreased mobility with physical limitations. Opened wound to left posterior shoulder d/t shearing to be assessed by wound care NP (nurse practitioner) [name] with weekly scheduled wound rounds. Surveyor noted there was no revision to R2's care plan to address/prevent shearing as a risk factor for R2. The left posterior shoulder was healed/resolved on 1/30/23. The skin/wound note dated 1/27/23 documents Wound care RN & DON (Director of Nursing) assessed skin on 1/27/23: New DTI (deep tissue injury) to left posterior upper thigh measuring: L= 6.0 cm, W = 5.0 cm, D = 0 cm, wound bed with 100% dark purplish/red intact non-blanchable skin to wound bed to left posterior upper thigh, no drainage, no s/s of infection, surrounding skin red/intact. Applied skin prep to DTI to left posterior hip f/b bordered foam dressing to protect skin. Orders obtained to change dressing Q (every) M/W/F & PRN. New skin issue discovered on 1/27/23: New DTI to left posterior hip measuring: L= 5.5 cm, W = 4.0 cm, D = 0 cm, wound bed with 100% dark purplish/red intact non-blanchable skin to wound bed to left posterior hip, no drainage, no s/s of infection, surrounding skin red/intact. Applied skin prep to DTI to left posterior hip f/b (followed by) bordered foam dressing to protect skin. Orders obtained to change dressing Q M/W/F & PRN. [Name] NP to assess both new DTI's with weekly scheduled wound rounds. Resident states no c/o (complaint of) pain, pain level = 0/10 per resident report. There is no further assessment of R2's left posterior upper thigh after 1/27/23. The Facility did not initiate the order dated 1/27/23 to apply skin prep followed by bordered foam dressing change dressing every Monday/Wednesday/Friday & PRN to the DTI on R2's left posterior upper thigh & left posterior hip as this order is not included on R2's January treatment administration record. The nurses note dated 1/29/23 documents Alert, responsive. Repositioned off right side often. Resident denies any pain or discomfort to right hip and upper thigh. The Medicare 5 day MDS (minimum data set) with an assessment reference date of 1/30/23 has a BIMS (brief interview mental status) score of 12 which indicates moderately impaired. R2 has no behavior including refusal of care. R2 requires extensive assistance with one person physical assist for bed mobility, did not transfer or ambulate, is dependent with one person physical assist for toilet use, is checked for indwelling catheter & ostomy. R2 is at risk for pressure injury development and is coded as having one unstageable slough &/or eschar not present upon admission and 3 unstageable DTI not present upon admission. NP-V's wound care initial evaluation dated 1/30/23 under physical examination documents Deep tissue injury to left posterior hip Deep purple area with deflated blister measuring 4.5 cm x 5.0 cm x 0.1 cm. Scant serosanguineous drainage. The base is 80% deep purple 20% red. No signs or symptoms of infection. Peri-wound pink and blanchable. Status POA (present on admission) Plan: Zinc oxide on bordered foam change daily. Deep tissue injury to left ischium Deep purple area measuring 5.5 cm x 5.0 cm x 0.1 cm. The base is 100% deep purple and there is no drainage. Peri-wound pink and blanchable. No signs or symptoms of infection. Status: POA Plan: Zinc oxide on bordered foam change daily. Unstageable pressure injury to right Achilles Full-thickness wound measuring 8.0 cm x 1.9 cm x 0.1 cm. The base is 100% slough covered and there is a moderate amount of serosanguineous drainage. Peri-wound with local erythema and slight warmth. Positive pedal pulse Status: POA Plan: Medihoney on bordered foam change 3 times a week, heel offloading boot at all times. Cellulitis to right Achilles wound Plan: Doxycycline twice daily x 10 days. Deep tissue injury to the right buttock. Deep purple area measuring 1.5 cm x 2.5 cm. Intact no drainage. 100% deep purple. Peri-wound pink and blanchable. No signs or symptoms of infection: Status: New Plan: Offload with every 2 hours turns, no briefs. Surveyor noted NP-V's initial evaluation documents R2's pressure injuries were present upon admission but the Facility's admission assessment dated [DATE] documents R2 did not have any open areas. The skin/wound note dated 1/30/23 documents Right side of buttock DTI assessed on 1/30/23 per [name] NP with weekly wound rounds. DTI to right buttock measures: L = 1.5 cm, W = 2.5 cm D = 0 cm, wound bed with 100% deep dark purple non-blanchable tissue to wound bed, no drainage present, no s/s of infection and skin surrounding DT fragile/intact. DTI to right buttock assessed by wound NP [name] NP on 1/30/23 with new orders obtained to apply [NAME] butt paste 16% Zinc oxide paste to be applied every shift & PRN to right buttock DTI. Depends removed from resident on 1/30/23 d/t DTI to right buttock d/t depends rubbing into resident's skin. Resident doesn't requiring to wear brief/depends d/t ostomy and catheter in place. Right Achilles unstageable pressure ulcer assessed on 1/30/23 per [name] NP. Right Achilles unstageable pressure ulcer measures: L = 8.0 cm, W = 1.9 cm, D = 0.1 cm, wound bed to right Achilles with 100% slough tissue to wound bed with moderate amount of serosanguinous drainage present, & surrounding skin to peri-wound red. New orders obtained per [name] NP on 1/30/23 for Doxycycline 100 mg (milligrams) po (by mouth) BID (twice daily) x (times) 10 days d/t infection to right Achilles ulcer. New wound orders obtained on 1/30/23 per [name] NP as follows: Cleanse pressure ulcer to right Achilles with wound cleanser, pat dry, apply medihoney to wound bed, Cover with large bordered foam dressing, Change dressing daily & PRN, applied Prevalon boots to bilateral feet on 1/30/23 to be worn when in bed to off-load heels. The diabetes mellitus care plan initiated 1/23/23 has an intervention documented of Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness initiated 1/23/23. There is no evidence in R2's medical record the Facility implemented this intervention either prior to the development of R2's unstageable right Achilles pressure injury or after the development. The January TAR with a start date of 1/30/23 documents Staff to turn/reposition resident every 2-3 hours & PRN every shift for several skin issues requiring frequent turning by staff. Surveyor reviewed R2's medical record including January MAR (medication administration record), January TAR (treatment administration record), February MAR & TAR, physician orders, progress notes, and information under the task tab and was unable to locate evidence the Facility was monitoring R2's feet. R2 has a diagnosis of diabetes mellitus. The nurses note dated 2/1/23 documents Family requesting that resident be sent out to hospital for wound evaluation. NP notified and spoke with family. DON and Administrator notified as well. NP called report to ED at [hospital initials]. [Name] ambulance notified of transfer and will be on the way. Family intentions are to have resident placed elsewhere. The hospital ER (emergency room ) Provider notes dated 2/1/23 under clinical impression documents Pressure ulcers of skin of multiple topographic sites. Under ED (emergency department) course documents: I reviewed the pressure ulcers on the patient, none look grossly infected and all are in the early stages. The patient himself has no complaints. He has known MS (multiple sclerosis), dementia, diabetes, chronic Foley catheter. Other than feeling generally weak and rundown he has no concerns. Family concerned as he has developed pressure ulcers on his back and heel. They do not clinically appear infected to me. The patient appears well-appearing. Family arrived at bedside. Including wife who is activated power of attorney, concerned that the patient has developed pressure ulcers and may not be receiving ideal care. Plan was for discharge from rehab tomorrow. They would like the pressure ulcers evaluated. I have pictures of them in the chart below. None of them appear to have any necrotizing component or any active infections. Afebrile The nurses note dated 2/2/23 documents: Wound care RN & DON assessed skin on 1/27/23 with two skin issues discovered. Both skin issues discovered by CNA & DON when transferring resident from bed to recliner via Hoyer lift, during transfer Mepilex discovered in several areas, Mepilex dressings removed with two new skin issues present under Mepilex dressings. Resident stated he had skin issues when he was in hospital prior to admit to facility. Resident with diagnosis of: Multiple sclerosis, type 2 DM (diabetes mellitus), moderate protein calorie malnutrition, unsteadiness on feet, immobility with physical limitations. DTI to left posterior upper thigh measuring: L = 6.0 cm, W = 5.0 cm, D = 0 cm, wound bed with 100% dark purplish/red intact non-blanchable skin to wound bed to left posterior upper thigh, no drainage, no s/s of infection, surrounding skin red/intact. Resident with no c/o pain to DTI to left posterior upper thigh, pain level = 0/10. Applied skin prep to DTI to left posterior hip f/b bordered foam dressing to protect skin. Treatment orders in place. Resident second skin issue discovered on 1/27/23: DTI to left posterior hip measuring: L = 5.5 cm, W = 4.0 cm, D = 0 cm, wound bed with 100% dark purplish/red intact non-blanchable skin to wound bed to left posterior hip, no drainage, no s/s of infection, surrounding skin red/intact. Applied skin prep to DTI to left posterior hip f/b bordered foam dressing to protect skin. Wound treatment orders obtained & in place. Resident with no c/o pain to left posterior hip, pain level=0/10 per resident report. RCA (root cause analysis) conducted. New interventions: APM scoop mattress applied to bed 1/26/23 & turning scheduled put in place for staff to turn/reposition resident every 2-3 hours & PRN d/t immobility, orders to apply [NAME] butt paste to bilateral buttock/scrotum for prevention of skin breakdown. Prior interventions: recliner chair in room with Roku cushion to recliner, off-loading bilateral heels with pillows when in bed, provide ostomy & catheter care. Updated both POAs (power of attorney) resident's spouse & daughter updated regarding skin issues on 1/27/22 (sic) (1/27/23). Care plan updated. [name] NP to assess both new DTI's to left posterior upper thigh & to left posterior hip with weekly scheduled wound rounds. During the survey, Surveyor spoke with a staff member-BB who requested to be anonymous regarding staffing. This staff member-BB informed Surveyor sometimes during the night shift there is only one nurse and one CNA on each unit. Surveyor inquired if according to a Resident's care plan they are to be repositioned every two hours can Residents be turned every two hours if there is only one nurse and one CNA. Surveyor was informed they aren't being turned every two hours and can only do one round. Surveyor reviewed the Facility's daily nurse schedule while R2 resided at the Facility and noted there was only one nurse with one CNA on R2's unit during the night shift on 1/23/23, 1/25/23, 1/26/23, 1/27/23, 1/28/23, 1/29/23, 1/30/23, & 1/31/23. On 4/18/23 at 9:22 a.m. Surveyor met with RN (Registered Nurse)/Wound Nurse-K to discuss R2's pressure injuries. RN/Wound Nurse-K informed Surveyor she doesn't remember R2. Surveyor asked RN/Wound Nurse-K to get her computer to be able to look at a picture of R2 but R2's medical record did not have R2's picture. Surveyor informed RN/Wound Nurse-K Surveyor had noted R2 was admitted with Mepilex on his right & left trochanter and sacrum. Surveyor informed RN/Wound Nurse-K Surveyor did not note any further documentation of the Mepilex. RN/Wound Nurse-K informed Surveyor if a Resident was admitted with Mepilex and has no redness then they will remove it. RN/Wound Nurse-K informed Surveyor the Mepilex should have been removed and knows she has told nurses several times about removing Mepilex. Surveyor inquired about the care plan process for skin integrity. RN/Wound Nurse-K informed Surveyor when a Resident is admitted care plan interventions are triggered in the admission assessment and if the Resident has a wound she will update the care plan after she sees the Resident. Surveyor inquired if there are no pressure injuries who would revise the care plan after admission. RN/Wound Nurse-K informed Surveyor if they have skin issues then she will update the care plan. Surveyor inquired how R2's pressure injuries developed. RN/Wound Nurse-K informed Surveyor to be honest don't know if I'll remember this guy without a picture. RN/Wound Nurse-K informed Surveyor looks like he was high risk stating she was just reading the notes, had a APM mattress in place. Surveyor informed RN/Wound Nurse-K since she couldn't remember R2 if she could review her notes and get back to Surveyor as to how R2 developed the pressure injuries. RN/Wound Nurse-K did not get back to Surveyor. On 4/18/23 at 11:11 a.m. Surveyor asked CNA (Certified Nursing Assistant)-N if she recalls R2. CNA-N informed Surveyor she doesn't remember R2. On 4/18/23 at 11:18 a.m. Surveyor asked CNA-Y if she recalls R2. CNA-Y informed Surveyor she'll have to really think on this and then informed Surveyor she can't remember taking care of him. On 4/18/23 at 11:30 a.m. Surveyor spoke by telephone with NP-V who is the wound NP at the Facility regarding R2. NP-V informed Surveyor R2 had a breakdown to his left hip, right Achilles, right buttocks and left ischium. NP-V informed Surveyor he was resistant to turning, had generalized discomfort, was on an alternating pressure mattress and pillow at that time which she could recall. NP-V informed Surveyor the right Achilles was unstable and had Cellulitis which is why she started R2 on Doxycycline that day. NP-V informed Surveyor other than resistive to turn there was nothing else in her notes regarding him. Surveyor inquired how did she know R2 was resistive to turning as Surveyor did not note any documentation regarding refusals to be turned. NP-V informed Surveyor when she was in the room with R2 he didn't want to turn. Surveyor inquired regarding her initial wound assessment dated [DATE] that indicated the pressure injuries were present upon admission as the Facility's initial assessment indicates there was Mepilex on the right & left trochanter and sacrum but there was no redness or open areas. NP-V informed Surveyor she thought there was documentation regarding R2 being admitted with pressure injuries. NP-V informed Surveyor the first visit was by their NP but doesn't really document regarding pressure injuries. NP-V informed Surveyor she only saw R2 one time and doesn't have too much. NP-V informed Surveyor R2 has a lot of risk factors and by the time she saw R2 he was already on an alternating mattress, other than Cellulitis everything else was kind of off loading. On 4/18/23 at 11:56 a.m. Surveyor asked NP-Z if she is involved with Resident's pressure injuries. NP-Z informed Surveyor if staff tells her about a pressure injury she can see the Resident but NP-V is the wound NP and staff usually inform NP-V. On 4/18/23 at 12:16 p.m. Surveyor asked CNA-AA if she recalls R2. CNA-AA informed Surveyor this person doesn't even ring a bell. On 4/18/23 at 1:36 p.m. Surveyor informed DON-B of Surveyor's concern of R2 being admitted to the Facility without any pressure injuries and R2 developed multiple DTI's & an unstageable pressure injury. Surveyor inquired how R2 developed these pressure injuries. DON-B informed Surveyor the expectation is when a resident is admitted with Mepilex the Mepilex should be taken off and it's no longer best practice to leave them on. DON-B informed Surveyor the Supervisor did an assessment and chose not to remove those. On 4/18/23 at 3:34 p.m. DON-B informed Surveyor R2 was admitted with Mepilex which were left on. DON-B informed Surveyor it is the belief of NP-V and herself this was the cause of the DTI's. DON-B informed Surveyor she educated the nurses on assessing skin and the need to remove dressings, what documentation is required in PCC (pointclickcare). DON-B informed Surveyor she educated the CNA's on when they identify a skin concern to report to the floor nurses and talked about plan of care for turning and repositioning. 38253 2.) R19 was admitted to the facility on [DATE] with diagnoses of hydrocephalus, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, a Stage 4 pressure injury to the sacrum, coronary artery disease, congestive heart failure, and peripheral vascular disease. R19 did not have a Minimum Data Set (MDS) assessment completed at the time of the survey. R19 had a court appointed Guardian. R19 was dependent on staff for all activities of daily living (ADL) per R19's ADL Care Plan. On 4/3/2023, a fax was sent from the facility R19 was receiving care to the admitting facility with pertinent information and medical record for the facility's review prior to admission. The fax cover sheet stated R19 Requires [sic] simple dressing change to sacrum 3x/week (three times per week). The fax contained diagnoses, a physical exam, speech therapy notes, occupational therapy notes, and wound progress notes. The wound note stated the Stage 4 pressure injury to the sacrum was present on admission 9/26/2022 measuring 2.8 cm x 4 cm x 3.5 cm with thick scar tissue to the wound edges and 20% epithelial tissue and 80% red/moist/smooth/shallow tissue to the wound base. No tunneling was present. A treatment of Dakin's 0.25% and Puracol Plus Ag+ with a foam dressing was to be changed Monday, Wednesday, and Friday. On 4/7/2023 on the Discharge Instructions, the history of the present illness was documented. (R19) was hospitalized from 11/24/2021 through 1/19/2022 and acquired a coccyx wound during that time. (R19) was readmitted to the hospital on 4/1/2022 with a large sacral ulcer with osteomyelitis that underwent surgical debridement and coccygeal ectomy on 4/5/2022. R19 had sacral wound debridement by general surgery on 6/17/2022. Plastic surgery is planning a flap closure in the future when nutritional status is optimized and after a colostomy is placed. R19 was discharged to the facility for continuation of therapies and wound care. The Action Plan portion of the discharge instructions stated wound care nurse consult for the sacral wound. The facility policy and procedure entitled Wound Management - Wound Prevention and Treatment dated 2/24/2021 states: POLICY: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as no-pressure-related wounds. PROVISION AND PROCEDURE: . 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. A licensed nurse will assess any noted pressure injuries. 7. When the resident is admitted with a pressure ulcer(s), the admitting nurse will document the size, location, appearance, odor (if any), drainage (if any), and current treatment ordered. 8. Interventions will be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing. 9. The admitting nurse will notify the attending physician of the condition of the pressure ulcer. On 4/7/2023 at 5:41 PM in the progress notes, Director of Nursing (DON)-B charted R19 was admitted from a neuro rehab facility and has had ongoing coccyx wound since 2022. On 4/7/2023 on the Admission Data Collection and Baseline Care Plan Tool in the Skin Condition Section of the form, nursing charted R19 had a tunneling pressure ulcer to the coccyx. The form was signed by DON-B on 4/10/2023, three days after admission. Surveyor noted no measurements or wound characteristics were documented for the coccyx wound. No treatment orders were in place. No Skin Integrity Care Plan was initiated. On 4/8/2023 on the Body Check Form, nursing circled the sacral area on the body diagram and charted the dressing was clean, dry, and intact. On 4/9/2023 on the Body Check Form, nursing circled the sacral area on the body diagram and documented the on-call physician or Nurse Practitioner (NP) was called for treatment orders. Hand-written on the side of the form were measurements of the wound: 3.6 cm x 4 cm x 0.5 cm and per the NP was the treatment order to cleanse the wound with normal saline, pack the wound with hydrofera blue followed by gauze and a 6x6 dressing. Surveyor reviewed the Treatment Administration Record (TAR) and the treatment ordered by the NP was not entered onto the TAR. On 4/9/2023 at 9:17 PM in the progress notes, nursing charted the Stage 4 coccyx wound was treated as ordered for bandage soilage. This progress note was written by the same nurse that completed the Body Check Form with the NP with the order hand-written on the side of the form. No treatment order was entered into R19's medical record. On 4/10/2023 on the Skin Impairment/Wound Form, Registered Nurse (RN)-K documented the Stage 4 pressure injury to the coccyx measured 3.5 cm x 4.0 cm x 0.5 cm with 100% granulation. RN-K documented R19 was seen by the NP with RN-K on that date for the weekly scheduled wound rounds. On 4/10/2023 on the TAR, the treatment was initiated for the coccyx pressure injury: cleanse with Dakin's quarter strength solution, apply skin prep to peri-wound, pack wound bed with DermaBlue Foam Transfer dressing cut to size followed by dry 4x4 gauze pads fluffed into the depth of the wound bed and cover with 6x6 bordered foam dressing daily and as needed. On 4/10/2023, R19's Skin Integrity Care Plan was initiated with the following interventions: -Bariatric alternating pressure mattress with foot extender applied to bed due to alternating pressure mattress too small for resident. -Avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short. -Encourage food nutrition and hydration to promote healthier skin. -Facility podiatrist to see resident to trim toenails to bilateral feet. -Follow facility protocols for treatment of injury. -Monitor/document location, size, and [NAME] [TRUNCATED]

Based on observation, interview, and record review, the Facility did not ensure Residents with pressure injuries receive appropriate care, treatment, & preventative measures to promote healing for 2 (R36 & R12) of 7 Residents with pressure injuries. * On 2/5/22 R36's right shin was swollen & discolored and R36 was showing signs of pain. An x-ray was ordered of R36's right shin which on 2/6/22 revealed an acute nondisplaced oblique fracture of distal shaft of tibia. R36's power of attorney requested R36 not be sent to the hospital and a brace/splint was applied by therapy. There were no instructions provided regarding assessing R36's foot under the brace and there is no evidence anyone was assessing R36's foot under the brace. R36's skin integrity care plan was not revised to include the brace/splint or assessment of the right foot. On 3/7/22 R36 was identified as having a pressure injury to the top of the right foot. There is no stage or description of the wound bed. There was no revision in R36's skin integrity care plan after R36 was identified as having a pressure injury until 3/9/22. On 3/9/22 R36's pressure injury to the top of the right foot is still not staged and there is no description of the wound bed. Two additional pressure injuries are identified. A DTI (deep tissue injury) to the right heel and a DTI to the right lateral plantar. * R12 was admitted to the facility on [DATE] with right side coccyx Stage 2 pressure injury, left coccyx Stage 2 pressure injury, right medial buttocks Stage 2 pressure injury and left lateral buttocks Stage 2 pressure injury. These pressure injuries were not comprehensively assessed as there is no description of the wound bed. On 1/5/22 the wound assessment documents the coccyx and right upper buttocks were identified as being Stage 3. There were no revisions to R12's skin integrity care plan. R12 was hospitalized from 1/25/22 to 2/4/22. The admission/re-admission summary and re-admission data collection tool dated 2/4/22 does not comprehensively assess R12's pressure injuries as there are no measurements or description of the wound bed which were completed by an LPN (Licensed Practical Nurse). There is no RN (Registered Nurse) assessment of R12's pressure injuries until 5 days later, on 2/9/22. On 4/25/22 R12's pressure injury was not covered with a dressing for approximately 5 hours. Findings include: 1. R36's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The at risk for skin breakdown care plan initiated 10/20/17 & revised 4/9/22 documents the following interventions: * Use a draw sheet or lifting device to move resident initiated 10/20/17 & revised 1/19/21. * Encourage to elevate legs periodically while in W/C (wheelchair) initiated 11/20/17 & revised 1/19/21. * Off load heels while in bed initiated 11/13/17 & revised 1/19/21. * Bilateral leg rests padded with foam initiated 6/26/19 & revised 1/19/21. * Heel lift boots initiated 4/28/21. * Left arm bolster to w/c to assist with upright positioning initiated 7/13/21. * Pressure relieving Wheelchair cushion and air mattress initiated 10/20/17 & revised 4/15/21. * Prevalon boot to right foot at all times initiated 3/9/22. The quarterly MDS (Minimum Data Set) with an assessment date of 1/21/22 documents R36 has short- & long-term memory problems and is severely impaired for cognitive skills for daily decision making. R36 requires extensive assistance with one person for bed mobility, extensive assistance with two plus person physical assist for transfer, does not ambulate and is dependent with one-person physical assist for toilet use. R36 is coded as always incontinent of urine and bowel. R36 is at risk for pressure injury development and is coded as not having any pressure injuries. The SBAR (situation, background, appearance, review & notify) note dated 2/5/22 under appearance documents Med Tech reported that resident displayed s/s (signs/symptoms) of pain and discomfort. Writer looked at right leg and noted that the resident tried to pull away from touch while yelling in pain. Resident had swelling and reddish/purple discolorization (sic) to the right shin. Under review and notify for recommendations of primary clinicians' documents X-ray of right shin ordered by On Call PA (physician assistant). The nurses note dated 2/6/22 documents Resident slept at intervals during night, rouses easily. No complaints offered unless right leg is touched or moved. Heel boots in place bilaterally. Discoloration noted to right shin. Cries out my Leg, My Leg if right leg is touched or moved. Given Tylenol once during night with good effect, then slept again. Vitals stable. Awaiting X-ray to come for right leg X-ray. Call light in reach & toy dog in beside her talking to it at times. Call light in reach. The APNP (Advanced Practice Nurse Prescriber) note dated 2/7/22 documents under chief complaint Right tibia fracture and under assessment documents Patient seen today for follow up on X-ray results. Over the weekend patient developed right leg pain. X-ray was obtained revealing acute nondisplaced oblique fracture of distal shift of tibia. Mild osteopenia. Moderate [CONDITION(S)] demonstrated. Nursing scheduled appointment with orthopedics for this week Thursday. Therapy was able to place splint to right lower extremity. There is no obvious deformity. Unable to obtain pulse due to location of splinting straps. Circulation appears to be intact, capillary refill less than 3 seconds. Patient denies pain while lying still. Does report significant pain with movement. Currently only taking Tylenol. [MEDICATION(S)] 25 mg (milligrams) every 6 hours as needed added today. Prescription sent in. No further concerns today. Surveyor noted there is no revision in R36's at risk for skin breakdown care plan regarding the splint for R36's right tibia fracture. The nurses note dated 2/8/22 documents Resident alert & rouses easily, resting quietly sleeping when undisturbed. Calls out with cares, 2 for all cares to minimize pain in right lower leg. Splint in place on right foot & lower leg. Give 1 dose of [MEDICATION(S)] for pain & slept well afterward, rouses easily & interacts at baseline, good eye contact. Call light in reach. The nurses note dated 2/10/22 documents Resident being monitored d/t LLE [sic] fx. Resident appears comfortable. Resident sleeping between meals. [MEDICATION(S)] given this morning with relief. Splint to RLE (right lower extremity) in place. No swelling or bruising noted. Rounding and safety maintained. Continue with POC (plan of care). The nurses note dated 2/10/22 documents Resident resting in bed, denies pain r/t (related to) fractured Rt (right) tibia at this time, VSS (vital signs stable), splint in place, repositioned by staff. Will cont. (continue) to monitor. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. The skin impairment/wound form dated 3/7/22 for the question does the resident have a pressure injury yes is answered. Location documents top of right foot. Stage is not documented and measure of wound documents approx. (approximately) 1.5 x (times) 1.5 cm (centimeters). The wound tissue bed section has not been completed and is blank. Under additional comments documents area is right where strap for brace lays on top of foot. Under current treatment documents 4x4s to create cushion, strap loosely applied to site. This form was completed by RN (Registered Nurse)-D. The Braden assessment dated [DATE] has a score of 13 which indicates moderate risk. Surveyor noted R36's at risk for skin breakdown care plan was not revised until 3/9/22. The skin impairment/wound form dated 3/9/22 for the question does the resident have a pressure injury yes is answered. Location documents top of right foot. Stage is not documented and measure of wound documents approx. (approximately) 2.5 x (times) 1.3 cm. The wound tissue bed section has not been completed and is blank. Under additional comments documents area is right where strap for brace lays on top of foot. Under current treatment documents Per [Physician's name], do wound cleanse f/b (followed by) Xeroform and Medi honey, cover with gauze island dressing daily. Under Additional Wound # for location documents right heel. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3.1 x 2.4 cm. The wound bed tissue bed section has not been completed and is blank. Under current treatment documents Per [wound doctor name], wound cleanse f/b [MEDICATION(S)] daily. Under Additional Wound # for location documents right lateral plantar. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3 x 4.2 cm. The wound bed tissue bed section has not been completed and is blank. Under current treatment documents Per [wound doctor name], wound cleanse f/b [MEDICATION(S)] daily. Under wound education provided documents Family called and educated on plan of care for healing. Explained plan of care for healing to resident. She nodded her head, unable to determine understanding d/t (due to) resident speaks Spanish but does indicate understanding at times, Had Dx (diagnosis) of dementia. The nurses note dated 3/9/22 documents Resident's daughter, [name] was called and informed of open area to right dorsal foot and dark areas to right plantar and right heel. Informed of treatment orders given per [wound doctor name] and informed resident will be followed q (every) week by [wound doctor name] for areas. The nurses note dated 3/9/22 documents IDT (interdisciplinary team) met to discuss resident wounds to the right foot. Resident has had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Recently resident had fracture to right leg requiring a brace to ensure no movement and to assist with comfort. Resident with diabetic foot checks nightly. NOR (new order received) to allow brace to be removed indefinitely from resident and ok to put Prevalon boot back on at all times. All wound care orders entered and reviewed. Care plan updated. Family made aware. The nurses note dated 3/10/22 documents Resident being monitored for new suspected DTI (deep tissue injury) to right plantar lateral foot and right heel caused by ankle splint. [MEDICATION(S)] applied as ordered. Dorsal portion of (right foot) has a wound and dressing changed per orders. Resident tolerated well. The skin impairment/wound form dated 3/16/22 (completed by DON B) for the question does the resident have a pressure injury yes is answered. Location documents right anterior foot. Stage is Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Measure of wound documents 2 x 3.5. The wound tissue bed is 10% granulation and 90% eschar. Under additional comments documents debridement completed by MD (medical doctor) to remove necrotic tissue, resident tolerated well with no c/o (complaint of) pain. Under current treatment documents wound cleanser wash, Medi honey, Xeroform, cover with bordered gauze dressing daily. Under Additional Wound # for location documents right heel. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3 x 3.5 cm. The wound bed tissue bed is 100% eschar. Under current treatment documents skin prep daily. Under Additional Wound # for location documents right lateral plantar. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3 x 4. The wound bed tissue bed is 100% eschar. Under current treatment documents skin prep daily. Surveyor noted R36's pressure injuries were assessed by the wound MD M on 3/16/22. On 3/16/22, wound MD M doctor staged the right heel and right lateral planter as unstageable DTI's. The quarterly MDS (Minimum Data Set) with an assessment date of 4/7/22 documents R36 has short- & long-term memory problems and is severely impaired for cognitive skills for daily decision making. R36 requires extensive assistance with one person for bed mobility, dependent with two plus person physical assist for transfer, does not ambulate and is dependent with one person physical assist for toilet use. R36 is coded as always incontinent of urine and bowel. R36 is at risk for pressure injury development and is coded as have one Stage 4 pressure injury and 2 unstageable DTI (deep tissue injury) pressure injuries. Surveyor noted weekly pressure injury assessments by wound MD M and facility staff dated 3/23/22, 3/30/22, 4/6/22, and 4/13/22. The skin impairment/wound form dated 4/20/22 for the question does the resident have a pressure injury yes is answered. Location documents right dorsal medial foot. Stage is Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Measure of wound documents 0.8 x 0.5 x 0.1 cm. The wound tissue bed is 70% granulation and 30% eschar. Under additional comments documents debridement completed by MD to remove necrotic tissue, resident tolerated well with no c/o pain. Wound progress improved. Under current treatment documents wound cleanser f/b Collagen gel, cover with bordered gauze dressing daily. Under Additional Wound # for location documents right heel. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 3 x 2 x not measurable cm. The wound bed tissue bed section has not been completed and is blank. Under current treatment documents skin prep daily. Under Additional Wound # for location documents right lateral plantar. Stage is Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Measure of wound 2.5 x 3.5 x not measurable cm. The wound bed tissue bed section has not been completed and is blank. Under current treatment documents skin prep daily, Moisturizers per wound daily. On 4/24/22 at 12:04 p.m. Surveyor spoke with R36's power of attorney and inquired how R36 received her right foot pressure injuries. R36's power of attorney informed Surveyor they happened after a brace was put on her leg following a fall to immobilize her leg. R36's power of attorney informed Surveyor the brace caused the pressure injuries and R36 was sitting in her chair for extended periods of time. On 4/26/22 at 9:26 a.m. Surveyor asked CNA-H if she knew how R36 developed the pressure injuries on her right foot. CNA-H informed Surveyor R36 had a funky brace, and she broke down. Surveyor asked CNA-H if she was given any instructions about the brace and was the brace/splint removed. CNA-H replied no and explained after R36 fractured her leg they weren't putting pants on her. R36 would wear a top, brief and was covered with a warming blanket. Surveyor asked who noticed the pressure injuries first. CNA-H replied, think me. Surveyor asked how she noticed the pressure injuries. CNA-H informed Surveyor she was going to put pants on R36, removed the brace and saw the sores. Surveyor asked if she reported this to anyone. CNA-H replied [first name] of RN (Registered Nurse)-D. On 4/26/22 at 1:02 p.m. Surveyor asked RN-D how she became aware of R36's pressure injuries. RN-D informed Surveyor staff came one day to her and informed her on the top of R36's right foot there was a pressure injury. RN-D informed Surveyor it was where the strap was. RN-D informed Surveyor after this was reported to her, she assessed R36, called the doctor, did a skin assessment and risk management form. Surveyor inquired how many pressure injuries did she observe. RN-D informed Surveyor she only remembers the one on top of her foot. On 4/26/22 at 1:45 p.m. Surveyor met with RN-J with DON (Director of Nursing)-B to discuss pressure injuries. RN-J informed Surveyor she works per diem at the Facility and goes on wound rounds on Wednesday with the wound doctor. Surveyor inquired about staging pressure injuries. DON-B informed Surveyor their nurses are instructed not to stage a wound unless they are wound certified. RN-J informed Surveyor she's not wound certified. DON-B informed Surveyor the wound physician stages the pressure injuries. Surveyor asked who revises the skin integrity care plans. RN-J informed Surveyor she has not worked on these. On 4/26/22 at 2:21 p.m. Surveyor observed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatments were observed according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/27/21 at 8:21 a.m. Surveyor spoke with DON-B regarding R36's right tibia fracture with a splint being applied after and inquired if R36 was evaluated in the hospital. DON-B informed Surveyor R36 was not sent to the hospital. DON-B explained she contacted R36's daughter to see which pathway she wanted for her mother. Did she want R36 sent to the ER or follow up with orthopedics as this is what the ER would probably say. DON-B informed Surveyor the daughter agreed to send R36 to the orthopedics at [name of orthopedics] as R36 had been seen there prior. DON-B indicated she contacted the orthopedics for an appointment and since R36's power of attorney was activated she (the daughter) would have to go with her. DON-B informed Surveyor due to her work schedule R36's daughter wouldn't be able to go with her, so the decision was to send the X-ray to [name of] orthopedics and they made a recommendation for a brace for comfort. DON-B informed Surveyor the Facility's therapy department had a brace which R36 could use and therapy placed the brace on R36. Surveyor asked if therapy gave any instructions for the brace. DON-B replied no explaining it was the orthopedics that recommended the brace for comfort. Surveyor asked if there were any instructions from therapy for nursing to assess R36's foot. DON-B replied no. Surveyor asked DON-B what would be the expectation for a Resident wearing a brace. DON-B informed Surveyor they should be checking skin integrity once a day under any kind of brace. Surveyor asked where Surveyor would be able to locate an order regarding R36's brace. DON-B replied I can tell you the order wasn't put in. We identified it was missed. DON-B informed Surveyor R36 is a diabetic and they do daily foot checks. Surveyor asked DON-B if the nurses were doing daily diabetic foot checks why didn't anyone observe the three pressure injuries before they were reported by a CNA. DON-B replied, I can only assume that they didn't look under the brace. Surveyor informed DON-B R36's pressure injury was not revised after receiving the brace. DON-B replied, typically it is. 2. R12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission/readmission summary dated 1/3/22 includes documentation of Has bordered dressings to coccyx and right ischial area. Both dressings covered with BM, Areas cleansed with normal saline and new dressings applied. Please see skin assessment for measurements . The skin impairment/wound form dated 1/3/22 answers yes for the question does the resident have a pressure injury. Location is right side coccyx. Stage is Stage 2 pressure injury: partial thickness skin loss with exposed dermis. Measurement of wound documents 0.5 cm (centimeter) x (times) 0.5 cm. There is no description of the wound bed. Under additional comments documents resident admitted with pressure area. Under current treatment documents NS (normal saline) cleanse F/B (followed by) Medi honey, cover with gauze island dressing daily and prn (as needed). Additional wound # for location documents Left coccyx. Stage is Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis. Measurement of wound documents 1.5 cm 0.4 cm. The wound tissue bed is not completed and is blank. Additional comments documents Resident admitted with pressure area. For current treatment documents NS cleanse F/B Medi honey, cover with gauze island dressing daily and prn. Additional wound # for location documents right medial buttock. Stage is Stage 2 pressure injury: partial thickness skin loss with exposed dermis. Measurements of wound documents 1.5 x 1.5 cm. The wound tissue bed is not completed and is blank. Under additional comments documents 'resident admitted with pressure area.' Current treatment documents NS cleanse F/B Medi honey cover with gauze island dressing daily and prn. Additional wound for location documents left lateral buttock. Stage of pressure injury documents Stage 2 and measurement of wound documents 1.5 x 1.0 cm. The wound tissue bed is not complete and is blank. Under additional comments documents resident admitted with pressure area. Current treatment documents NS cleanse F/B Medi honey, cover with gauze island dressing daily and prn. Surveyor noted the Facility did not comprehensively assess R12's pressure injuries as there are no description of the wound beds. The actual skin impairment care plan initiated 1/3/22 and revised on 3/2/22 has the following interventions: * Encourage good nutrition and hydration in order to promote healthier skin initiated 1/3/22. * Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] * [R12's name] will be encouraged to adhere to wound physician's recommendation to reposition side-to-side while in bed, avoiding sitting or laying (sic) on back initiated 3/2/22. * [R12's name] will be encouraged to limit time out of bed to less than 1 hour for each meal to promote wound healing initiated 3/2/22. * Provide pressure relieving devices, off-loading cushion to heels initiated 1/3/22. The skin impairment/wound form dated 1/5/22 answers yes for the question does the resident have a pressure injury. Location is coccyx. The stage is documented as Stage 3 pressure injury: full-thickness skin loss. Measurement of wound documents 2 x 2.2 x 0.1 cm. The wound bed is 40% slough and 30% granulation. Additional wound for location documents right upper buttock. The stage is Stage 3 Pressure injury: full thickness skin loss. Measurement of wound documents 4 x 0.6 x 0.1 cm. The wound bed is 70% granulation. Additional comments documents [name of wound doctor] to follow weekly on wound rounds. Current treatment documents NS cleanse F/B Medi honey, cover with gauze island dressing daily and prn. Under current wound/skin integrity interventions documents Pressure relief mattress, offloading cushion for heels, pressure relief cushion in w/c (wheelchair), incontinence care and Foley catheter cares. Left buttock open area assessed by [name of wound doctor] as a shear wound, not pressure. R12's skin integrity care plan was not revised until 3/2/22. R12 was hospitalized from 1/9/22 to 1/18/22. The admission/re-admission summary dated 1/18/22 includes documentation of .Skin intact, to feet and legs, lower legs red ruddy in color. Bruises noted to bilateral hands and arms. Puncture sites to bilateral antecubital sites. 11 sheer areas noted scattered across bilateral buttocks. [name of wound doctor] to assess in AM (morning). [Name of] NP (nurse practitioner) updated on readmit. The skin impairment/wound form dated 1/19/22 answers yes for the question does resident have pressure injury. Location is coccyx. Stage is Stage 3 pressure injury: full thickness skin loss. measure of wound is 1.6 x 0.7 x 0.1 cm. The wound bed is 60% granulation and 40% slough. Additional comments documents Pressure area to coccyx has improved since last assessment done by [name of wound doctor] on 1-5-22. Resident went out to hospital on 1-9-22 with critical INR (international normalized ratio). This is the initial exam since returning from hospital. Current treatment documents normal saline cleanse fb Medi honey, cover with gauze island dressing daily. Additional wound for location documents right upper buttock. Stage is Stage 3 pressure injury: full thickness skin loss. Measurement of wound is 0.5 x 0.6 x 0.1 cm. Wound bed is 100% granulation. Additional comments documents This is the initial exam since readmission from hospital on 1-18-22. Last wound care assessment prior to hospital was 1-5-22. Wound progress improved per MD. Current treatment is normal saline cleanse fb Medi honey, cover with gauze island dressing daily. R12 was hospitalized from 1/25/22 to 2/4/22. The admission/re-admission summary dated 2/4/22 includes documentation of .Sacrum has two small open areas and a non-blanchable area was noted on the left buttock. Brownish decolorization noted on bilateral lower legs. Resident seemed content being back at the facility. The readmission data collection tool dated 2/4/22 for sacrum documents 2 open areas were noted in the sacrum. Both small in size. For left buttocks documents Small red, non-blanchable area noted on the left buttock. This data collection tool was completed by LPN (Licensed Practical Nurse) Supervisor-G. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. The skin impairment/wound form dated 2/9/22 yes is answered for the question does the resident have a pressure injury. Location is left lower buttock. Stage is not completed. Measurement of wound is 1.3 x 0.4 cm and the wound tissue bed is not completed and is blank. Under current treatment documents wound cleanse f/b Medi honey, cover with gauze island dressing daily. Additional wound for location is right upper buttock. The stage is not completed, and measurement of wound is 1.5 x 0.6 x 0.1 cm. The wound bed is not completed and is blank. Current treatment is wound cleanse fb Medi honey, cover with gauze island dressing daily. Surveyor noted this RN assessment is 5 days after R12 was readmitted to the Facility and is not comprehensive as there are no description of the wound beds and the pressure injury is not staged. Surveyor noted the wound doctor did not assess R12 on 2/9/22. R12' skin integrity care plan was not revised until 3/2/22 and there are no further revisions after this date. The admission MDS (Minimum Data Set) with an assessment reference date of 2/11/22 has a BIMS (brief interview mental status) score of 12 which indicates moderate impairment. R12 requires extensive assistance with two plus person physical assist for bed mobility, does not ambulate, is checked for indwelling catheter and is frequently incontinent of bowel. R12 is at risk of pressure injury development and is coded as having two Stage 3 pressure injuries which were present upon admission. The skin impairment/wound form dated 2/16/22 answers yes for the question does the resident have a pressure injury. Under location documents coccyx. The Stage is not completed. Measurement of wound documents 0.5 x 0.5 x 0.1 cm. Wound tissue bed is 80% granulation and 20% slough. Under additional comments documents Debridement procedure done by [name of wound doctor], resident tolerated well. Current treatment documents wound cleanse f/b Medi honey, cover with gauze island dressing daily. Wound doctor's note dated 2/16/22 documents resolved 2/16/22 for right and left lower buttocks and stages the coccyx as Stage 3. Surveyor noted weekly pressure injury assessments by the wound doctor and facility staff dated 2/23/22, 3/2/22, 3/9/22, 3/16/22, 3/23/22, 3/30/22, 4/6/22, and 4/13/22. The skin impairment/wound form dated 4/20/22 answers yes for the question does the resident have a pressure injury. Location is coccyx. Stage is Stage 3 Pressure Injury: full thickness skin loss. Measurement of wound documents 1.8 x 0.7 x 0.2 cm. Granulation is 80% and slough is 20%. Additional comments documents Debridement procedure done by [name of wound doctor], resident tolerated well. Wound progress deteriorated. Current treatment is wound cleanse f/b collagen gel, cover with gauze island dressing daily. There were no revisions to R12's skin integrity care plan. On 4/24/22 at 11:59 a.m. Surveyor observed R12 in bed on her back with the head of the bed elevated high. Surveyor observed R12 is wearing bilateral Prevalon boots. On 4/25/22 at 7:08 a.m. Surveyor observed CNA (Certified Nursing Assistant)-E in the process of morning cares. CNA-E informed Surveyor she completed R12's upper body as R12 has a doctor's appointment. With gloves on CNA-E washed under R12's abdominal fold and then washed R12's perineal area from front to back. CNA-E covered R12's lower half with a blanket, informed R12 she was going to have you turn over for me, R12 grabbed onto the left transfer bar and CNA-E assisted R12 with positioning on her left side. CNA-E then went into the bathroom changed the water in the basin, removed her gloves, washed her hands, and placed gloves back on. CNA-E informed R12 she was going to wash her bottom. Surveyor observed there is stool in R12's rectal area and the dressing was coming off. CNA-E removed the dressing and soiled incontinence product, removed her gloves, washed her hands and placed gloves on. CNA-E washed R12's rectal area to remove the stool, and washed R12's right buttocks. Surveyor observed R12's coccyx pressure injury. CNA-E had R12 position on her back while CNA-E removed her gloves, washed her hands, and placed new gloves on. R12 was positioned on her right side, CNA-E washed R12's left buttock. Surveyor asked CNA-E if R12 only has one open area. CNA-E replied just this one pointing to R12's coccyx pressure injury. CNA-E removed her gloves, washed her hands, and placed gloves on. CNA-E placed a product under R12, applied periguard to R12's buttocks, positioned R12 on the other side, applied periguard and straightened out & fastened the incontinence product. CNA-E removed her gloves, washed her hands, and placed new gloves on. CNA-E removed R12's pressure relieving boots, placed pants on. CNA-E placed a sling under R12 and informed R12 she was going to find gripper socks. CNA-E removed her gloves, washed her hands, and left R12's room at 7:37 a.m. At 7:39 a.m. CNA-E returned with gripper socks, washed her hands and placed gloves on. CNA-E placed gripper socks and pressure relieving boots on R12. At 7:42 a.m. CNA-E informed R12 she was going to get the Hoyer, removed her gloves and washed her hands. At 7:45 a.m. CNA-E entered R12's room with a Hoyer lift and CNA-K entered with a high back wheelchair with a panacea cushion in the wheelchair. R12 was then transferred from the bed into the wheelchair by CNA-E & CNA-K. At 7:50 a.m. Med Tech-F entered R12's room stating the van is here and gave R12 an envelope. CNA-K combed R12's hair and then R12's placed a hat on. CNA-E and CNA-K placed a jacket on R12 and R12 was wheeled out of the room. At 7:53 a.m. Med Tech-F administered R12 Tylenol per her request, CNA-E gave R12 a snack and Med Tech-F wheeled R12 towards the front lobby. Surveyor noted R12 does not have a dressing over the Stage 3 coccyx pressure injury. On 4/25/22 at 11:45 a.m. Surveyor observed R12 sitting in a wheelchair in her room with an over bed table in front of her wearing Prevalon boots. Surveyor asked R12 how long she has been back. R12 informed Surveyor about half an hour or maybe an hour and a half. Surveyor asked R12 if she was going to sit up for a while. R12 replied yes and explained she is going to eat lunch sitting up. Surveyor asked if staff did any cares for her since she returned. R12 replied no explaining they brought her into the room and set her up to watch TV. On 4/25/22 at 12:44 p.m. Surveyor observed R12 sitting in the wheelchair eating lunch. Surveyor noted R12 has not had a dressing over her pressure injury for approximately 5 hours. On 4/25/22 at 1:13 p.m. Surveyor asked CNA-E if she told anyone R12's [TRUNCATED]

Based on observation, interview and record review the facility did not ensure residents received care and services consistent with professional standards of practice to prevent pressure injuries and did not ensure residents received necessary treatment and services to promote the healing of existing pressure injuries for 3 of 5 (R159, R35, and R156 ) residents reviewed for pressure injuries. R159 developed a pressure injury to her right ishial tuberosity. The pressure injury was not assessed, staged or measured. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in decline of the wound to a stage 4 pressure injury. The Facility failure to comprehensively assess, measure and implement treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor notified Nursing Home Administrator (NHA) - A of the immediate jeopardy on 3/11/21 at 4:18 PM. The immediate jeopardy was removed on 3/11/21, however the deficient practice continues at a scope/severity of G (harm/isolated) as the facility continues to implement its action plan and as evidenced by: R35 developed an avoidable unstageable necrotic pressure injury to her right heel and an avoidable unstageable Deep Tissue Injury (DTI) to her left heel. The facility assessed R35 to be at risk for pressure injuries, but had not developed a care plan with interventions to prevent pressure injuries. Once the pressure injuries developed, the facility did not comprehensively assess the pressure injuries to R35's heels. R156 was noted to have a wound on 6/7/20 to the sacrum. This was not comprehensively assessed until 6/9/20. On 6/9/20 the area was assessed as a stage 3 pressure injury to the sacrum. Findings include: The facility Wound Prevention and Treatment policy dated 2/4/21 documented: Policy: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment and prevention of pressure as well as non-pressure related wounds. Provision and Procedure: 1. The facility will ensure that based on the comprehensive assessment of a resident: a) A resident received care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and b) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. 3. Interventions will be implemented in the resident's care plan to prevent pressure ulcer development when the resident has no areas of concern. 4. When the resident is admitted with a pressure ulcer (s), the admitting nurse will document the size, location, odor (if any), drainage (if any) and current treatment ordered. 5. Interventions will be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing. 6. The admitting nurse will notify the attending physician and the resident and the resident's representative of the condition of the pressure ulcer. 7. The pressure ulcer(s) will be evaluated weekly, and the nurse will document the size, location, odor (if any), drainage (if any) and current treatment ordered. 8. The nurse will notify the physician any time the pressure ulcer shows signs of non-healing or infection and request treatment order changes. 9. The nurse will notify the resident and or the resident's representative of any changes related to the improvement, deterioration, and/or treatment changes on an on-going basis. 1. R159 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R159's Braden scale for predicting pressure injury risk on 9/11/20 documented a score of 14 indicating moderate risk. R159's Annual Minimum Data Set (MDS) with an Annual Reference Date of 6/12/20 documented R159 to need extensive 1 person assist for bed mobility, 2 person total assist for transfer and Functional Limited Range of Motion impairment of 1 side - upper and lower extremity. R159's Care Plan interventions included: Wheelchair cushion - implemented on 8/2/19 Draw sheet or lifting device to move resident - implemented on 8/2/19 Off load heels while in bed - implemented 8/2/19 and revised 3/16/20 Encourage good nutrition and hydration in order to promote healthier skin - implemented 6/22/20 Follow facility protocol for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Pressure relieving bed mattress - implemented on 6/22/20 Reposition every 2-3 hours and PRN (as needed) - implemented on 6/22/20 Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface - implemented on 6/22/20 Pressure relieving bed mattress with pump - implemented on 9/17/20 Monitor, document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate and any other notable changes or observations - implemented on 9/17/20. Reposition side to side (off wound) every 2-3 hours and PRN. Up in wheelchair only for meals and 1 hour at a time to work on puzzles. Resident chooses not to lay in bed to off load wound, prefers to roll around in wheelchair or work on puzzles while sitting up in wheelchair - implemented 10/15/20 R159's Skin Impairment/Wound note Pressure injury form dated 1/28/2021 at 8:00 AM documented: Barriers to wound healing: Resident has poor po (by mouth) intake and often eats less than 25% of meals. Current Wound/Skin Treatment/Interventions: Resident is repositioned side to side every 2-3 hours, has air pressure relieving mattress on bed and Roho cushion in chair when up in chair. Wound Education provided: Reviewed wound status and progression with family, discussed resident's intake and risks of continued poor intake up to and including death. Encouraged to continue repositioning and encouraged to increase oral intake. Non-Pressure barriers to wound healing: Current Wound/Skin Treatment/Interventions: Wound Education provided. Review of R159's progress notes indicated wound presence: RN 9/2/2020 8:08 PM eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Situation: The Change In Condition/s reported on this Change in Condition Evaluation are/were: Skin wound or ulcer. Nursing observations, evaluation, and recommendations are: CNA (Certified Nursing Assistant) found new area when turning resident. Border foam applied to area for protection after cleaned and barrier cream applied. The Registered Nurse (RN) that documented this information no longer worked for the facility, thus was not available for interview. RN-F 9/2/2020 8:24 PM Note Text: NP (Nurse Practitioner) called with update of new open area, order okay for border foam dressing and barrier cream daily or as needed. Surveyor noted there was no documentation of a comprehensive wound assessment. There was no documentation of the wound location, stage of the wound, measurements or description of the wound characteristics. In addition, staff did not transcribe the treatment orders onto the Treatment Administration Record (TAR). On 3/11/21 at 1:36 PM Surveyor interviewed RN-F who reported treatment orders or dressings should be on the TAR. RN-F stated If it wasn't on the TAR that's an oversight on my and (Name of Previous DON-Y) part. I probably assumed she put the order on the TAR but I should have verified it. RN 9/3/2020 5:20 AM Note Text: Resident resting in bed. Dressing to right upper thigh area C/D/I (clean, dry intact). No drainage noted. Skin warm and dry. Denies pain. Call light within reach. Surveyor noted there was no assessment of the wound documented to include wound characteristics or measurements. In addition, there was no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] RN-E 9/3/2020 22:35 Note Text: Pt is in bed sleeping peacefully, no s/s pain or distress noted this shift, open area on right buttock/thigh is not bleeding and no s/s (signs/symptoms) infection noted, no other needs or concerns at this time. Surveyor noted there was no assessment of the wound documented to include wound characteristics or measurements. In addition, there was no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/11/21 at 1:15 PM Surveyor interviewed RN-E who reported she would look at the TAR to know what treatment was ordered. Surveyor advised RN-E there was no treatment on the TAR. RN-E reported she did not recall what treatment was in place at that time and stated: But if I charted on it, we must have been monitoring it. It must have been passed on in report or something. RN 9/4/2020 at 3:29 AM Note Text: Resident resting quietly in bed at this time. Dressing clean, dry, and intact. Positioned on side. RN 9/4/2020 at 3:10 PM Note Text: Dressing clean dry and intact. Will continue to monitor. RN 9/4/2020 at 10:54 PM Note Text: Resident resting quietly in bed at this time. No s/s pain/discomfort. Dressing clean dry and intact. RN 9/5/2020 at 2:51 AM Note Text: Resident sleeping soundly in bed. No evidence of any pain or discomfort. Dressing clean & intact. RN 9/5/2020 at 2:08 PM Health Status Note Note Text: Dressing to right buttock/thigh area significantly soiled. Writer cleaned wound and changed dressing. Resident has no c/o (complaint of) pain or discomfort at this time, going about daily activities as usual. Will continue to monitor. Surveyor noted there was no assessment of the pressure injury to include wound characteristics, measurement or odor if present. There was no documentation regarding the appearance or amount of the significant soiling and no documentation the Physician was notified. In addition, there was no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-F 9/5/2020 at 4:53 PM Note Text: Resident is currently up in the dining area working on her crossword puzzle. Dressing to right buttock/thigh CDI (clean, dry, intact). Resident has no c/o pain or discomfort at this time, VSS (vital signs stable). On 3/11/21 at 1:36 PM Surveyor interviewed RN-F who reported she helped get the resident out of bed that day. She wanted to work on a puzzle, so I was able to see the dressing. RN 9/6/2020 at 1:35 AM Note Text: Resident sleeping quietly. No evidence of any pain or discomfort seen. Dressing in place to right buttock/thigh area. Call light in reach. Surveyor noted documentation indicated the pressure injury was identified on 9/2/20. The wound was not assessed, staged or measured. A foam dressing was applied, however no treatment was implemented on the TAR. Staff continued to document the presence of a dressing on the wound and soiling of the dressing up until 9/5/20. There was no evidence the facility was assessing the wound or completing treatment to the pressure injury and there was no treatment implemented on the TAR after it was identified on 9/2/20. There was no further documentation on the wound until 9/15/20. On 9/10/20 the Facility Skin & Wound - Total Body Skin Assessment: Weekly form documented: No new wounds. Further review of R159's skin & wound total body skin assessment weekly forms from August to November 2020 documented: No new wounds even though R159 had developed a wound on 9/2/20. Surveyor located a Wound Physician note dated 9/15/20. This was the first documentation of R159's pressure injury since it was identified on 9/2/20. The wound physician notes documented: 9/15/20 Stage 4 pressure wound of the right posterior upper thigh >(greater than) 1 days duration. 5 x 3 x 0.1 cm (centimeters). 100% thick adherent devitalized necrotic tissue. Surgical excisional debridement procedure - devitalized tissue and necrotic muscle and surrounding fascial fibers were removed at a depth of 1.5 cm and healthy bleeding tissue was observed. 9/22/20 Stage 4 pressure wound of the right posterior upper thigh. 4 x 3 x 1.6 cm. 90% necrotic, 10% granulation tissue. Improved. Debrided. 9/25/20 Stage 4 pressure wound of the right posterior upper thigh. 4 x 3 x 1.6 cm. 80% necrotic, 20% granulation tissue. Wound progress improved. Debrided 9/29/20 Stage 4 pressure wound of the right posterior upper thigh. 3.5 x 3.4 x 1.8 cm. 70% necrotic, 30% granulation tissue. Improved. Debrided. Surveyor noted the Wound Physician began to follow R159's pressure injury on 9/15/20 and continued to treat the pressure injury and implement appropriate changes in treatment which subsequently led to some improvement of the wound. 2/3/21 Stage 4 pressure wound of the right posterior upper thigh. 2.5 x 3 x 1 cm. 20% necrotic, 20% slough, 60% granulation tissue. Improved. On 2/6/2021 at 11:49 AM R159 experienced a change in condition. The Power of Attorney (POA) was notified, decided to send resident to the hospital for evaluation and treatment and she was subsequently admitted to the hospital. Progress notes documented R159 was readmitted to the facility on [DATE] at 3:00 PM. R159's readmission data collection tool did not document any wounds present. There was no assessment or measurements of any wounds. There was no documentation in the progress notes or medical record of any wound assessments or measurements. Progress notes on 2/12/2021 at 11:27 AM documented: Resident resting in bed, awake, responsive to staff. Cares and repositioning done. Wounds to coccyx, right and left hips. Area to left outer ankle noted necrotic. Pressure relieving boots to bilateral. feet. Air mattress to bed. Foley catheter in place for wound healing. Right arm swollen, positioned elevated on pillow. Dressings changed to all areas. Surveyor noted this was the first documentation of wounds since R159 was readmitted to the facility. There was no assessment of the wounds to include staging, measurements or characteristics of the wounds. Progress notes on 2/12/2021 at 4:14 PM documented: Spoke with daughter/POA, informed daughter patient was having trouble swallowing pills and asked if it was OK to discontinue vitamins and supplements and change her pain medication to liquid [MEDICATION(S)] for pain instead of Oxycodone. Daughter agreed with this change in care. NP was listening in to conversation, it was also brought up to possibly consider hospice if pt declines again or if daughter wants to send her out and have it become a cycle as patient is sleeping a lot and not eating much at facility. Progress notes on 2/13/2021 at 7:38 PM documented: Spoke with daughter about putting patient on hospice, reported to daughter that patient has not been eating or drinking, she barely takes her medication. I offered her the option of sending pt to hospital, informed daughter patient is declining. Daughter stated she needed to talk to family to make decision and daughter would call back when decision was made. Progress notes on 2/13/2021 at 9:05 PM documented: Spoke with daughter who stated family wants patient to go to the hospital for evaluation and possible higher level of care. (R159 was sent and admitted to the hospital - she did not return to the facility). On 3/10/21 at 12:27 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor and DON-B reviewed R159's medical record together. DON-B stated the right ischium was the same as the right posterior thigh and that the wound care Physician documented it as such. After review of the medical record, DON-B agreed there was no evidence of an assessment, measurements or treatment implemented after the wound was first identified on 9/2/20. Surveyor clarified the care plan interventions that were implemented with DON-B. The care plan indicated mattress with pump. This is an air pressure relieving mattress with air pockets to adjust the pressure. DON-B stated the facility implements a pressure reducing cushion and mattress for everyone upon admission, and we change them out if they have wounds or are at higher risk. Surveyor discussed R159's care plan intervention dates. The care plan was not specific as to when interventions were implemented/revised so it was difficult to determine what and when interventions were implemented. DON-B provided Surveyor R159's care plan that was in place prior to the pressure injury identification and after. Appropriate care plan interventions were put in place prior to development of the pressure injury and revised after the pressure injury was identified, however they were not implemented upon the initial identification of the pressure injury on 9/2/20, but rather when the stage 4 was identified on 9/15/20. Surveyor asked DON-B about R159's readmission to the facility on [DATE]. Documentation indicated the resident arrived at 3:00 PM. The readmission data collection tool did not document any wounds present and there was no documentation in the medical record regarding any wounds present. On 2/12/20 progress notes documented wounds to coccyx, right and left hips and left outer ankle was necrotic. Surveyor advised DON-B there was no documentation in R159's medical record to indicate any of R159's wounds were assessed, staged or measured. DON-B stated: Yeah, I saw that. There needs to be some education done. Surveyor asked DON-B if the wounds were assessed or measured, to which he replied: No. That's because they told me about it the next day, but I was literally running out the door for an emergency I planned to come in the next day (on Saturday) but I heard she was already being sent back out. Surveyor asked DON-B if he was responsible for assessing and measuring the wounds, to which he replied: Yes. I was planning to do training this week with the nurses on how to measure, but then you guys came in. Surveyor confirmed with DON-B there are RN's and Licensed Practical Nurses working on other shifts. Surveyor asked DON-B: Would you expect the RN to do an assessment and measure the wound if a resident admits with a wound? DON-B replied: Yes. But they usually leave it for me to do. That's why I am going to do training. Surveyor asked DON-B what the nurses do if he is not available or not at the facility. DON-B stated: They call me and I usually go in. Surveyor confirmed with DON-B: So when you're not here, no other licensed nurse documents an assessment and measurements of wounds? DON-B stated: No. I do it when I come in. But I am going to train everyone this week on measuring wounds. On 3/11/21 at 10:31 AM Surveyor interviewed Medical Doctor-G and Nurse Practitioner-H. Medical Doctor-G reported she was in to see R159 on 9/17/20 and was aware of the pressure injury. She reviewed her progress notes which documented the NP was notified of the wound on 9/2/20 and according to the facility, it was a superficial wound on the right posterior thigh which appeared to be an old pressure injury. She reported the NP did not see the wound, as she (R159) was up in her wheelchair. The facility did not assess, stage or measure the pressure injury to R159's right posterior thigh when it was identified on 9/2/20. The facility did not implement appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, when the resident readmitted to the facility on [DATE] with several pressure injuries, none of the wounds were assessed, staged or measured. The failure of the Facility to comprehensively assess, measure and implement treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The immediate jeopardy was removed on 3/11/21 when the following was implemented; Residents with pressure injuries have the potential to be affected. A comprehensive assessment was completed by an RN on all residents with pressure injuries. Residents with pressure injuries had an audit of the provision of current treatment to assure the current MD orders are placed on the Treatment Administration Record (TAR) and are being followed. Each resident plan of care was reviewed to reflect wound prevention and healing. Licensed staff currently working was educated on the current wound management and pressure ulcer prevention program and change of condition process. The education included comprehensive assessment completed by a RN (including wound measurements, description of the wound, odor and drainage). Licensed nurses were educated on physician notification and ensuring MD orders are placed on the TAR. Any regular, agency or casual licensed staff that are working were educated prior to the start of their next scheduled shift with 100% licensed staff nurses educated by March 16, 2021. All new skin issues will be placed in Risk management upon discovery. A comprehensive RN assessment will be conducted on all new wounds and weekly until healed. All new skin issues will be reviewed by the Director of Nursing (DON) and or designee for interventions to promote wound healing and those interventions are placed on the TAR. The licensed staff nurse will notify the DON of treatment changes, decline in wound status or barriers encountered with resident treatments. MD recommendations regarding wound care will be reviewed in daily clinical meeting to assure timely follow up. The wound nurse or DON will review all pressure injuries weekly and document the wound evaluation in the medical record. The Interdisciplinary Team (IDT) will review pressure injuries weekly for any necessary changes to the plan of care. New pressure injuries will be evaluated for the root cause and interventions will be implemented based on causative factors. The IDT will have a weekly wound meetings which will include an audit of all pressure injuries wound status, current interventions for healing, adherence to current treatment and care plans. Results of the audits will be reviewed in Quality Assessment Performance Improvement (QAPI) for any further education or modifications to the plan of correction. The deficient practice continues at a scope/severity of G (harm/isolated) as evidenced by: 2. R35 is [AGE] years old and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . After completing her rehabilitation, R35 planned to discharge home where she lived independently. ASSESSMENT AND CARE PLAN The facility's Admission Data Collection Baseline Care Plan Tool was not completed until 2/9/21. The section titled Skin Condition was blank and was not completed. It only noted that R35's skin was warm. The section titled Skin Integrity Planning was blank, indicating that the facility had not completed a baseline care plan related to R35's risk for pressure injuries. The 2/9/21 Admission Minimum Data Set (MDS) noted that R35 was cognitively intact. She required extensive assistance from 1 staff person for bed mobility and had limited range of motion on her left lower side. R35's skin was noted to be intact, with the exception of the surgical wound from her [CONDITION(S)]. The Care Area Assessment was completed on 2/9/21 and noted that R35 was at risk for the development of pressure injuries due to: incontinence, weakness, deconditioning, and requiring more assistance with bed mobility and repositioning. The facility planned to put the following preventative measures in place: pressure reducing surfaces to bed and chair and staff assistance with repositioning every 2-3 hours. Although the facility determined on 2/9/21 that R35 was at risk for developing pressure injuries, a pressure injury care plan was not completed until 2/15/21. This was after R35 was found to have pressure injuries to both her left and right heel on 2/4/21. The 2/15/21 care plan noted that R35 was at risk for skin impairment due to recent surgical hip, with a goal for R35 to be free from skin injury. Interventions included: educate resident; encourage good nutrition; identify potential causative factors; implement pressure reducing devices such as wheel chair cushion, air mattress, and off-loading heels; and turn/reposition resident every 2-3 hours. INTERVIEW AND OBSERVATIONS On 3/8/21 the facility provided the survey team with a list of residents who had pressure injuries. R35 was not on the list as having a pressure injury. On 3/8/21 at 12:08 PM, R35 was interviewed. She said that she had blisters to both of her heels. On 3/8/21 at 12:09 PM, Director of Nursing (DON) - B was interviewed. DON - B was also the facility's designated Wound Nurse. When asked why R35's heel blisters were not included on the list of residents with pressure injuries, DON-B said that he was unaware that R35 had blisters to her heels. DON - B said that he planned to assess R35's heels and would provide the assessment to the surveyor. On 3/9/21 at 3 PM, the survey team met with Nursing Home Administrator (NHA) - A, DON - B, and Vice President of Clinical Services (VPCS) - J. The surveyor shared the preceding information and requested the skin assessment for R35's heels. On 3/10/21 at 9:02 am, DON - B and Wound MD - I assessed R35's heels. (Wound MD - I was an outside consultant who provided wound consultation to the facility.) MD - I said that this was the first time he was treating R35. MD - I assessed R35's right heel as an unstageable necrotic pressure injury that measured 4.0 x 5.0 x Not Measurable cm. MD - I noted that it had thick adherent black necrotic tissue. The left heel was assessed as an unstageable Deep Tissue Injury (DTI) due to pressure that measured 3.0 x 4.0 x Not Measurable cm. MD - I recommended the following treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Gauze island with border once daily for 30 days. MD - I recommended that both heel wounds be off-loaded and to float the heels in bed. MD - I said that the right heel pressure injury could be debrided; but determined he would not debride the wound because R35 would be discharged from the facility in the next 1-2 days. MD - I's written report documented that the right heel was not debrided because it was a Non-infected heel necrosis. MD - I told R35 that she should seek treatment from a wound clinic, once she was discharged from the facility. R35 had a pair of blue heel boots on her nightstand and MD - I told R35 that she should wear the blue heel boots at all times. DON - B said that R35 did not like to wear the heel boots. INTERVIEW WITH VICE PRESIDENT OF CLINICAL SERVICES On 3/10/21 at 10:25 AM and 12:01 PM, VPCS - J was interviewed. VPCS - J said that the facility identified the pressure injuries to R35's heels on 2/4/21. VPCS - J provided a 2/4/21 physical therapy progress note that indicated bruising was found on both of R35's heels. Heel protector boots were placed on R35 and DON - B was notified. The surveyor indicated that although the pressure injury was identified on 2/4/21, there was no comprehensive assessment of the wound nor had a care plan been developed until 2/15/21, which was 11 days after the pressure injuries to the heels were discovered. VPCS - J referred to a progress note dated 2/15/21. VPCS-J said that a nurse had identified the area on that date and the RN had been called to assess the area. According to the 2/15/21 progress note, LPN - K documented at 7:42 am, that R35 had no complaint of heel pain and that the heels were elevated on the heel lift pillow. At 11:17 am, RN - D documented that the heels were dry with black scabs to site. R35 was noted to have no complaints of pain. Again, the bilateral heel wounds were not comprehensively assessed. Although a care plan was initiated on 2/15/21, it only noted that R35 was a risk for pressure injuries. The care plan did not address the pressure injuries to R35's heels. VPCS - J said that Nurse Practitioner (NP) - H had seen R35 on 2/15/21. NP - H's note did not include a comprehensive assessment of R35's pressure injuries to her heels. NP - H documented that R35 had blood blisters to both heels. (This conflicts with RN - D's assessment on 2/15/21 that noted both heels were scabbed.) NP - H noted that skin prep was applied and covered with border foam. However, there was no order for this treatment to R35's pressure injuries until 2/17/21, according to R35's physician orders. According to the February 2021 Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . VPCS - J said that the bruising identified on R35's heels on 2/4/21 were Deep Tissue Injuries (DTIs) that R35 had acquired prior to her facility admission. VPCS - J said that DTIs usually present themselves 24 - 72 hours after the injury happened. VPCS -J said that since R35 was admitted on [DATE], it was likely that the DTIs occurred at the hospital and presented on 2/4/21. The surveyor indicated that the facility would have had to comprehensively assess the heels on 2/4/21 to determine that R35 had DTIs to both heels. The facility had not completed a comprehensive assessment of the heels until 3/8/21. INTERVIEW WITH DON - B On 3/10/21 at 12:50 PM, DON - B was interviewed. DON - B said that he did not recall being notified on 2/4/21 of the bruising to R35's heels. DON - B said that he did not recall if LPN - K or RN - D notified him on 2/15/21 of the pressure injuries to R35's heels. DON - B said that both he and the nurse practitioner should be notified when a pressure injury is discovered. DON - B said that the RN on duty should assess the pressure injury. DON - B said that he first learned of the pressure injury to R35's heels, when asked about it by the surveyor on 3/8/21. DON - B said that he then completed an assessment of the pressure injuries on 3/8/21. DON - B said that this was the first time R35's pressure injuries had been comprehensively assessed by the facility. The assessment was consistent with Wound MD - I's assessment on 3/10/21. The right heel measured 4.2 x 3.7 cm. No depth was noted. The wound was intact and the wound bed was not visible. The left heel measured 4.5 x 4.0 cm. No depth was noted. The wound was intact and the wound bed was not visible. The plan was for Wound MD - I to see R35 on 3/10/21. INTERVIEW WITH RN - D RN - D was interviewed on 3/10/21 at 1:30 PM. RN - D did not recall why she looked at R35's heels on 2/15/21 when she documented that R35 had scabbed areas to both of her heels. RN - D did not recall if LPN - K asked her to assess the heels. RN - D did not recall if she notified NP - H about the pressure injuries to R35's heels. RN - D said that if she was called to look at a pressure injury, she would be responsible for assessing the injury. RN - D said the assessment would include the site, size, drainage, pain, etc. When asked why she did not complete a comprehensive assessment of the pressure injuries, RN - D said that she had been working as the RN Manager and the nurse on the floor and it was difficult to do both jobs. RN - D did not recall if she had notified DON - B, who is also the facility's wound nurse, of R35's wound. INTERVIEW WITH MEDICAL DIRECTOR - G On 3/11/21 at 9:08 AM Medical Director (MD) - G, who is also R35's attending physician, was int [TRUNCATED]

Based on record review and staff interviews, the facility did not have evidence of a thorough investigation regarding an allegation of sexual abuse, involving R1 and R2 which occurred at 4:00 pm on 2/18/20 and did not have evidence that measures were put in place to prevent further potential abuse. The facility's completed investigation did not contain statements from all involved staff and staff statements that were obtained did not include specific details involving R2's behaviors and events of 2/18/20. After the first resident to resident sexual encounter between R1 and R2, the facility did not develop interventions to prevent R2 from abusing R3 or other female residents. The facility did not protect R3 while an investigation involving R1 was underway. The facility did not conduct an investigation into the observation of R2 observed being naked and trying to remove R3's clothes. This deficient practice affected 3 of 3 residents (R1, R2, and R3) involved in allegations of sexual abuse. Using a reasonable person concept, it is likely that a female resident (R3) would feel terrified when a naked man is standing in her room trying to take off her pajama bottoms. Findings include: The facility's policy and procedure for Incident Reporting and Investigation dated 12/2016 indicates the following under E. Investigations of Incidents and Adverse Events: * obtain factual information regarding the incident. * determine what remedial and/or corrective action, if any, may be appropriate to protect residents, prevent reoccurrence and improve quality of care. * interviews are conducted with all parties and witnesses involved in the incident. Surveyor reviewed a facility self-report investigation that occurred on 2/18/2020 that indicated R1 and R2 were engaged in a sexual act. R1 and R2 both have dementia with activated Health Care Power of Attorney's (HCPOA). The facility's investigation summary states in part; On February 18, 2020 at approximately 4:00 pm, it was reported to the Administrator .that R2 and R1 had been seen by agency Certified Nursing Assistant (CNA) J in a sexual position on the bed in R1's room. She (CNA) J called for help. The nurse on duty on the second floor, LPN-D and Activities Director (AD) G immediately responded and moved R2 from the side of R1's bed where he was standing when they entered the room. They redressed R2 and took R2 back to his room. The facility's investigation summary indicates that the facility's first order of business was that staff moved quickly to protect R1. When CNA J first entered R1's room, she saw R2 who was naked .lying on top of R1 whose pants and brief were at her knees when CNA J called for help, R2 stood up next to R1's bed. In the meantime, AD G came to my office (Administrator's) to report this incident to me. I called our Medical Director (MD) I who came in less than 15 minutes, examined and assessed both R1 and R2 neither had any bruises or scratches. R1 appeared relaxed and in good spirits. R1 told MD I she had invited R2 into her room. This coincided with AD G's description .where R1 did not appear in any distress. Two officers from Waukesha Police Department arrived .They went upstairs to speak to R1 and R2. R1 told the officers she had not been assaulted and was fine. R2 was not-interviewable. When the officers came back down stairs they said they did not see any violent behavior from R2. R1's HCPOA did not want R1 to go to the hospital for an examination .R2's wife was not surprised but thought this type of behavior was in the past as she had gone through this with him as his dementia progressed .she thought R2 had more than likely mistaken the other resident for her. In fact R2 was told by the AD G that R1 was not his wife, and R2 argued that, in fact, she was his wife. . MD I was concerned that may be a change of condition/altered mental status and decided to sent R2 to the emergency department .Initial hospital notes indicate agitation as the principle problem likely related to [MEDICAL CONDITION] with dementia and urine retention as possibly contributing to his agitation .Following our thorough review of the circumstances of this resident- to- resident incident, we have not been able to show willful intent on R2's part, particularly when he and his wife both stated R2 more than likely thought R1 was R2's wife. R1 did not report pain, MD I could see no physical injury or emotional harm at the time of MD K's assessments and nothing of this nature was discovered while following R1 on our twenty-four hour report and beyond. This was signed by Administrator A on 2/25/20. The facility investigation provided did not include staff statements or complete information from all staff involved. The facility's investigation does not indicate that before the Medical Director had assessed R2 and before the police arrived, R2 was found naked in another female resident's room (R3) trying to take off her pajama bottoms. There was no documented interventions to prevent R2 from entering another Resident's room and to prevent potential further abuse, after R2 was observed in R1's room. There was no information on the timeframe's surrounding the event. On 8/4/20 at 10:30 AM, Surveyor spoke with Administrator-A. Surveyor requested any interviews or statements pertaining to the investigation involving R2. Administrator-A was able to locate 3 staff statements. This included, AD-G, LPN-D (Licensed Practical Nurse) and Agency CNA-J. These statements just reference the event between R1 and R2. There are no additional statements from other involved staff nor any information pertaining to the subsequent resident-to-resident incident involving R2 and R3. Surveyor review confirmed three residents were involved in the events of 2/18/20. They are: R2. R2's medical record was reviewed by Surveyor. R2 was admitted on [DATE] and his HCPOA has been activated since 7/3/19. R2's Admission, and History with Physical does not indicate any sexual behaviors. R2's admission MDS with a target date of 1/30/20 reflects a BIMs score of 00 which indicates R2 is severely cognitively impaired for daily decision making skills. The MDS has documented R2 has clear speech, is understood, understands with clear comprehensions, has adequate vision with corrective lenses. R2 was noted to have trouble concentrating on things. The MDS is checked for wandering and had this type of behavior 1 to 3 days. The MDS indicates yes to the question asking if Resident's wandering places Resident at significant risk of getting into potentially dangerous places (outside, stairs, etc.) The MDS also responds yes to the question if Resident's wandering significantly intrudes on the privacy of activities of other residents. The MDS also indicates that it is very important for R2 to see family/friends. The MDS also indicates R2 requires supervision with 1 physical assist with bed mobility, transfers, and ambulation in the corridor. He requires limited assistance of 1 for personal hygiene and toilet use. R1. R1's medical record was reviewed by Surveyor. R1 was admitted on [DATE] and has an activated HCPOA since 3/15/16. R1 does not have a documented history for sexual interactions. A quarterly Minimum Data Set (MDS) with a target date of 12/26/19 indicates a Brief Interview for Mental Status (BIMs) score of 15 indicating R1 is cognitively intact for daily decision making skills. The MDS also indicates R1 is independent with ambulation, requires supervision with 1 for bed mobility, and transfers independently with set up. For personal hygiene, toileting and dressing R1's requires extensive assist with 1. According to the MDS, R1 has adequate hearing, clear speech, is understood, understands and has adequate vision. R3. R3's medical record was reviewed by Surveyor. R3 was admitted on [DATE] and has an activated HCPOA since 1/6/18. R3's quarterly MDS with a target date of 11/22/19 documents R3's BIMs score of 2 indicating R3 is severely cognitively impaired for daily decision making skills. R3 requires extensive assistance with 1 for bed mobility, dressing, and personal hygiene. R3 requires extensive assistance of 2 staff for toileting and transfers. According to the MDS, R3 has adequate hearing, clear speech is usually understood and understands and has adequate vision. Incident 1. R2's Progress Note on 2/18/20 at 4:00 PM by LPN-D indicates R2 was having sex with R1 in R1's bed. LPN-D indicates they saw R2 naked standing by the bed refusing to leave R1's bedside. R1 was in her bed with her brief down past her knees. The Progress Note on 2/18/20 at 5:00 PM by LPN-D indicates R2 was naked laying with his head on R1 lower torso area. This was discovered by staff who then intervened. R2 was difficult to redirect and R1 did not express any concerns. The Progress Note prior dated 2/18/20 at 6:34 PM by RN-C indicates that R2 was naked and trying to remove R3 clothes. R2 was difficult to direct and 911 was called and the police came in. The Progress Note dated 2/18/20 at 7:54 PM by Registered Nurse (RN)-C indicates they were notified by LPN-D that R2 had his pants down R1 and its unsure if they had intercourse or not. And MD-I came in to the facility to evaluate. R1's plan of care was updated on 2/23/20 to include no male caregivers. R1 did not have any documented changes from this event. There is nothing in R2's care plan to indicate that staff implemented any changes to protect other residents from further potential abuse immediately following this incident. Incident 2. R3's Progress Note on 2/18/20 at 7:00 PM by LPN-D indicates R3 was heard making noises and upon entering R2 was naked attempting to remove R3 pajamas in bed. R2 was resistive and Administrator-A and RN-C were notified. Progress Note dated 2/18/20 at 8:00 PM by LPN-D indicates R2 was naked in R3 room attempting to pull down her pajama bottoms in bed. R2 was difficult to redirect out of R3 room. The note indicates Administrator-A and RN-C were notified for event and assistance, The Progress Note on 2/18/20 at 8:00 PM by RN-C indicates that MD-I came in to evaluate after R2 had 2 physical altercations this evening. R2 was sent out to the hospital for further evaluation. The facility investigation indicates R2 was sent out to the hospital and does not include the encounter with R3. The investigation does not include what R2 was doing between the encounter with R1 and the encounter with R3. On 8/4/20 at 10:28 AM Surveyor spoke with LPN-D. LPN-D indicated Agency CNA-J alerted them. LPN-D then went to R1's room. R2 was naked standing next to R1's bed. R1 was not expressing any concerns. R2 was difficult to redirect. LPN-D indicated they notified RN-C. They indicated Admissions Director-F was doing 1 to 1 at some point. LPN-D indicated MD-I came in to assess. The police came in and they were not asked any questions by them. LPN-D indicated RN-C took over and they did not have any involvement with R2. On 8/4/20 at 10:39 AM, Surveyor spoke with AD-G who indicated they assisted R2 with redirection and took R2 back to his room. AD-G then gave R2 a snack and they left to go downstairs to tell Administration. AD-G did not recall who they told. AD-G indicated her shift ends at 4:00 PM and it would have been before then. On 8/4/20 at 11:09 AM Surveyor spoke with Administrator-A. Administrator-A did not conduct an investigation into the encounter between R2 and R3 because no act occurred. Administrator-A indicated she was notified of the 1st event however, RN-C was confused with the time and timeline of events. The police came in and did not have anything they could do. The MD did come in and then sent R2 out to the hospital for the changes in behavior. Administrator-A has no additional interviews or statements besides what was already provided. The investigation summary contains no definitive timelines and facts involving R1, R2 or R3. STAFF STATEMENTS NOT INCLUDED IN INVESTIGATION On 8/4/20 at 12:29 PM. Surveyor spoke with Admissions Director -F who stated they were helping Administrator-A out and called the police. Then she went to spend 1:1 time with R2 by wheeling R2 around after the 2nd event with R3. R2 was calm and was in his room after the event. Admission Director- F indicated she left by 8:00 PM and told RN-C they were leaving. The police had just left when Admission Director -F went upstairs. Admission Director-F is unsure of any exact times besides when they left for the evening. On 8/4/20 at 1:23 PM Surveyor spoke with MD-I. MD-I indicated they came in after the suppertime with the 2nd event. MD-I assessed R1 and R3 and found no trauma. MD-I assessed R2 and felt he was having a medical change in behavior and sent R2 to the hospital. MD-I thought R2 had mistaken R1 for his spouse and felt R3 was a change in behavior. On 8/4/20 at 1:35 PM Surveyor spoke with CNA-E who was working the floor on 2/18/20 and who had R2 on her assignment. CNA-E recalls R2 eating dinner in the dining room. CNA-E recalled hearing about the encounter between R2 and R1. CNA-E remembers after dinner seeing R2 lying in bed. CNA-E indicated it was quick for R2 to be in R3's room. CNA-E indicated they saw Admissions Director-F wheeling R2 around earlier then they took over. CNA-E doesn't remember exactly where R2 was between R1 and R3 encounters. R2 was eating in the dining room, lying in bed and being wheeled on the unit. On 8/4/20 at approximately 2:00 PM Surveyor observed R1 laying in their bed. R1 appeared to be sleeping and had a roommate that also appeared to be sleeping. R1 was not awake to be interviewed by Surveyor. On 8/4/20 at approximately 2:15 PM Surveyor observed R3 laying in bed. R3 appeared to be sleeping. R3 was not awake to be interviewed by Surveyor. On 8/4/20 at 2:40 PM, Surveyor spoke with RN-C. RN-C could not recall times or actual events. RN-C remembered the police and the MD being in the facility. The police were not able to do anything. RN-C indicated Administrator-A was on the floor the 1st event and they took care of everything. RN-C indicated Administrator-A told them to call the police. The MD came in and sent out R2 for being a safety risk to others. RN-C indicated the Administrator took over and they were working downstairs. RN-C did not recall what happened after the 1st encounter between R1 and R 2 or the actual time line of events that evening. On 8/4/20 at 2:51 PM, Surveyor spoke with Administrator-A who indicated she was not upstairs. Administrator-A talked to RN-C in her office. Administrator-A could not recall the actual events that happened that evening. DON-B (Director of Nurses) was not in work status when these events occurred. Administrator-A had no additional information and expressed there are things to work on with this investigation. Administrator-A agreed this is not a thorough investigation.

Based on interview and record review, the facility did not ensure that 1 of 3 (R1) residents reviewed for accidents was provided adequate supervision and assistance to prevent accidents. According to her care plan, R1 required the assistance of 2 staff using a sit-stand lift for transfers. R1 was transferred with the sit-stand lift and 1 staff person, which resulted in R1 dislocating her left shoulder. This created actual harm for R1. Findings include: R1 is [AGE] years old and has a [DIAGNOSES REDACTED]. R1's care plan, dated 3/9/18 noted that R1 is totally dependent on 2 staff with the sit to stand lift. The progress notes on 4/10, 4/11, and 4/12/18 indicated that R1 required the assistance of two staff for transfers with the sit-stand lift. Additionally, R1 was participating in a restorative nursing program where she was working on transfers with the sit-stand lift. On 4/19 and 4/20/18 the restorative notes indicated that R1 needed physical help with the placement of her hands and feet on the lift. The 4/21/18 restorative note stated that R1 could not follow verbal cueing to place her hands and feet on the lift. Staff had to physically do this for her, as she was very anxious and confused. The 4/23/18 progress note indicated that R1 was guarding and holding her left arm, along with statements of ouch. She was pushing staff's hands away. An X-ray was completed and indicated that R1 had sustained a left shoulder dislocation. R1 was sent to the emergency room at the hospital for evaluation and treatment. R1 returned to the facility with a sling to her left shoulder. The progress notes did not indicate how R1 had sustained this injury. On 9/24/18 at 2:50 PM, the Director of Nursing - B (DON - B) was interviewed and asked how R1 had dislocated her left shoulder. On 9/25/18 at 8:10 am, DON - B provided a copy of the facility's incident report, dated 4/23/18. The Final Outcome/Disposition documented the following: Resident is a sit to stand. sling rode up body causing arms to lift and sling to under arms. Resident is obese and leans to Left side with arm on arm rest of wheelchair causing shoulder to rise and exert pressure to shoulder area. [DIAGNOSES REDACTED]. Resident has immobilizer in place. Transfers changed to Hoyer lift and follow-up ortho appointment scheduled. The incident report also contained the following statement from Certified Nursing Assistant (CNA) - C who had transferred R1 on 4/23/18. Resident performed a sit-to-stand for transfer. During transfer belt rode up resident sides. Resident was placed in wheelchair and belt removed. When applying belt to resident, I had to assist resident with her arm placement. I noted following interaction that resident arm was down side and resident did not adjust it independently. It was unclear from the incident report how R1 had dislocated her shoulder. It did appear that R1 was transferred with the assistance of only 1 staff person using the sit-stand lift; which was not in accordance with her care plan. The incident report did not contain other interviews with staff who might have participated in the transfer. On 9/25/18 at 11:10 am, CNA - C was interviewed. CNA - C said that she had difficulty recalling the incident. The incident report was provided to CNA - C to review. CNA - C thought that she completed the transfer by herself - without the assistance of a second staff person. CNA - C said that nothing unusual occurred during the transfer. R1 might have hollered/called out; but CNA - C said this was typical behavior for R1. R1 did not report anything regarding the transfer to the nurse. CNA - C said that it was not until later that staff noticed R1 guarding her left arm/shoulder. The facility's Lift Policy dated 8/31/18 was reviewed. The section on page 11 contained the following documentation: Unless otherwise documented, the use of a mechanical resident lift for transfers will be conducted with the assistance of two team members to prevent resident and/or team member injury .In rare circumstances, a location may designate that a lift transfer can be performed with one person .This should be with the approval of the Administrator and the Regional Director of Health Services. On 9/25/18 at 3 PM, the preceding information was shared with Administrator - A, DON - B, and Regional Director of Health Services - D (Regional Director - D). DON - B confirmed that R1 had been transferred with the assistance of only 1 staff person on 4/23/18, which was not in accordance with R1's care plan. Regional Director - D confirmed that the facility's lift policy included both the sit-stand lift and the Hoyer/Full Mechanical lift. Regional Director - D confirmed that all lift transfers should be conducted with two staff persons; except in rare circumstances as the policy stated. On 9/25/18 at 3:50 PM, the surveyor met with Regional Director - B. Regional Director - B said that the facility had no additional information to dispute the preceding information. Regional Director - B and the surveyor reviewed the 4/23/18 incident report. Regional Director - B said that the incident was not an injury of unknown origin, because the facility knew how R1 had dislocated her left shoulder. Regional Director - B said that after reviewing the incident report, she thought that R1 had dislocated her left shoulder during the transfer and provided the following explanation. The belt, which was to be placed beneath the resident's chest, had come loose when R1 was in the sit-stand lift and rode up under the resident's arm pits. As the belt rode up, it would not support R1's body and her body would have slid down, such that R1 was hanging by the belt under her arm pits. It was thought that the belt in this position and the weight of her body may have caused R1 to dislocate her left shoulder. In summary, R1 sustained a left shoulder dislocation during a sit-stand transfer that was not completed in accordance with her care plan. After the incident, R1 had a decline in her transfer ability At the time of the transfer, R1 was using a sit-stand lift and receiving restorative therapy. On 4/25/18, R1's transfer care plan was changed to a Hoyer (Full Body) Lift and the assistance of two staff persons. R1's current care plan (Target Date 9/20/18) noted that R1 continues to be transferred with the Hoyer Lift and two staff persons.

Based on observation, interview, and record review, the facility did not always ensure each Resident received adequate supervision and assistance devices to prevent accidents for 2 of 8 Residents (R11 and R9) reviewed for falls. * R11 rolled out of bed with the bed not in the lowest position and sustained a left hip fracture leading to actual harm. Surveyor observed R11's bed not in lowest position with R11 in the bed during the survey. *R9 is identified to be at risk for falls and has a history of falls. R9's care plan dated 2/27/17 and 9/21/17 indicates the use of grippy socks/non-slip socks on while in bed. On 10/26 and 10/30/17, Surveyor observed R9's fall prevention intervention, consisting of wearing grippy/non-slip socks while in bed, was not in place. Example #1 involving R11 rises to a scope and severity level of G (harm/isolated). Findings Include: The facility fall management policy entitled, Fall Management & Investigation Program, revised 10/15/11 stated, Purpose: To utilize all reasonable efforts to provide a system to review the resident's risk potential for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize falls and identify resident's continued needs. The policy stated under Interventions and Care Plan Process the following bullet points: *The resident's data toll will be reviewed for potential fall risks *A resident's care plan will be developed by a qualified healthcare professional and will include all identified risks with appropriate interventions. *The residents' plan of care will be reviewed and revised in conjunction with the MDS review, or when there is a significant change in condition or a fall occurs. *A resident's care plan will be reviewed and updated with each additional fall which might occur. *Facility staff, residents and family members will be made aware of the different interventions to be used with the resident through the care plan process. 1. R11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/29/17, R11 fell at the facility and sustained a right hip fracture. R11's most recent Minimum Data Set (MDS) assessment prior to falling was dated 5/28/17 and indicated R11 was severely cognitively impaired and required extensive assistance from two staff members for bed mobility and toilet use. The MDS indicated R11 required extensive assistance from one staff member for hygiene. Surveyor requested R11's fall risk assessments, and was provided a form entitled, Data Collection Tool dated 2/28/17 (prior to R11's fall) and had multiple resident assessments for R11. The Data Collection Tool form indicated R11 had a history of [REDACTED]. The form noted R11 to have obtained a wrist fracture injury related to falling prior to residing at the facility. There was a check mark next to the words, Problem Identified which indicated yes. The form noted, If yes, initiate plan of care. Surveyor reviewed R11's Resident Care Card dated 7/3/17. Under the heading, Safety Devices R11's Care Card had check marks next to Low bed, mat on floor, body pillow. R11's Care Card also indicated to have a cushion in R11's broda chair and dycem beneath the cushion. R11's Care plan stated, Resident has a history of falling R/T (related to) impaired mobility, and impaired cognition. The start date was 3/7/17. On 8/29/17, the following interventions were added to R11's Care Plan: *Provide resident with low bed. *Mat on the floor next to bed *Body pillows in bed *Cushion on broda chair, dycem beneath cushion *Air mattress (with) bolsters both side Surveyor requested to review all of R11's falls since admission. On 10/26/17 at 9:41AM, Medical Records-H stated to Surveyor that R11 had one fall while residing at the facility and provided Surveyor with the investigation from R11's fall, which occurred on 8/29/17. Surveyor reviewed R11's incident report dated 8/29/17. The incident report indicated R11 fell at 9PM on 8/29/17. The description stated, Res receiving cares transferred per Hoyer lift to bed. CNA (CNA-F) getting wash cloth wet to wash resident heard thump 'help, I'm on the floor.' The report indicated the fall happened in R11's room and R11 fell from the bed. Under the heading, Injury Type, the report stated, Sent to (hospital) due to left hip pain. The report indicated the facility updated R11's doctor and family immediately. The report stated under outcome/disposition: Res was sent to (hospital) ER (emergency room ) for eval due to left hip pain. Hospice to provide scoop air mattress for bed. The Post Fall Investigation form dated 8/29/17 indicated the following intervention for R11, Hospice to be contacted with request for air mattress with scoop edges for bed. Surveyor reviewed CNA-F's statement dated 8/30/17. CNA-F's statement read, I had just gotten res in the bed went to B.R. (bathroom) 'approx 30 sec'- as soon as I went in B.R. I heard a thud and res saying she was on the floor. Went back in (room). Res was on floor next to the bed lying on left side. Res was flat on her back in the middle of bed, pillow under her head. Still dressed. Lift sling and pants were off and covered with a sheet. Res behavior normal, not moving about. It-bed- was a little off the floor was not in the lowest. Floor matt was next to the bed on the floor, res body was on the floor. On 10/26/17 at 2:38P.M., Surveyor interviewed CNA-F regarding R11's fall on 8/29/17. CNA-F indicated she was caring for R11 at that time. CNA-F indicated the bed was not in the lowest position when she walked away from R11's bed prior to R11 falling. CNA-F indicated the bed was not in a high position but also not in the lowest position- She indicated the bed was at about thigh height. CNA-F indicated the mat was halfway by the bed, but not fully in place and R11 had been halfway on the floor. Surveyor reviewed R11's hospital discharge summary which indicated R11 was admitted to the hospital on [DATE] and discharged on [DATE]. The hospital discharge summary stated, Your primary [DIAGNOSES REDACTED]. The admission [DIAGNOSES REDACTED]. The Discharge summary noted R11 received the hospital procedure of an open Reduction Internal Fixation of the left hip at 5P.M. on 8/30/17. This means R11 had surgery to realign the left hip while at the hospital. The discharge team summary noted CT results indicating R11 had sustained an acute left introchanteric hip fracture, possible nondisplaced left pubic body fracture. An X-ray taken on 8/30/17 indicated a dynamic hip screw was in place for R11. On 10/31/17, the facility provided Surveyor with evidence that the facility provided house-wide education starting on 8/30/17 to all staff after noting R11's bed was not in the lowest position during the fall. R11's Care Area assessment dated [DATE] stated, (R11) is at risk for falls due to impaired mobility, medication usage, and history of falls. She is dependent on staff for transfers and uses a broda chair for mobility. Staff monitor for tolerance of transfers. Staff provide and monitor for side effects of her medications. See MD (Medical Doctor) orders dated 8/31/17. See nursing dated 8/31/17. Will proceed with care plan with revisions as needed. On 10/25/17 at 2:35PM, Surveyor observed Certified Nursing Assistant (CNA)-D and CNA-E assist R11 into bed. The bed was off the ground, at thigh height, once R11 was in the bed in order for CNA-E and CNA-D to provide cares. CNA-E provided peri-care and finished caring for R11 at 2:40PM. At 2:40PM, CNA-E removed her gloves and went to wash her hands. CNA-D placed a large pillow on R11's right side and placed R11's call light within reach. CNA-D then left R11's bedside to walk towards R11's bathroom on the other side of the room. This was done without lowering the bed to the lowest position or placing the fall mat on the floor next to R11's bed. CNA-E returned to R11's bedside and placed R11's fall mat next to R11's bed and lowered the bed at 2:43PM. On 10/30/17 at 1:55PM, Surveyor interviewed CNA-D and asked if a resident requires a low bed, is in bed, and staff have to walk away, what should happen to the bed? CNA-D indicated the bed should go all the way down (lowest position). Surveyor asked, even if it is going to be brief? CNA-D indicated yes, the bed has to go all of the way down. Surveyor requested R11's fall risk assessments, and was provided a form entitled, Data Collection Tool. The form was dated 8/29/17 (date of R11's fall) and had multiple resident assessments. The form indicated R11 had a history of [REDACTED]. The form noted R11 to have obtained a left hip fracture injury related to falling. There was a check mark next to the words, Problem Identified which indicated yes. The form noted, If yes, initiate plan of care. Surveyor reviewed R11's Resident Care Card dated 10/21/17. Under the heading, Safety Devices R11's Care Card had check marks next to Low bed, mat on floor, body pillow. R11's Care Card also indicated to have a cushion in R11's broda chair and dycem beneath the cushion. On 10/30/17, at 2:50P.M., the Survey team conducted the daily exit with the facility. Director of Nursing (DON)-B was present during the exit. Surveyor asked DON-B what was her expectation of staff if a resident should have a low bed, is in bed, and staff need to walk away from the bed. DON-B indicated it was her expectation if staff needs to walk away that the bed go into the lowest position. On 10/31/17 at 7:39A.M., NHA-A indicated to Surveyor that the entire facility staff will receive training (for fall precautions). Surveyor shared the above concerns with NHA-A and DON-B prior to the final exit and during the final exit on 10/31/17. DON-B and NHA-A indicated staff training and review of Resident Care Cards would occur immediately prior to exiting. No additional information was provided to Surveyor after exiting the facility. 2. R9's [DIAGNOSES REDACTED]. R9 is not her own decision maker. R9 is assessed to be at risk for falls. R9's care plan addresses her ability to walk without assistance and the use of grippy socks on when in bed. R9's Care Plan, titled resident is able to walk in corridor without assistance, dated 2/27/17, included, in part, the following approaches: Grippy Socks when in bed, Assist to nap after lunch, and independent with wheeled walker. R9's Resident Care Card, dated 9/21/17, located in R9's room on back of the door, notes under safety devices, Non-slip socks on in bed. R9's medical record indicates: On 6/25/17 at 7:30am, R9 was in her room when she fell to the floor causing a fracture to her left hip. On 7/16/17 at 1:25pm R9 was found on the floor in her bedroom when she attempted to self-transfer from her wheelchair to her bed, without injury. On 10/02/17 at 5:30am, R9 was found on the floor when she went to get up from bed to go to the bathroom, without injury. On 10/26/17 at 2:00pm, Surveyor observed R9 sleeping in bed. R9's feet were uncovered and it was observed that she had no non-slip/grippy socks on her feet. On 10/26/17 at 2:15pm, Surveyor interviewed Registered Nurse (RN) L who stated that R9's care plan is located on the back of her door. It was last updated on 9/21/17. It identifies that R9 should have non-slip socks on when in bed. RN L observed R9's feet with Surveyor noting that R9 did not have her non-slip socks on in bed. On 10/26/17, the facility did not ensure R9 was wearing her non-slip/grippy socks, (used for safety), while in bed. On 10/30/17 at 1:25pm, Surveyor observed R9 in bed sleeping. R9's feet were uncovered. Surveyor observed that R9 was not wearing her non-slip/grippy socks on her feet. On 10/30/17 at 1:30pm, Surveyor interviewed Certified Nursing Assistant (CNA) M who stated that R9 is able to do most Activities of Daily Living (ADLs) on her own. R9 will wear her shoes that she is able to slip in and out of. After R9 transfers in to bed we should be checking to ensure that her gripper socks are on. I will put her socks on right now. On 10/30/17 at 1:35pm, Surveyor interviewed Registered Nurse Supervisor (RNS) J who stated the expectation is that the CNA staff to follow and assist R9 into bed and assist her with putting on her grippy socks. We may need to schedule the nursing staff to check that the gripper socks are on one or two times every shift. On 10/30/17, the facility did not ensure R9 was wearing her non-slip/grippy socks, (used for safety), while in bed.

Based on record review and staff interview, the facility did not ensure a comprehensive re-assessment was conducted for 2 of 4 residents' documented as having a decline in bowel function. Resident #2's admission Minimum Data Set (MDS) assessments, dated 7/01/13 and 10/01/13, indicate (0) for bowel incontinence (always continent). The MDS, dated [DATE], indicates (2) for bowel incontinence (frequently incontinent). The facility did not conduct a comprehensive assessment regarding Resident #2's bowel patterns, when the Resident experienced a decline in bowel continence, and did not implement a program to restore as much bowel continence as possible. Resident #5 had a decline in bowel continence. The facility did not conduct a comprehensive assessment regarding Resident #5's bowel patterns, when the Resident experienced a decline in bowel continence and did not implement a program to restore as much bowel continence as possible. Findings include: Surveyor # reviewed the Bowel Incontinence Management Program, dated 5/01/12. The policy indicates that the each resident who is incontinent of bowel is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal bowel function as possible, and avoid incontinence whenever possible. The policy indicates the resident will be assessed on admission, and re-assessed if there is a significant change in status and annually. The procedure indicates that on admission a Data Collection Tool is completed to determine if a resident is incontinent (3-Day Bowel and Bladder Flow Sheet). If the resident is incontinent of bowel, a bowel assessment is to be completed. The procedure indicates that once the evaluation is complete, the determination for the resident's ability to participate in a bowel management program can be made. The Bowel Management Program indicates bowel incontinence must be care planned for and should include goals and approaches to achieve the goal. 1.) On 1/14/14 Surveyor # reviewed Resident #2's medical record. The record indicates Resident #2 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. A 3-Day Bowel and Bladder Flow Sheet was completed on 6/26/13 through 6/28/13 (Part of the facility's Bowel Management Program where the resident is checked hourly). The Flow Sheet indicates Resident #2 is continent of bowel. The "Additional Notes" on the bowel evaluation indicates staff were interviewed, the resident is continent and the resident lets staff know when she has to use the bathroom. The admission Minimum Data Set (MDS), dated [DATE], indicates Resident #2 has Brief Interview for Cognitive Status (BIMS) score of 7 (severely impaired cognitive skills), requires extensive assistance of 2 for transfers and for toilet use, and is continent of bowel. The Care Area Assessment (CAA), dated 7/03/13, indicates Resident #2 is assisted by staff for toileting. The quarterly Minimum Data Set (MDS), dated [DATE], indicates Resident #2 has Brief Interview for Cognitive Status (BIMS) score of 1 (severely impaired cognitive skills), requires limited assistance of 2 for transfers and for toilet use, and is continent of bowel. The ADL (Activities of Daily Living) Functional/Rehabilitation plan of care, dated 10/01/13, includes the approach that Resident #2 is continent of bowel and is assisted by staff with toileting. The Resident Care Card, dated 11/12/13, indicates Resident #2 needs assist with toileting for bowel. The significant change Minimum Data Set (MDS), dated [DATE], indicates Resident #2 has Brief Interview for Cognitive Status (BIMS) score of 0 (severely impaired cognitive skills), requires extensive assistance of 2 for transfers and for toilet use, and is frequently incontinent of bowel. This MDS also indicates that Resident #2 is not on a bowel or bladder retraining program for continence. The Care Area Assessment (CAA), dated 11/27/13, indicates Resident #2 will make some toileting needs known, but most needs are anticipated by staff. There is no evidence that the facility completed the bowel assessment in conjunction with the significant change MDS, dated [DATE], when Resident #2 had a decline in bowel status from total bowel continence to frequently incontinent of bowel. (A Bowel Assessment Form was in the process of being completed during this recertification survey dated 1/14/14 through 1/21/14) There is no evidence that the facility developed a plan of care from information based on an accurate bowel assessment. On 1/15/14, at 10:15 a.m., Surveyor # observed Certified Nursing assistant (CNA)-D and CNA-E offering and providing Resident #2 assistance with toileting. Resident #2 was assisted to the toilet with the use of a sit to stand mechanical lift. Resident #2 did not have a bowel movement during this observation. On 1/16/14, at 11:00 a.m., Surveyor # spoke with Registered Nurse (RN) -C who indicated the facility did not complete a bowel assessment in conjunction with the significant change MDS, dated [DATE], when Resident #2 had a decline in bowel status from total bowel continence to frequently incontinent of bowel. RN-C indicated a bowel assessment was not utilized to accurately develop an individualized bowel management program when Resident #2 had a decline in bowel status from total bowel continence to frequently incontinent of bowel. There was no evidence that the facility completed an accurate and complete bowel assessment for Resident #2, when the resident had a decline in bowel continence. There was no evidence that the facility used the results from an assessment to accurately develop an individualized bowel management program for Resident #2. On 1/24/14 the facility submitted additional information to review regarding Resident #2's cognitive status and decline. Surveyor # reviewed this information and noted that the additional information conveys that Resident #2 has cognitive impairments related to her [DIAGNOSES REDACTED].#2's continence status was comprehensively assessed until Surveyor # brought the concern to the facility's attention, this is approximately 1 and 1/2 month after the decline occurred. 2.) Surveyor # reviewed Resident #5's medical record from 1/14/14 to 1/16/14. Resident #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission MDS (minimum data set) signed as completed on 3/7/13 has a BIMS (brief summary score) of 1. A score of 1 indicates severe cognitive impairment. Resident #5 requires limited assistance with set up help only for transfers & toileting and is continent of bowel. The bladder incontinence plan of care dated 3/9/13 has one approach dated 3/9/13 that addresses the bowels. This approach documents "Ensure adequate bowel elimination." Surveyor # was unable to locate a bowel plan of care in Resident #5's medical record. The 3 day bowel & bladder evaluation dated 6/13/13 documents under additional notes "Res. (Resident) is alert & oriented but has confusion. Not always able to make toileting needs known. Staff assist with toileting & incontinence cares. Freq. (frequently) incontinent of bladder. Continent of bowel. Res. occ. (occasionally) tries to toilet self & occ. refuses assist. Staff assist with toileting during rounds @ (at) noc (night) & prn (as needed) in am & pm." The quarterly data collection tool dated 9/3/13 includes a gastrointestinal section. The only question that is answered is "no" is checked for abdominal distention. There are no checks answering "continent" or "incontinent." The quarterly MDS signed as completed on 9/5/13 has a BIMS score of 0. A score of 0 indicates severe cognitive impairment. Resident #5 requires extensive assistance with two plus persons physical help for transfers & toileting and is frequently incontinent of bowel. Surveyor # was unable to locate a bowel assessment after Resident #5's bowel continence declined from continent to frequently incontinent. The Resident Care Card dated 10/9/13 which is used by the CNA's (Certified Nursing Assistants) under the bowel section is checked for "bathroom", "assist" with a handwritten notation of "prn (as needed)" and "bowel program" with a handwritten notation of "per facility request." Documented in the bladder section is instructions for the staff of "Staff to offer during rounds am (morning), hs (hour of sleep), noc (night) & prn (as needed)." On 1/14/14 at 11:07 a.m. Surveyor # observed CNA-W and Med Tech-Z transfer Resident #5 onto the toilet using a sit to stand lift. After Resident #5 was on the toilet, CNA-W and Med Tech-Z removed their gloves and washed their hands. Med Tech-Z left the room while CNA-W stood outside the bathroom door. At 11:13 a.m. CNA-W stated "she's falling asleep" and went into the bathroom asking Resident #5 "do you have to go to bathroom?" At 11:15 a.m. CNA-W and Med Tech-Z entered the bathroom, washed their hands, and placed gloves on. Resident #5 was lifted off the toilet and CNA-W washed Resident #5's buttocks. Surveyor # observed BM (bowel movement) on the wash cloth. After CNA-W finished washing Resident #5, CNA-W placed an incontinent product on Resident #5. As CNA-W was starting to fasten the side, CNA-W indicated that she's going. Surveyor # observed there was BM in the product that CNA-W had just placed on Resident #5. Resident #5 was lowered back on the toilet. On 1/16/14 at 3:06 p.m. during the daily exit conference the Administrator and Director of Nursing were informed that Surveyor # was unable to locate a bowel assessment after Resident #5 declined from continent to frequently incontinent of bowel which was identified on the quarterly MDS 9/5/13. On 1/21/14 at 8:19 a.m. Surveyor # asked RN (Registered Nurse)/MDS Nurse-AA if there was any information regarding Resident #5's bowel assessment as Surveyor # was unable to locate an assessment when Resident #5 experienced a decline in her bowel continence identified on 9/5/13. RN/MDS-AA informed Surveyor # that she completed the bowel assessment yesterday. At 8:46 a.m. Surveyor # asked RN/MDS-AA why the bowel assessment wasn't completed in September when the decline was identified. RN/MDS-AA informed Surveyor # that it looked like the patterning went to medical records and the assessment wasn't done.