Every finding on record at Avina of Weyauwega

Based on interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to effect all 47 residents residing in the facility. The staff line list did not include resolved symptom dates or times to ensure staff remained off of work for the appropriate time period post-illness. Findings include: The facility's Return to Work Guidance for Specific Illness policy, dated 5/14/26. indicates: Restrictions for Healthcare Personnel (HCP) experiencing influenza-like illness (ILI) should be excluded from work for at least 24 hours after fever has subsided (without the use of fever reducing medicines). If symptoms such as cough and sneezing are still present when they return to work, they should wear facemasks during patient care. Adherence to respiratory hygiene/cough etiquette and the importance of performing frequent hand hygiene (especially before and after each resident contact) should be reinforced. Return to work: HCP with respiratory virus symptoms and/or a positive test may return to work when all of the following are met: a. At least 3 full days have passed since symptom onset (day 0 = day of symptom onset) or, if asymptomatic, day of positive test; and b. Symptoms are improving, including being fever-free for 24 hours without the use of fever-reducing medication. Restrictions for HCP for acute gastroenteritis (AGE): Food handlers who have symptoms consistent with AGE shall be excluded from work until a minimum of 72 hours after symptoms have resolved. Exclude all other ill employees until a minimum of 48 hours after resolution of AGE symptoms. When the excluded person(s) returns to work, reinforce the importance of performing frequent hand hygiene. From 6/29/26 to 7/1/26, Surveyor reviewed the facility's infection surveillance program and noted the staff line list for illness did not contain symptom resolved dates or times. In addition, the line list contained examples of the following staff who returned/potentitally returned to work early following ILI and AGE symptoms: ~ Licensed Practical Nurse (LPN)-S called in sick on 3/3/26 with diarrhea. LPN-S returned to work on 3/5/26. The line list did not contain a symptom resolved date or time to indicate LPN-S remained off of work for the appropriate time period after the resolution of symptoms. ~ Dieatary Aide (DA)-T called in sick on 4/29/26 with fever, chills, and a sore throat. DA-T returned to work on 5/1/26. The line list did not contain a symptom resolved date or time to indicate DA-T remained off of work for the appropriate time period after the resolution of symptoms. ~ [NAME] (CK)-U called in sick on 5/13/26 with nausea, vomiting, diarrhea, fever, and body aches. CK-U returned to work date on 5/13/26. The line list did not contain a symptom resolved date or time to indicate CK-U remained off of work for the appropriate time period after the resolution of symptoms. On 7/1/26 at 12:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility should monitor the resolved symptom dates and times for employees who return to work which they were currently not doing.

Based on observation, interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 46 of 47 residents residing in the facility. Staff did not monitor and document food cooling temperatures. Staff did not date food items with an open date. The cooler contained expired food and personal items of staff. Staff did not complete appropriate hand hygiene during dishwashing and food service at the steam table. The microwave and various food storage items were not in clean condition.Findings include:Food Cooling:The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3 501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celcuis (C) (135 Farenheit (F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less.During an initial kitchen tour with [NAME] (CK)-L on 6/29/26 that began at 8:50 AM, Surveyor and CK-L observed the following items in the walk-in freezer that were pre-cooked and saved for resident consumption:~ A covered container labeled extra pot roast dated 6/15/26~ A bag labeled Corn beef dated 4/17/26~ A container labeled Corn beef dated 3/17/26~ A container labeled pork dated 6/20/26Surveyor observed the following pre-cooked items saved for resident consumption in the walk-in cooler:~ A container labeled Teriyaki chicken dated 6/28/26~ A container labeled Chicken Alfredo dated 6/25/26~ A container labeled Peas dated 6/25/26~ A container labeled Chicken Soup dated 6/14/26~ Two containers of tomato soup, one dated 6/28/26 and one dated 6/26/26Surveyor did not observe a food cooling log.During a continuous kitchen observation on 6/29/26 that began at 10:50 AM, Surveyor toured the kitchen with Dietary Manager (DM)-N who verified the above items (aside from the containers of tomato soup) in the walk-in freezer and cooler were pre-cooked and saved for future resident consumption. DM-N stated staff are trained on proper food cooling procedures and are required to document food that is cooled and saved for future consumption. DM-N walked toward the wall to retrieve the June 2026 cooling log and verified the log was blank. DM-N stated the food in the walk-in cooler and freezer should be documented as cooled in an appropriate manner and monitored for appropriate cooling temperatures. Undated/Unlabeled/Unsealed/Expired Food Items:The 2022 FDA Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition: (A) A food specified in 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17 (A).The 2022 FDA Food Code documents at 3-302.12 Food Storage Containers, Identified with Common Name of Food: Foods may be difficult to identify after they are removed from their original packaging. Consumers may be allergic to certain foods or ingredients. The mistaken use of an ingredient, when the consumer has specifically requested that it not be used, may result in severe medical consequences.The 2022 FDA Food Code documents at 3-302.13 Pasteurized Eggs: Substitute for Raw Eggs for Certain Recipes: Pasteurized eggs or egg products shall be substituted for raw eggs in the preparation of foods such as Caesar salad, hollandaise or Bearnaise sauce, mayonnaise, meringue, eggnog, ice cream, and egg-fortified beverages that are not: (A) Cooked as specified under subparagraphs 3-401.11 (A)(1) or (2); or (B) included in 3-401.11 (D).During an initial kitchen tour with CK-L on 6/29/26 that began at 8:50 AM, Surveyor observed two bakery racks with two muffin tins labeled Activities dated 6/24/26. The tins were uncovered and open to air. CK-L stated the muffins were baked by activities staff and stored in the kitchen.Surveyor also observed the following items in the walk-in cooler:~ An open and uncovered package of hot dogs dated 6/19/26 ~ An open and undated package of bologna in a bag that was open to air~ An open and undated bag of shredded cheese- An open, undated, and unlabeled Body [NAME] drink~ An open and undated 2-liter bottle of lemon lime soda~ An open and undated 2-liter bottle of Sunkist strawberry soda~ An open and undated 2-liter bottle of root beer ~ Two undated cartons of a dozen eggs in a plastic bag Surveyor observed the following items in the dry storage area:~ An open and undated bag labeled Flavored chips~ An open and undated box of corn starch ~ A dented can of cream of corn. CK-L stated dented cans are not put on the shelf and are kept in DM-N's office to be returned.Surveyor observed the following items on the kitchen prep counter and in the reach-in cooler:~ An open and undated bag of hamburger buns~ Two open and undated bags of hot dog buns~ An open and undated container of milk~ Fourteen individual undated containers of milk On 6/30/26 at 10:50 AM, Surveyor toured the kitchen with DM-N who verified the following items in/on the walk-in cooler, dry storage/storage area, prep counter, and reach-in cooler:~ An open and uncovered package of hot dogs dated 6/19/26~ An open and undated package of bologna in a bag that was open to air~ An open and undated bag of shredded cheese~ A container labeled Chicken Alfredo dated 6/25/26~ A container labeled Peas dated 6/25/26~ A container labeled Chicken Soup dated 6/14/26~ An open and undated Body [NAME] drink~ Two undated cartons of a dozen eggs in a plastic bag~ An open and undated bag labeled Flavored chips~ An open and undated box of corn starch ~ Two muffin tins labeled Activities dated 6/24/26 that were uncovered and open to air~ An open and undated bag of hamburger buns~ Two open and undated bags of hot dog buns~ An open and undated container of milk~ Fourteen individual undated containers of milkSurveyor interviewed DM-N who stated food stored for future resident consumption is saved for three days if stored in the cooler. DM-N verified the chicken soup, chicken alfredo, peas, and muffins were expired. DM-N stated the muffins were not stored correctly and indicated DM-N previously spoke to activity staff about better storage of food items in the kitchen. DM-N stated all staff are trained in proper storage of food. DM-N verified the undated items in the walk-in cooler and storage/dry storage areas should contain open dates. DM-N indicated all open items should contain an open date and be covered and properly stored. DM-N stated the bottles of soda were discarded and the unlabeled, unpasteurized cartons of eggs were for a staff member from a coworker's farm. DM-N acknowledged food for staff should not be stored in the walk-in cooler and stated staff are aware that personal food should not be stored with resident food. Hand Hygiene:The 2022 FDA Food Code documents at 2-301.14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single- use articles and: .(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination.The 2022 FDA Food Code documents at 3-304.15 Gloves, Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.During an initial kitchen tour on 6/29/26 that began at 8:50 AM, Surveyor observed Dietary Aide (DA)-M wash dishes in the dishwasher. DA-M rinsed the dishes, placed them in a rack, and pushed the rack into the dishwasher. DA-M was not wearing an apron or gloves. DA-M informed Surveyor that surface temperature strips are placed in racks to ensure the dish machine reaches 180-degrees F. After the rack of dishes went through the dishwasher, DA-M reached into the rack of clean dishes to retrieve the temperature strip and touched cups and utensils with unclean hands. DA-M located the temperature strip, put the utensil it was attached to back in the clean dish rack, and returned to the dirty side of the dishwasher. DA-M did not complete hand hygiene prior to leaving the the dish room and touching multiple clean dishes.During a kitchen tour and observation on 6/29/26 that began at 10:50 AM, Surveyor observed CK-L wash hands and don gloves prior to serving lunch at the steam table. CK-L used the same gloved hands to touch serving utensils and tortilla shells and reached into a bag of shredded cheese to put cheese on a burrito. CK-L left the steam table with same gloved hands to retrieve a bucket of plastic lids to place on food items for room trays. CK-L also looked in a drawer for a pair of scissors and left the steam table several times to take food to the microwave. CK-L microwaved food and touched prep areas in the kitchen with the same gloved hands. CK-L returned to the steam table and continued to touch tortilla shells, shredded cheese, and food items with the same gloved hands. CK-L did not change gloves or complete hand hygiene during lunch service. Immediately following the observation, Surveyor interviewed DM-N who verified DA-M did not complete hand hygiene while washing dishes. DM-N stated staff should change gloves if they touch food during meal service or if they leave the serving line and complete other tasks. Unclean Equipment/Food Storage/Cross-Contamination:During an initial kitchen tour with CK-L on 6/29/26 that began at 8:50 AM, Surveyor observed the following:~ The seasoning storage area contained a bin with bags of sugar, salt, flour, and brown seasoning. Sugar, salt, and flour were spilled on top of the bin.~ An open container of grape jelly that contained jelly and peanut butter on the sides and rim. ~ The inside of the microwave contained a soiled cleaning rag as well as food splatters inside and outside on the handles and control panel. CK-L stated the microwave was not used during breakfast that day. Surveyor interviewed DM-N who verified the microwave contained a soiled cleaning rag and food splatters and stated the microwave was dirty and should be cleaned. (Surveyor noted the microwave was not cleaned prior to use during the lunch meal, however, the cleaning rag was removed prior to heating resident food.) Upon entering the storage area that contained the bin of sugar, salt, flour, and seasoning, DM-N verified the bin was dirty and should be cleaned. The open container of grape jelly with jelly and peanut butter on the sides and rim was being used by kitchen staff during the tour to make peanut butter and jelly sandwiches. DM-N verified the container of jelly had jelly and peanut butter on the sides and rim and was stored in an unsanitary manner with the potential for cross-contamination for residents with allergies.

Based on observation, interview, and record review, the facility did not assess for the risk of entrapment, ensure bed dimensions were appropriate, obtain informed consent, or obtain a physician order prior to the installation of bed rails for 1 resident (R) (R26) of 6 sampled residents.Findings include:The facility's Positioning Devices policy, revised 1/2026, indicates: .Residents who require the use of positioning devices to maintain body alignment, pressure relief, or other measures will be managed accordingly per current standards of practice .These devices may be in the form of wedges, positioning rails, turning sheets, sprints or braces, bolsters, cushions .1. Determination for the use of positioning devices should be interdisciplinary, ensuring the resident's rights and dignity are maintained, goals are acknowledged and honored, and appropriate referrals are made. 2. The use of positioning devices will be based on the resident's comprehensive assessment in accordance with the resident's care plan .5. Staff will provide appropriate assistance to ensure the resident can use the positioning device(s) safely, including assessment, education, or therapy sessions .8. A resident will be assessed to ensure positioning devices are properly used, and the resident is not at increased risk for complications.R26 was admitted to the facility on [DATE] and had diagnoses including cancer of the breast and bone. A Minimum Data Set (MDS) assessment, dated 6/18/26, stated R26 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. The assessment also indicated R26 had behaviors, including delusions, and did not indicate R26 used bed rails. R26 had an activated Power of Attorney for Healthcare (POAHC) to assist with medical decisions.On 6/29/26 at 11:01 AM, Surveyor observed R26 asleep in bed with metal positioning rails on both sides of the upper portion of the bed.From 6/29/26 to 7/1/26, Surveyor reviewed R26's medical record which did not contain a physician order for positioning rails or consent from R26 or their POAHC for the use of positioning rails. In addition, R26's medical record did not contain risk versus benefit education on the use of positioning rails or a care plan that indicated R26 had positioning rails on both sides of the bed. Bed rail assessments with measurements and dimensions to reduce the risk for entrapment were also not completedOn 7/1/26 at 11:10 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who verified R26 did not have an order or assessment for bilateral positioning rails. ADON-C also verified R26 and their POAHC did not provide consent for the use of bilateral positioning rails or receive risks versus benefits education. ADON-C confirmed the facility did not have a standing order for positioning rail use and stated an order should be requested from the physician. ADON-C verified an assessment should be completed prior to use as well as consent and risks versus benefits education.On 7/1/26 at 11:20 AM, Surveyor and ADON-C observed R26 in bed with metal positioning rails attached to both sides of the bed. ADON-C verified the bed was a facility-owned bed.

Based on interview and record review, the facility did not ensure 1 resident (R) (R28) of 4 sampled residents received the necessary care and services to prevent pressure injuries from developing and/or promote healing.R28 had pressure injuries on the sacrum and coccyx. R28's Treatment Administration Record (TAR) contained multiple missing entries for treatments in March, April, May, and June of 2026.Findings include:The facility did not provide a wound care policy despite multiple requests from Surveyor.R28 was admitted to the facility on [DATE] and had diagnoses including pressure injury of sacrum stage 2 and non-pressure chronic ulcer of left foot. A Minimum Data Set (MDS) assessment, dated 6/11/26, stated R28 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. An MDS assessment, dated 3/19/26, indicated R28 had a stage 2 pressure injury upon admission.R28's TAR contained the following wound care orders:~ Sacrum: Cleanse with soap and water, apply collagen to ulcer followed by Vaseline gauze and bordered foam. Chage every other day (started: 3/19/26; discontinued: 3/30/26). (R28's TAR indicated the order was not completed on 3/29/26.)~ Coccyx: Cleanse with soap and water and pat dry. Apply zinc oxide cream to cover twice daily (BID) and as needed (PRN) (started: 4/6/26; discontinued: 4/22/26). (R28's TAR indicated the order was not completed on 4/18/26 and 4/19/26 at bedtime (HS).)~ Coccyx: Cleanse with soap and water and pat dry. Apply collagen to wound bed and cover with 6x6 white foam bordered dressing daily and PRN (started: 4/22/26; discontinued: 5/11/26). (R28's TAR indicated the order was not completed on 4/30/26 and 5/1/26.)~ Sacrum: Cleanse with soap and water and pat dry. Apply zinc oxide cream BID and PRN (started: 5/11/26; discontinued: 6/24/26). (R28's TAR indicated the order was not completed on 5/21/26, 5/22/26, 5/26/26, 5/27/26, 6/2/26, and 6/11/26 at HS.)On 7/1/26 at 9:01 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who was the facility's wound care nurse. LPN-E stated nurses should document in a resident's TAR when/if wound care is completed.On 7/1/26 at 10:47 AM, Surveyor interviewed Corporate Clinical Consultant (CCC)-D who reviewed R28's TAR for March through June 2026 and confirmed there were multiple missing entries for wound care. CCC-D was unsure if the nurses completed wound care and forgot to document it or if they did not complete wound care. CCC-D stated nurses should document wound care when it is completed and should document refusals in a resident's progress notes.On 7/1/26 11:14 AM, Surveyor informed [NAME] President of Clinical Operations (VPCO)-K and CCC-D of the dates in R28's TAR that did not indicate coccyx and sacrum wound care was completed from March through June 2026. VPCO-K and CCCD indicated they would follow-up with Surveyor after determining why the dates were not initialed as completed. On 7/1/26 at 12:31 PM, CCC-D provided Surveyor with R28's TAR that only included wound care for the sacrum and coccyx. All empty documentation dates were highlighted. CCC-D indicated if a treatment was not initialed or documented, it was not done. CCC-D indicated if there were no notes on the TAR that was provided to Surveyor, then wound care was not completed.

Based on interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 3 residents (R) (R29, R24, and R28) of 18 sampled residents.R29 had a diagnosis of chronic heart failure which was not included on their facility diagnoses list or care plan. In addition, the facility did not provide cardiac monitoring assessments for R29 or nursing interventions for heart failure and staff did not notify the provider of a significant weight change.R24 had a diagnosis of chronic heart failure. Staff did not weigh R24 as ordered or notify the provider of a significant weight change. R28 had a non-pressure injury on the left foot. R28's Treatment Administration Record (TAR) contained multiple missing entries for treatments in April and May of 2026.Findings include: The facility's Weight Monitoring policy, revised 1/2026, indicates: .3. Information gathered from a nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to adjust the resident-specific nutritional concerns and preferences. The care plan should address the following .c. Identify resident-specific interventions. d. Timeframe and parameters for monitoring .4. Interventions will be identified, implemented, monitored, and modified consistent with resident-assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. 5. A weight monitoring schedule will be developed on admission for all residents .If clinically indicated, monitor weight daily. 6. Weight analysis: The newly recorded weight should be compared to the previously recorded weight. A significant change in weight is defined as: a. 5% change in weight in one month; b. 7.5% change in weight in three months; c. 10% change in weight in six months .The dietitian will inform the physician of a significant change in weight, and the physician may also order additional nutritional interventions. 1. R29 was admitted to the facility on [DATE]. R29's facility diagnoses list included chronic obstructive pulmonary disease (COPD) and moderate persistent asthma. A Quarterly Minimum Data Set (MDS) assessment, dated 5/29/26, stated R29 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The assessment did not indicate R29 had a diagnosis of heart failure. R29 was their own decision maker. From 6/29/26 to 7/1/26, Surveyor reviewed R29's medical record. A hospital discharge summary from 5/13/26 contained a diagnosis of chronic heart failure with preserved ejection fraction that was not on the facility's diagnoses list. R29 was started on Lasix 20 milligrams (mg) daily during the hospitalization. R29's care plan, revised, 2/28/26, indicated R29 had a nutritional problem/potential nutritional problem due to obesity, alcohol dependence, and alcoholic fatty liver disease. R29 was on a general diet with +10.5% weight gain trend over 3 months. The care plan contained a goal to maintain adequate nutritional status as evidenced by maintaining weight with no trending or significant weight gain, no signs or symptoms of malnutrition, and consuming at least 75% of at least 2 meals daily. The care plan contained interventions to obtain and monitor lab/diagnostic work as ordered and report results to the provider (revised 11/19/25). (R29's care plan did not include monitoring/interventions for chronic heart failure.) R29's medical record contained an order for weekly weights x 4 weeks then monthly (dated 5/23/26) and indicated furosemide (Lasix) was initiated 5/14/26 post-hospitalization for an associated diagnosis of chronic heart failure. R29's medical record contained the following weights: ~ 4/14/26: 233 pounds (lbs) ~ 5/1/26: 239 lbs (up 6 pounds) (There was no progress note or documentation that the provider was updated.) ~ 5/13/26: 225 lbs (down 14 lbs) ~ 5/14/26: 226 lbs ~ 5/22/26: 232 lb (up 6 lbs) (There was no progress note or documentation that the provider was updated.) ~ 6/11/26: 234.8 lbs ~ 6/13/26: 239.8 lbs (up 5 lbs) (A progress note did not address the weight change or a provider update.) Provider notes on 5/14/25 and 5/19/26 by Nurse Practitioner (NP)-W indicated R29 had chronic heart failure with preserved ejection fraction newly diagnosed during recent a hospitalization. R29 was started on furosemide 20 mg daily. Monitor for symptoms of fluid overload, weight changes, and medication tolerance. A Nutritional Assessment progress note on 5/15/26 indicated R29 had a diagnosis of chronic heart failure. R29's weight on 5/14/26 was 226 lbs (recent hospital weight was 224.7 lbs). R29 had overall weight gain since initial admission. R29 triggered for significant 5.4% weight loss x 2 weeks comparing 5/1/26 weight, non-significant 3.5% weight loss x 3 months, and 7% gain x 6 months. The weight gain was acceptable and likely related to improved oral intake since initial admission. The weight gain may be related to fluid-trace bilateral edema per provider on 5/14/26. Weights per provider order. A nutrition progress note on 5/15/26 indicated R29 was at risk of malnutrition due to potential weight loss based on facility weight record. Provider notes on 5/26/26 and 5/28/26 by NP-W indicated R29 had chronic diastolic (congestive) heart failure. R29's weight trended up from 225.6 lbs on 5/13/26 to 232 lbs on 5/22/26 to 230.4 lbs on 5/24/26. No lower extremity edema was present. Continue furosemide 20 mg daily. Monitor for symptoms of fluid overload, weight changes, and medication tolerance. A provider note on 6/9/26 by NP-W indicated R29 appeared compensated and to continue furosemide. A medical director note on 6/13/26 indicated R29 was hospitalized from [DATE] to 5/13/26 and had a new diagnosis of chronic heart failure with preserved ejection fraction (5/2026). Monitor for symptoms of fluid overload and weight changes due to chronic heart failure. A provider note on 6/23/26 by NP-W indicated R29's weight was stable. On 6/20/26, nursing staff reported +1 pitting bilateral lower extremity (LE) edema. R29 currently had +2 pitting bilateral LE edema. Furosemide was increased to 40 mg daily. Lab work was ordered for 7/6/26 and to monitor potassium closely given loop diuretic up titration. Monitor for symptoms of fluid overload and weight changes. R29 declined compression stockings. Elevation was encouraged. A provider note on 6/30/26 by NP-W indicated on 6/20/26, nursing staff noted +1 pitting bilateral LE edema. By 6/23/26, it had progressed to +2 pitting bilateral LE edema. Furosemide was increased from 20 to 40 mg daily. Amlodipine was decreased from 10 to 5 mg daily. Repeat labs were ordered for 7/6/26. R29 declined compression stockings. LE elevation was encouraged. On 7/1/26 at 10:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-O who verified R29's medical record did not contain a diagnosis of chronic heart failure and stated R29 was not aware of the diagnosis. LPN-O state R29 had bilateral LE swelling and the provider adjusted R29's Lasix order on 6/30/26. LPN-O stated staff do not update the provider regarding significant weight changes unless there is an order to do so. LPN-O confirmed R29 had an order for weekly weights and stated the provider requested additional weights for R29 on the morning of 7/1/26 due to medication adjustments and extremity swelling. On 7/1/26 at 12:19 PM and 2;09 PM, Surveyor interviewed Regional Consultant (RC)-Q who stated staff update the provider regarding weight based on the order. RC-Q stated staff should follow weight frequency orders and update the provider if a resident has a 3 lb difference in daily weight or a 5 lb weight difference in one week. RC-Q stated a resident diagnosed with chronic heart failure is typically weighed daily. RC-Q stated the MDS nurse initiates a resident's diagnoses from their hospital record and verified the nurse missed R29's diagnosis of chronic heart failure. RC-Q indicated a resident's care plan is derived from their diagnoses and MDS assessment. On 7/1/26 at 2:16 PM, Surveyor interviewed NP-W who verified R29 was diagnosed with chronic heart failure during a hospitalization with a discharge date of 5/13/26. NP-W confirmed R29 was prescribed furosemide for the diagnosis. NP-W indicated staff should monitor for signs and symptoms of fluid overload, incuding significant weight changes, and update as necessary. NP-W stated a significant weight change includes a 3 lb weight change in one day or a 5 lb change in one week. 2. R24 was admitted to the facility on [DATE] and had diagnoses including chronic diastolic heart failure, severe protein-calorie malnutrition, and anemia. An MDS assessment, dated 6/25/26, stated R24 had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. R24 had a Power of Attorney for Healthcare (POAHC) for medical decisions. A care plan indicated R24 had a history of and risk for unplanned weight loss related to variable meal intakes and weight fluctuations due to fluid status with edema, chronic heart failure, and chronic kidney failure. The care plan contained a goal to maintain adequate nutrition status with no further significant, involuntary weight changes. The care plan contained interventions to monitor and evaluate weight loss, determine percentage lost and follow facility protocol for weight loss, weigh weekly or as ordered at the same time of day, and document weight or if weight is declined. R24's medical record contained the following orders: ~ Med Pass 2.0 calorie two times daily for oral nutrition supplement related to unspecified severe protein-calorie malnutrition (dated 2/6/26) ~ General diet with 2 liter fluid restriction (dated 9/23/24) ~ Weekly weights (dated 7/7/25) R24's medical record contained the following weights: ~ 5/12/26: 187.8 lbs (wheelchair scale) ~ There were no documented weights for 5/19/26 and 5/26/26. ~ 6/2/26: 186.8 lbs (mechanical lift) ~ 6/15/26: 177 lbs (wheelchair scale - down 9.8 lbs) ~ There were no documented weights for 6/9/26 and 6/23/26. ~ 6/30/26: 183.4 lbs (mechanical lift - up 6.4 lbs) A provider note by NP-W on 6/2/26 indicated R24 had a diagnosis of chronic diastolic (congestive) heart failure. Will request updated weight. Continue current management with furosemide 40 mg twice daily. A Nutritional Assessment progress note on 6/23/26 indicated R24 was on a general diet with a 2 liter daily fluid restriction and consumed 25-100% of meals. Possible weight loss was contributed to furosemide and vitamin D. R24 received a supplement of Med Pass 2.0 twice daily and currently weighed 177 lbs on 6/15/26 - significant 5.2% loss x 1 month; non-significant 4.2% loss x 3 months, and significant 10.2% loss in less than 6 months. Weight loss could be attributed to diuretic treatment. Meal intakes are marginal. A supplement provides an additional 480 calories/day. Continue weights as ordered and document meal intakes daily. On 7/1/26 at 12:19 PM, Surveyor interviewed RC-Q who indicated staff update the provider regarding weight based on the order. RC-Q stated staff should follow weight frequency orders and update the provider if a resident has a 3 lb difference in daily weight or a 5 lb difference in one week. RC-Q stated a resident with a diagnosis of chronic heart failure is typically weighed daily. 3. R28 was admitted to the facility on [DATE] and had a diagnosis of non-pressure chronic ulcer of the left foot. An MDS assessment, dated 6/11/26, stated R28 had a BIMS score of 11 out of 15, indicating moderately impaired cognition. R28's TAR contained the following wound care orders: ~ Wound care to left foot (started 4/27/26; discontinued 5/20/26). (R28's TAR indicated wound care was not completed on 4/30/26 or 5/6/26.) On 7/1/26 at 9:01 AM, Surveyor interviewed LPN-E who was the facility's wound care nurse. LPN-E stated if wound care is completed, staff should document in the resident's TAR. On 7/1/26 at 10:47 AM, Surveyor interviewed Corporate Clinical Consultant (CCC)-D who reviewed R28's TARs for March to June 2026 and confirmed there were multiple undocumented entries for wound care. CCC-D was unsure if the nurses completed wound care and forgot to document or if wound care was not completed. CCC-D stated nurses should document if they complete wound care and should also document refusals. *The facility did not provide a wound care policy despite multiple requests from Surveyor.

Based on interview and record review, the facility did not ensure 2 residents (R) (R11 and R54) of 2 sampled residents who required assistance with activities of daily living (ADLs) were provided care in a timely manner.R11 did not receive a shower for 2 weeks and stated staff did not provide shower assistance per R11's request. R54's care plan indicated they required assistance with personal hygiene. The facility did not ensure documentation was completed to indicate personal hygiene was provided for R54. Findings include: The facility's Activities of Daily Living (ADLs) policy, revised 1/5/26, indicates: Care and services will be provided for the following ADLs: 1. Bathing .3. Toileting .A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. R11 was admitted to the facility on [DATE] and had diagnoses including cellulitis of buttock, type 2 diabetes with foot ulcer, cellulitis of unspecified part of limb, abnormalities of gait and mobility, and morbid obesity. A Minimum Data Set (MDS) assessment, dated 6/8/26, stated R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The assessment also indicated R11 required substantial/maximal assistance for showering/bathing and lower body dressing and was dependent on staff for toileting hygiene. A care plan, initiated 5/6/26 and revised 6/15/26, indicated R11 had an ADL self-care performance deficit related to activity intolerance, fatigue, and shortness of breath. The care plan contained the following interventions: Toilet use: R11 requires 1 assist (revised 5/28/26); Bathing: R11 requires 1 assist (revised 5/28/26). R11's Kardex (an abbreviated care plan used by nursing staff), dated 6/26/26 and posted on their bathroom door, indicated they required the assistance of 1 staff for bathing, toileting, and personal hygiene, and maximal assistance for lower body dressing. A provider note on 6/30/26 indicated R11 was hospitalized from [DATE] to 5/6/26 for bilateral leg cellulitis and left 5th toe osteomyelitis that resulted in a resection of the left 5th metatarsal. R11 was readmitted to the hospital from [DATE] to 5/19/26 for left foot wound dehiscence and a right buttock abscess. R11 was readmitted to the hospital from [DATE] to 6/2/26 for cellulitis. On 6/29/26 at 10:24 AM, Surveyor interviewed R11 who stated they had not received a shower in 2 weeks. R11 stated they required assistance for bathing, however, staff did not provide assistance during showers. R11 also stated they continually have to request assistance with peri-care after toileting. R11 stated staff told them to complete cares independently and they repeatedly tell staff they cannot complete tasks without assistance. On 6/29/26, Surveyor reviewed R11's shower documentation which indicated the following: ~ 6/5/26: Shower completed-Setup or clean-up assistance-Helper sets up or cleans up; resident completes activity. Helper assists prior to or following the activity. Documentation completed by (Certified Nursing Assistant (CNA)-X). ~ 6/16/26: Shower completed-Supervision or touching assistance-Helper provides verbal cues and/or touching/steady and/or contact guard assistance. Assistance may be provided throughout or intermittently. Documentation completed by (CNA-P). ~ 6/23/26: Shower refused. Documentation completed by (CNA-P). On 6/29/26 at 3:43 PM, Surveyor interviewed R11 who verified they refused a shower on 6/23/26 because they were tired at the time. R11 stated they requested a shower 6/24/26 but did not receive a shower and has not had a shower since 6/16/26. R11 also stated they feel they have to beg for assistance with peri-care after a bowel movement. On 6/29/26 at 3:44 PM, Surveyor interviewed CNA-P who stated R11 had surgery on the left foot, has a dressing in place, and is non-weight bearing on the foot. CNA-P stated R11 requires assistance with washing the lower body and with peri-care during toileting. CNA-P indicated therapy assessed R11 as set-up assistance for showers and cares but R11's Kardex states they require set-up assistance for showers and the assistance of 1 staff for ADLs. CNA-P did not know if R11 could wash their peri-area in the shower. CNA-P stated Kardexes are not updated timely and indicated care plans and Kardexes should be updated to reflect a resident's abilities. CNA-P stated R11 refused the shower they offered on 6/23/26 because it was too late and they preferred to shower on 6/24/26. CNA-P stated they passed on the request to night shift staff in verbal report. On 7/1/26 at 1:30 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-O who stated R11 required the assistance of 1 staff for most ADLs and was nonweight-bearing on the left foot. LPN-O stated R11 required assistance with showering and toileting and indicated R11 should receive weekly showers per their shower schedule. 2. R54 was admitted to the facility on [DATE] and had diagnoses including fracture of neck of left femur and pain. An admission MDS assessment, dated 5/10/26, stated R54's BIMS score was 10 out of 15, indicating moderate cognitive impairment. The assessment also indicated R54 was incontinent of bowel and bladder and required substantial or maximal assistance with toileting hygiene. R54 discharged from the facility on 6/1/26. A care plan, dated 5/4/26, indicated R54 required substantial assistance of two staff for transfers and use of a bed pan and urinal. On 6/30/26 at 11:25 AM, Surveyor completed a confidential interview where it was stated a nurse entered R54's room on 5/9/26 at approximately 2:00 PM. R54 was incontinent of bowel and stated they needed their brief changed. The interviewee stated the nurse could not assist at that time and said they would come back, however, the nurse did not return until almost 4:00 PM when R54's roommate activated the call light. The interviewee stated staff do not get R54 out of bed and they never sat on the toilet. On 7/1/26, Surveyor reviewed R54's ADL charting which was incomplete for all ADLs, including toileting hygiene, toilet transfers, personal hygiene, chair to bed transfers, and bowel and bladder function. Surveyor noted ADL charting for 5/9/26 was not documented for all three shifts. On 7/1/26 at 11:38 AM, Surveyor attempted to interviewed R54 who did not return the call. On 7/1/26 at 11:58 AM, Surveyor interviewed Director of Nursing (DON)-B and Corporate Clinical Consultant (CCC)-D. DON-B and CCC-D stated staff should document throughout their shift, every shift, every day. DON-B and CCC-D acknowledged the incomplete documentation for R54 and verified the documentation was not completed per the facility's policy.

Based on 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.Certified Nursing Assistant (CNA)-F had a conviction that required the facility to obtain further information prior to employment. The facility did not obtain further information regarding the conviction.The facility did not ensure a background check for Occupational Therapist (OT)-H was completed every four years.Findings include:The facility's Abuse Prevention Program, dated 2/7/17, indicates: .The purpose of the policy is to assure the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by .conducting pre-employment screening of employees .The 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, the facility will .Obtain a Wisconsin Criminal History Report 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.On 6/30/26 at 3:27 PM, Surveyor reviewed caregiver background checks for 6 facility staff and 2 contracted staff and noted the following:1. CNA-F was hired on 6/14/22 and had a Background Information Disclosure (BID) form dated 6/3/26. CNA-F's Department of Justice (DOJ) report was dated 6/3/26 and listed a conviction that required the facility to investigate the circumstances further by obtaining and reviewing Judgement of Conviction paperwork prior to hire.On 7/1/26 at 12:10 PM, Surveyor interviewed Human Resources (HR)-J who stated background checks are completed before an offer of hire is completed and every 4 years thereafter. HR-J stated they follow the offense exemption list. If something triggers from the list, HR-J requests further information regarding the offense. HR-J stated they had been in their current position for 1 year and were unsure why there was not a Judgment of Conviction on file for CNA-F.On 7/1/26 at 12:14 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who acknowledged the facility did not obtain a Judgment of Conviction for the offense listed on CNA-F's background check but should have the information on file.2. OT-H was a contracted employee whose date of hire was 3/7/22. OT-H had a BID form dated 3/16/22 and DOJ and Government Findings reports dated 4/29/22 which were not within the last 4 years.On 7/1/26 at 12:14 PM, Surveyor interviewed NHA-A who acknowledged OT-H's most recent background check was not completed within the last 4 years. NHA-A stated they understood the facility was responsible to ensure the contracted entity completed timely background checks for their employees.

Based on staff interview and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 1 resident (R) (R1) of 3 sampled residents. R1 did not receive insulin, intravenous (IV) cefepime, levofloxacin, or blood sugar checks as ordered.Findings include:The facility's admission Orders policy, dated 1/5/26, indicates: .1. The written and/or verbal orders should include at a minimum .b. Medication orders if indicated .2. The orders should allow staff to provide essential care to the resident consistent with the resident's mental and physical status on admission.The facility's Medication Orders policy, dated 1/5/26, indicates: Written Transfer Orders (sent with a resident by a hospital or other health care facility): Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician.The facility's Medication Administration policy, dated 1/1/25, indicates: .23. Administer medication(s) according to physician order.From 4/27/26 to 4/28/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and discharged on 2/28/26. R1 had diagnoses including adult failure to thrive, diabetes, protein calorie malnutrition, stasis dermatitis left lower extremity with venous ulcer due to chronic peripheral hypertension, pressure injury stage 3 left and right thigh, diabetic ulcer toe left foot associated with type 2 diabetes, and an abdominal wound. R1's Minimum Data Set (MDS) assessment, dated 2/27/26, indicated R1 had moderately impaired cognition.Surveyor reviewed R1's discharge medication list, dated 2/25/26, and noted the following orders:~ Insulin, Isophane 100 units/milliliter (ml) subcutaneous (SQ) injection. Inject 20 units into skin every day in the morning. May also inject 10 units at bedtime (HS) nightly as needed (for blood sugar >100) for type 2 diabetes (start date: 12/9/25). ~ Insulin, Regular (Novolin) Kwik Pen SQ 100 units/ml injection. Inject 10 units into skin three times daily (TID) before meals. Inject 10 units every morning before breakfast; inject 10 units every evening before supper; inject 10 units every night before bed unless blood sugar is less than 100 mg/deciliter (dl). Max 30 units per day for type 2 diabetes (start date: 11/25/25). ~ Levofloxacin 750 milligrams (mg). Take 1 tablet every evening for 10 days (start date: 2/25/26). ~ Sodium Chloride (NaCl) 0.9 % solution 100 ml cefepime 2 grams (gm) (2000 mg) IV. Inject 2000 mg into the vein two times daily (BID) for 14 doses for Pseudomonas skin infection (start date: 2/25/26). ~ Blood glucose test strips use 1 TID for type 2 diabetes. Surveyor reviewed R1's Medication Administration Record (MAR) for 2/25/26 to 2/28/26 and noted the following:~ Insulin NPH (Human)(Isophane) pen-injector 100 unit/ml. Inject 10 units SQ at bedtime related to type 2 diabetes mellitus with foot ulcer. Hold if blood sugar <100. The insulin was not administered on 2/25/26 and was documented with a code 5 (Hold/See Progress Notes).An Orders-Administration note, dated 2/252/6 at 10:24 PM, indicated the insulin was not in the facility's contingency stock. The physician was notified and indicated to hold until the insulin arrived from pharmacy. The insulin was discontinued on 2/26/26. ~ Novolin R Flex Pen Injection solution Pen-injector 100 units/ml (Insulin Regular (Human) Inject 10 units SQ with meals related to type 2 diabetes mellitus with foot ulcer. The insulin was not administered on 2/25/26 and was started on 2/26/26 at 5:00 PM. R1 missed 3 doses of the insulin. ~ Levofloxacin oral tablet 750 mg. Give 1 tablet by mouth at bedtime for 10 days related to pressure ulcer of right hip stage 3, pressure ulcer left hip stage 3. The medication was not administered at bedtime on 2/25/26 and was not started until 2/26/26. ~ Cefepime HCL intravenous solution 2 gm/100 ml. Use 2 grams intravenously BID for 7 days related to pressure ulcer right hip stage 3, pressure ulcer left hip stage 3, and open wound of abdominal wall. The antibiotic was not administered on 2/25/26 at bedtime and was not administered on 2/26/26 AM. Cefepime was first administered on 2/26/26 at 7:00 PM. ~ Fingerstick glucose monitoring after meals and at bedtime four times daily (QID). R1's blood sugar was not checked after supper on 2/25/26 or after breakfast on 2/26/26. On 4/28/26 at 12:36 PM and 3:43 PM, Surveyor interviewed Regional Director of Operations (RDO)-C who was uncertain if staff were aware of the orders for insulin, fingerstick glucose monitoring, IV cefepime, and levofloxacin. RDO-C stated it was difficult to determine or anticipate a resident's medications prior to admission and indicated the facility could receive three or four copies of orders which could change prior to the resident's arrival. RDO-C verified the orders were missed and the medications were not administered on 2/25/26. RDO-C stated the errors were discovered via an audit of admission documents. Staff education was initiated but not completed and proof of eduation was not provided.

Based on staff interview, record review, and policy review, the facility did not ensure documentation that medications were administered was accurate for 1 resident (R) (R3) of 7 sampled residents. R3 was sent to the emergency room (ER) on 2/23/26 when staff indicated R3 was lethargic, sweaty, and difficult to arouse. Documentation sent with R3 indicated R3's bedtime (HS) medications were administered; however, the medications were not administered.Findings include: The facility's Medication Administration policy, dated 4/9/25, indicates: Medications are administered by licensed nurses .as ordered by the physician in accordance with professional standards of practice .20. Sign Medication Administration Record (MAR) after administered .Document.refusals . Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), heart disease, bipolar disorder, and pain disorder. Review of R3's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/9/26 indicated R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was cognitively intact.A progress note, dated 2/23/26 at 11:39 PM, indicated a Certified Nursing Assistant (CNA) notified the writer that R3 was not R3's self. R3 was lethargic, did not talk, and did not wake up during a transfer from wheelchair to bed or during bedtime (HS) cares. The writer was unable to wake R3 who was minimally responsive to a sternal rub, non-verbal, and unable to keep R3's eyes open. The writer instructed a nurse to call 911. R3 was sent to the ER.A progress note, dated 2/24/26, indicated R3 returned from the ER at approximately 8:00 AM. A progress note, dated 2/25/26, indicated R3 had a follow-up evaluation after a recent ER visit. R3 was sent to the ER on [DATE] when staff indicated R3 would not open R3's eyes, did not talk, and was unresponsive. R3 was on multiple sedative medications, including morphine, lorazepam, and gabapentin. The ER assessment indicated R3's condition was likely due to the additive effects of home sedatives and oversedation. R3 was discharged to the facility on 2/24/26. R3's February 2026 Medication Administration Record (MAR) contained the following orders: Lorazepam (an antianxiety medication) oral tablet 0.5 milligrams (mg) give 1 tablet by mouth at bedtime; Acetaminophen oral tablet 200 mg give 1000 mg by mouth three times daily (8:00 AM, 12:00 PM, and 8:00 PM); Gabapentin oral capsule 300 mg give 3 capsules by mouth three times daily (8:00 AM, 12:00 PM, and 8:00 PM). Morphine sulfate oral solution 20 mg/milliliter (ml) give 0.25 ml by mouth every 2 hours as needed for moderate to severe pain or shortness of breath. The medication was administered on 2/23/26 at 1:37 PM for a pain level of 7 out of 10 and on 2/22/26 at 7:28 PM for a pain level of 10 out of 10. During an interview on 3/5/26 at 12:15 PM, the Assistant Director of Nursing (ADON) stated a staff member told the ADON that R3 was lethargic, diaphoretic, and clammy during the night shift on 2/23/26. The ADON said R3 did not respond to a sternal rub and staff called 911. The ADON stated she received different stories regarding whether R3's HS medications were administered; however, Registered Nurse (RN)1 verified the medications were not administered. The ADON located the HS medications in the medication cart and stated the MAR RN1 sent with R3 to the ER indicated R3's HS medications were administered. The ADON stated it was not the correct procedure to mark medications as administered prior to administering them. During an interview on 3/5/26 at 2:10 PM, RN1 stated on the night of 2/23/26, she attempted to administer R3's HS medications, however, R3 was sweaty and refused the medications. RN1 verified she documented that she had administerd the medications prior to attempting to administer them. RN1 was aware she should not document medications as administered prior to administering them.During an interview on 3/6/26 at 11:57 AM, the Director of Nursing (DON) confirmed staff should not document that a resident's medication was administered prior to administering the medication. The DON stated nursing staff should follow the facility's medication administration policy.

Based on observation, staff interview, and record review, the facility did not ensure an active physician order was in place for an indwelling catheter for 1 resident (R) (R1) of 3 residents reviewed for catheters. R1 had an indwelling catheter for which staff provided care. R1 did not have an active physician order for the catheter or for catheter care. Findings include:Review of R1's admission Record indicated R1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including benign prostatic hyperplasia. Review of R1's care plan, dated 7/28/25, indicated R1 had a urinary catheter. Interventions included to monitor for signs and symptoms of discomfort, leaking, and obstruction. Review of R1's physician orders, dated 10/6/25, revealed no current orders for a urinary catheter or catheter care. During an observation on 10/6/25 at 11:35 AM, R1 was in bed with catheter tubing visible. During an interview on 10/7/25 at 11:16 AM, Licensed Practical Nurse (LPN)1 said LPN1 provided catheter care to R1 earlier but did not check to see if there was a current order in place. LPN1 stated when R1 was readmitted to the facility from the hospital, nursing staff should have clarified if R1 still required a catheter. LPN1 stated LPN1 had not been documenting catheter care on R1's Treatment Administration Record (TAR) since there was not a current catheter order. During an interview on 10/7/25 at 12:42 PM, the Director of Nursing (DON) said nursing staff should look at a resident's physician orders each time they provide care. The DON stated staff are expected to document after care is provided and if there is not a current order, staff should clarify and obtain one.

Based on staff interview and record review, the facility did not develop a plan of care to address a mental health diagnosis and meet the psychosocial and emotional health needs of 1 resident (R) (R2) of 2 sampled residents.The facility did not accurately assess R2's mental health, which included a diagnosis of paranoid schizophrenia, to ensure R2's plan of care addressed R2's psychosocial and emotional health requirements. The facility's Treatment/Services for Mental/Psychosocial Concerns policy, dated 9/29/22, indicates: It is the policy of the facility to provide behavioral health services in accordance with state and federal regulations .The facility will ensure a resident who displays or is diagnosed with mental disorders or psychosocial adjustment difficulty or who has a history of trauma and/or post-traumatic stress disorder (PTSD) receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being .The facility's Conducting an Accurate Resident Assessment policy, dated 2/18/25, indicates: The purpose of this policy is to assure all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas .Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. A qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identify strengths to maintain or improve medical status, functional abilities, and psychosocial status .Information provided by the initial comprehensive assessment establishes baseline data for the ongoing assessment of resident progress. The physical, mental, and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals .to ensure accuracy in the Minimum Data Set (MDS) coding of a diagnosis of schizophrenia, supportive documentation must be present in the medical record and should include, but is not limited to, evaluation of the resident's physical, behavioral, mental, psychosocial status, and comorbid conditions, ruling out physiological effects of a a substance or other medical conditions, indications of distress, change in functional status, resident complaints, behaviors, symptoms, and or state preadmission screening and resident review evaluation .The facility's Comprehensive Care Plans policy, dated 3/25/25, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality .Individualized interventions for trauma survivors that recognize the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers .as well as identify ways to mitigate or decrease the effect of the trigger on the resident .From 8/25/25 to 8/26/25, Surveyor reviewed R2's medical record. R2 had diagnoses including anxiety, major depressive disorder, cognitive communication disorder, and PTSD. During R2's stay at the facility, R2 was diagnosed with Lyme disease and received psychiatric care through an outside source. R2 resided at the facility from 6/23/25 until 8/9/25 when R2 was transferred to the hospital and admitted to a psychiatric facility. R2's medical record contained an Aggressive and Harmful Behavior Assessment, dated 6/24/25, with a score of 5.0 that indicated R2 was potentially able to integrate into the peer community and was at minimal risk for aggression. There were no other similar assessments completed during R2's stay at the facility.R2's hospital History and Physical (H&P) (received and scanned into R2's medical record on 6/23/25) indicated R2 had a diagnosis of paranoid schizophrenia. Surveyor noted R2's facility diagnoses list, care plan, and Aggressive and Harmful Behavior Assessment did not include the diagnosis. R2's hospital H&P and referral documentation also indicated R2 received 1:1 supervision in the hospital due to ongoing suicidal and homicidal ideation. On 8/26/25, Surveyor reviewed R2's psychotherapy progress notes which included a diagnosis of paranoid schizophrenia that was indicated prior to R2's admission to the facility on 6/23/25. Surveyor noted R2's psychiatric provider completed a suicidal ideation/homicidal ideation (SI/HI) safety plan, dated 5/11/25, that was not included in R2's medical record. Surveyor reviewed R2's facility progress notes and noted the following: ~ On 6/30/25. R2 was seen by Nurse Practitioner (NP)-D who indicated R2 reported sleep difficulties due to waking up with flashbacks, episodes of tearfulness, and hearing voices. The note indicated nursing staff would reach out regarding the concerns. R2's medical record did not indicate R2's outside psychiatric provider was updated to obtain orders or recommendations.~ R2 was hospitalized from [DATE] to 7/11/25 due to medical concerns. Hospital discharge documentation, dated 7/11/25, indicated a referral for a neuropsych evaluation was completed. R2's medical record did not indicate a neuropsych appointment was made.~ On 7/16/25, R2 was seen by NP-D who documented R2 had underlying diagnoses of paranoid schizophrenia, PTSD, and psychogenic syncope. The note indicated NP-D would ensure R2 had psychiatric follow-up and contained a recommendation to contact Hospital (HSP)-H for a neuropsych evaluation.~ On 8/6/25, R2 was seen by NP-D who indicated R2's psychiatric status remained a significant concern. Following an incident on 8/3/25 when R2 hit R2's head against the wall and reopened a forehead abrasion, there were ongoing concerns. Nursing staff reported that R2 attempted to self-harm again on 8/5/25 but was redirected. The note indicated nursing staff would contact R2's outside psychiatric provider again for a plan of care. R2's medical record did not contain a progress note, new orders, or a psychotherapy update. ~ On 8/26/25 at 10:00 AM, Surveyor interviewed Regional Director of Operation (RDO)-C and Assistant Director of Nursing (ADON)-B. ADON-B indicated the admission and MDS nurse missed R2's schizophrenia diagnosis upon admission. RDO-C indicated if the diagnosis was recognized, it would have been properly assessed and care planned. RDO-C confirmed care plan updates and assessments were not completed following behavioral concerns for R2. ADON-B indicated paperwork with R2's paranoid schizophrenia diagnosis was received, however, the facility did not communicate or care plan the diagnosis correctly to ensure R2 received the appropriate care and treatment. ADON-B verified consistent communication occurred with R2's outside psychiatric provider and indicated calls were made for updates. ADON-B was unsure if R2's care plan/safety plan was requested from the psychiatric provider and was unsure if the psychiatric provider was contacted for collaboration of care since contact attempts were not documented. RDO-C and ADON-B indicated R2's outside psychiatric provider needed to pre-approve the neuropsych evaluation at HSP-H for payment to occur. ADON-B indicated multiple calls were made to follow-up on the evaluation approval, however, return calls were not received. ADON-B confirmed staff did not document any attempts to schedule the neuropsych evaluation. In addition, RDO-C and ADON-B confirmed R2's neuropsych evaluation was not scheduled and did not occur.

Based on staff interview and record review, the facility did not make a prompt and thorough effort to resolve a grievance for 1 resident (R) (R7) of 1 resident.R7's Guardian ((GD)-F) reported to Former Nursing Home Administrator (FNHA)-E that R6 provided R7 with illegal drugs and alcohol. FNHA-E did not file a grievance on behalf of R7 and the facility did not investigate the concern or follow-up with GD-F. Findings include:The facility's Grievance policy, revised 2/12/25, indicates: When a grievance is noted (either verbal or written), the resident or their representative may speak to any member of the facility staff and report the nature or the grievance or submit a written grievance form .An investigation of the grievance will be conducted; A review of the resident's medical record regarding the resident's clinical condition will be completed when indicated; The resident, resident representative, and the healthcare team that have been involved with the resident may be interviewed; The Department Head and/or Grievance Officer will work with staff for problem/grievance resolution; All grievances receive immediate priority and must be investigated with efforts toward resolution within seven days; The resident or resident representative will be provided with a verbal follow-up to the grievance including the steps taken to investigate the grievance and the results of the grievance. A signature by the resident or resident representative will be obtained on the grievance documentThe Federal Drug Administration (FDA) Regulation of Cannabis and Cannabis-Derived Products, Including Cannabidiol (CBD), updated 7/16/24, indicates: Cannabis is a plant of the Cannabaceae family and contains more than eighty biologically active chemical compounds. The most commonly known compounds are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Parts of the Cannabis sativa plant have been controlled under the Controlled Substances Act (CSA) since 1970 under the drug class Marihuana (commonly referred to as marijuana) .Marihuana is listed in Schedule I of the CSA due to its high potential for abuse, which is attributable in large part to the psychoactive effects of THC, and the absence of a currently accepted medical use of the plant in the United States.The Center for Drug Evaluation and Research (CDER) (a branch of the FDA), updated 8/25/25, indicates: The Cannabis sativa L. plant, which is the source of both marijuana and hemp, contains bioactive compounds known as cannabinoids. Delta-9 tetrahydrocannabinol (THC) is a psychoactive cannabinoid and is typically found in relatively high amounts in cannabis that is used as a source of marijuana .From 8/25/25 to 8/27/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia, Wernicke's encephalopathy (a brain disorder caused by vitamin B1 deficiency commonly associated with chronic alcohol abuse), alcohol dependence, fatty liver, and depression. R7's Minimum Data Set (MDS) assessment, dated 8/13/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R7 had moderately impaired cognition. R7 had a Guardian who was responsible for R7's healthcare decisions.On 8/25/5 at 1:09 PM, Surveyor interviewed GD-F via phone who indicated GD-F told FNHA-E that R6 provided R7 with illegal drugs and alcohol. (GD-F did not indicate when the information was reported to FNHA-E.) GD-F indicated the facility did not monitor R7 to make sure R7 did not receive illegal drugs and THC was discovered in R7's urine. GD-F indicated GD-F informed FNHA-E that R7 could not be exposed to alcohol, CBD/THC, or any illegal drugs due to R7's history of Wernicke's encephalopathy. GD-F also stated GD-F found a gummy (THC) wrapper in R7's pants that were brought home to be washed. During an emergency room (ER) visit, R7's urine drug screen (collected on 7/5/25) was positive for THC. GD-F also indicated a vape was found in R7's room which was given to FNHA-E and later given back to R7. GD-F was unsure if the vape contained THC or tobacco and did not know what steps the facility took to ensure R7 was not exposed to illegal drugs or alcohol. Surveyor reviewed the results of R7's urine drug screen (collected on 7/5/25) which were presumptive positive for cannabinoids.On 8/27/25 at 11:45 AM, Surveyor interviewed Regional Director of Operations (RDO)-C in the presence of Assistant Director of Nursing (ADON)-B and NHA-A. RDO-C, ADON-B, and NHA-A were not aware of GD-F's concerns, including R7's presumptive positive urine drug screen for cannabinoids, since they were not at the facility when the concerns were reported. RDO-C verified FNHA-E did not file a grievance but wrote a note (on 7/7/25) that indicated FNHA-E had a discussion with GD-F. It was uncertain what FNHA-E did after becoming aware of the presumptive positive THC test. A follow-up visit with R7's provider occurred on 7/9/25 but there was no mention of the test. RDO-C was unsure if the presumptive positive was due to the medications that R7 took and was uncertain what nursing staff did after becoming aware of the results of the test. No evidence of illegal drugs was found for R7.On 8/27/25 at 12:35 PM, Surveyor interviewed Social Services Director (SSD)-G who indicated FNHA-E informed SSD-G that GD-F stated R7 should not be exposed to illegal drugs or alcohol. SSD-G indicated FNHA-E stated FNHA-E would take care of the situation.On 8/27/25 at 3:05 PM, Surveyor interviewed RDO-C who verified FNHA-E should have filed a grievance for GD-F's concerns.

Based on staff interview and record review, the facility did not ensure care plans were updated for 2 residents (R) (R6 and R7) of 4 sampled residents.R6 and R7 had a history of drug and/or alcohol abuse. R6 and R7's care plans were not updated after R6 and R7 tested presumptive positive for cannabinoids.Findings include: The facility's Comprehensive Care Plans policy, dated 3/25/25, indicates: The comprehensive care plan will be reviewed and revised by the Interdisciplinary Team after each Comprehensive and Quarterly MDS assessment.The facility's Resident Possession and Use of Illegal Substances policy, revised 1/9/25, indicates: It is the policy of this facility to uphold the resident's right to retain and use personal possessions, unless to do so would infringe upon the rights or health and safety of other residents. The possession and use of illegal substances will not be tolerated .2. If the facility determines through observation that a resident may have access to illegal substances that they brought into the facility or secured from an outside source, the facility will not act as an arm of law enforcement. In accordance with state law, a referral will be made to local law enforcement. 3. If facility staff identify items or substances that pose risks to residents' health and safety and are in plain view, they will confiscate them. 4. Facility staff will not conduct searches of a resident or their belongings unless the resident or resident's representative agrees to a voluntary search and understands the reason for the search.The Federal Drug Administration (FDA) Regulation of Cannabis and Cannabis-Derived Products, Including Cannabidiol (CBD), updated 7/16/24, indicates: Cannabis is a plant of the Cannabaceae family and contains more than eighty biologically active chemical compounds. The most commonly known compounds are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Parts of the Cannabis sativa plant have been controlled under the Controlled Substances Act (CSA) since 1970 under the drug class Marihuana (commonly referred to as marijuana) .Marihuana is listed in Schedule I of the CSA due to its high potential for abuse, which is attributable in large part to the psychoactive effects of THC and the absence of a currently accepted medical use of the plant in the United States.The Center for Drug Evaluation and Research (CDER) (a branch of the FDA), updated 8/25/25, indicates: The Cannabis sativa L. plant, which is the source of both marijuana and hemp, contains bioactive compounds known as cannabinoids. Delta-9 tetrahydrocannabinol (THC) is a psychoactive cannabinoid and is typically found in relatively high amounts in cannabis that is used as a source of marijuana. Cannabidiol (CBD) is a non-psychoactive cannabinoid that is present at relatively high levels in hemp, defined as cannabis and derivatives of cannabis with extremely low concentrations of delta-9 tetrahydrocannabinol .1.From 8/25/25 to 8/27/25, Surveyor reviewed R6's medical record. R6 was most recently admitted to the facility on [DATE] and had diagnoses including left below knee amputation, congestive heart failure (CHF), diabetes, cognitive communication deficit, drug abuse, and suicidal ideation without current plan or intent. R6's Minimum Data Set (MDS) assessment, dated 7/7/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R6 had intact cognition. R6 made R6's own healthcare decisions.R6's medical record contained a urine drug screen panel, collected on 5/27/25, that was presumptive positive for cannabinoids.R6's care plan, dated 7/18/25, indicated R6 had a history of substance abuse/chemical dependency related to a history of illegal drug use prior to admission, marijuana use, and THC use. The care plan contained interventions (dated 7/18/25) to encourage R6 to express thoughts or feelings, encourage R6 to follow Medical Doctor (MD) orders, monitor R6 for behaviors, notify the MD for signs and symptoms of new changes, and Social Services to provide supportive listening as needed. The care plan did not include monitoring for the presence of illegal drug use and did not indicate to notify the Nursing Home Administrator (NHA) if observed so law enforcement could be contacted per the facility's policy. Surveyor noted the care plan was not updated after R6's presumptive positive urine drug screen on 5/27/25. 2. From 8/25/25 to 8/27/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia, Wernicke's encephalopathy (a brain disorder caused by vitamin B1 deficiency commonly associated with chronic alcohol abuse), alcohol dependence, fatty liver, and depression. R7's MDS assessment, dated 8/13/25, had a BIMS score of 11 out of 15 which indicated R7 had moderately impaired cognition. R7 had a Guardian who was responsible for R7's healthcare decisions.R7's medical record contained a urine drug screen panel, collected on 7/5/25, that was presumptive positive for THC.R7's care plan, dated 4/1/25, indicated R7 had a history of substance abuse/chemical dependency related to a history of alcohol abuse. The care plan contained interventions (dated 4/7/25) to encourage R7 to express thoughts or feeling, encourage R7 to follow MD orders, monitor for signs that R7 was drinking, instruct R7 that drinking is against facility policy and may lead to involuntary discharge, monitor R7 for behaviors, and notify the MD and Social Services of any changes. The care plan did not include monitoring for the presence of illegal drug use and did not indicate to notify the NHA if observed so law enforcement could be contacted per the facility's policy. Surveyor noted the care plan was not updated after R7's presumptive positive urine drug screen on 7/5/25.On 8/27/25 at 3:05 PM, Surveyor interviewed Regional Director of Operations (RDO)-C who verified R6 and R7's care plans should have been updated to include monitoring for the presence of illegal drug use and to notify the NHA if observed so law enforcement could be notified per the facility's policy.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 3 residents (R) (R10, R4 and R5) of 3 residents observed during the provision of cares. R10 was on enhanced barrier precautions (EBP). On 6/27/25, staff exited R10's room without removing personal protective equipment (PPE) and transferred R10 with a lift without donning the appropriate PPE. In addition, staff did not sanitize the lift after use. During an observation of pericare for R4 on 6/27/25, staff did not appropriately remove gloves and complete hand hygiene and touched items in R4's room with soiled gloves. In addition, a used bed pan was stored on R4's floor. On 6/27/25, staff put clean wash clothes in an unsanitized sink and used them to complete pericare for R5. In addition, staff did not appropriately remove gloves and complete hand hygiene during the provision of pericare. Findings include: The facility's Enhanced Barrier Precautions policy, revised 2/25/25, indicates: Personal protective equipment (PPE) for enhanced barrier precaution (EBP) is only necessary when performing high-contact care activities and may not need to be donned prior to entering a resident's room .Position a trash can inside the resident's room and near the exit for discarding PPE after removal prior to exit of the room or before providing care for another resident in the same room .High-contact resident care activities include: a. dressing .c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting. The facility's Infection Control-Cleaning and Disinfection/Non-Critical and Shared Equipment policy, dated 2/4/21, indicates .Any equipment used in rooms (such as items listed below) must be cleaned with a disinfectant wipe immediately after use/upon exit of the room C. Mechanical lift equipment. The facility's Perineal Care policy, revised 3/7/25, indicates: .Remove gloves, perform hand hygiene, and apply new gloves prior to continuing care (after completing pericare) .If a resident has bladder or bowel incontinence, don a clean pair of gloves and apply a barrier cream to protect the skin around the perineum .Remove gloves and perform hand hygiene. 1. On 6/27/25 at 4:33 AM, Surveyor observed Certified Nursing Assistant (CNA)-D exit R10's room in a gown and gloves. CNA-D walked down the hallway, retrieved a garbage bag, walked back up the hallway, and re-entered R10's room. Surveyor noted R10 was on EBP. On 6/27/25 at 4:38 AM, Surveyor observed CNA-C and CNA-D enter R10's room to transfer R10 with a Hoyer lift. CNA-C and CNA-D donned gloves but did not don gowns prior to the transfer. When Surveyor asked CNA-C if CNA-C and CNA-D should have worn gowns, CNA-C indicated a gown was only needed during cares. When Surveyor indicated the sign on R10's door stated PPE was required for transfers, CNA-C confirmed CNA-C and CNA-D should have donned gowns for the transfer. On 6/27/25 at 4:43 AM, Surveyor observed CNA-D exit R10's room with the lift. CNA-D did not sanitize the lift and left the lift in the hallway. On 6/27/25 at 5:41 AM, Surveyor interviewed CNA-D who confirmed lifts should be sanitized after use 2. On 6/27/25 at 4:49 AM, Surveyor observed CNA-E complete pericare for R4. During the observation, Surveyor noted CNA-E did not change gloves or complete hand hygiene and did not remove soiled gloves until all cares were completed and R4 was repositioned in bed. Surveyor observed CNA-E touch R4's pillows, position wedges, and blankets with soiled gloves. On 6/27/25 at 4:50 AM, Surveyor observed a used bed pan on the floor on the left side of the head of R4's bed. CNA-E confirmed that was where staff kept R4's bed pan. On 6/27/25 at 5:05 AM, Surveyor interviewed CNA-E who confirmed CNA-E should have changed gloves and completed hand hygiene during pericare and should have removed soiled gloves prior to touching items in R4's room. 3. On 6/27/25 at 5:11 AM, Surveyor observed CNA-C complete pericare for R5. Prior to completing pericare, Surveyor observed CNA-C run water and put two wash cloths in R5's sink. When Surveyor asked if CNA-C had sanitized the sink, CNA-C indicated CNA-C had not sanitized the sink and stated staff do not use basins. During the observation of pericare, Surveyor noted CNA-C did not change gloves or remove gloves and complete hand hygiene until R5 was fully dressed. On 6/27/25 at 5:27 AM, Surveyor interviewed CNA-C who confirmed CNA-C should have removed gloves and completed hand hygiene during pericare. On 6/27/25 at 10:46 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should not exit precaution rooms without removing PPE and should don a gown and gloves while transferring a resident on EBP. DON-B indicated staff should don PPE before entering the room and remove PPE before exiting the room. DON-B verified staff should change gloves and complete hand hygiene between dirty and clean tasks and sanitize lifts with bleach wipes after use. DON-B indicated staff should fill a basin with warm water instead of emerging wash cloths in a resident's sink and should not put wash cloths in an unsanitized sink. In addition, DON-B verified bed pans should not be stored on the floor and should be stored in a plastic bag in a drawer or in the bathroom.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R19 and R27) of 5 sampled residents which had the potential to affect more than 4 of the 49 residents residing in the facility, including 3 residents who shared a bathroom with R19. The facility did not ensure R19 smoked cigarettes in a safe manner consistent with the facility's smoking policy. R19 smoked in R19's room with no revisions to R19's care plan to ensure the safety of R19 or other residents in the vicinity. On one occasion, a hot cigarette butt had singed trash in a garbage can in R19's bathroom. R27 exited the building unsupervised on multiple occasions. During the survey, Surveyor noted care-planned interventions (WanderGuard bracelet in place and window only partially opened) were not implemented. The facility's failure to supervise, remove smoking materials from, and ensure R19 did not smoke in the facility and it's failure to supervise and ensure the whereabouts of R27 created a finding of immediate jeopardy that began on 3/5/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 4/10/25 at 1:15 PM. The jeopardy was removed on 4/10/25, however, the deficient practice continues at a scope/severity level E (potential for no more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: Example 1 - Unsafe Smoking: The facility's Resident Smoking Policy, dated 3/30/22, indicates: All residents who smoke may only smoke in a designated smoking area. At no time is smoking permitted in the facility .Extinguished smoking materials must be placed in the appropriate receptacles .The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely .Smoking at this facility is a privilege and any non-compliance with our smoking policy may result in loss of smoking privileges while at the facility or involuntary discharge from the facility . From 4/7/25 to 4/10/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] for treatment of a non-healing right below-the-knee amputation stump wound. R19 had diagnoses including bilateral below-the-knee amputations, chronic obstructive pulmonary disease (COPD), type 2 diabetes, adjustment disorder with depressed mood, and anxiety. R19's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated that R19 was cognitively intact. R19's care plan, initiated 10/31/24, indicated R19 was a smoker and chose not to smoke in the designated smoking area. R19 stated R19 is a rule breaker and becomes easily frustrated when approached in an incorrect area (revised on 2/16/25). The care plan had a goal that R19 will not suffer injury from unsafe smoking/vaping practices through the review date (initiated 10/31/24) and contained the following interventions: Instruct R19 about smoking/vaping risk and hazards and about smoking cessation aids that are available; Instruct R19 about the facility's policy on smoking/vaping, locations, times, and safety concerns; Notify charge nurse immediately if it is suspected R19 has violated the facility's smoking policy; Observe clothing and skin for signs of cigarette burns; R19 can smoke unsupervised; R19 is able to light own cigarette and keep lighter and carton of cigarettes at bedside (all initiated 10/31/24). Numerous progress notes in R19's medical record indicated R19 had disruptive behavior, including threatening other residents and inappropriate behavior toward staff. The facility called the police department on multiple occasions because of R19's behavior. Staff documented on a weekly basis that R19 violated the facility's smoking policy and smoked outside of the designated smoking area. Surveyor noted R19's smoking care plan was not revised after numerous progress notes documented that R19 had violated the smoking policy. A progress note, dated 11/3/24, indicated R19's room had a strong odor of cigarette smoke. Staff instructed R19 not to smoke cigarettes inside the facility and to smoke in the designated smoking area. R19's care plan was not revised following the incident and a new smoking assessment was not completed. R19 had two smoking assessments completed since admission to the facility. A smoking assessment, dated 2/4/25, indicated R19 has no smoking related incidents and could smoke independently. A smoking assessment, dated 2/12/25, also indicated R19 had no smoking related incidents and could smoke independently. A progress note, dated 3/5/25, indicated staff responded to R19's room due to a strong odor of cigarette smoke. R19 initially denied smoking in R19's room but then admitted to smoking a cigarette in the room. NHA-A reviewed the smoking policy and rules with R19 and attempted to remove R19's smoking materials from the room, however, R19 would not allow NHA-A to remove the smoking materials. There was no revision to R19's care plan to ensure R19's safety or the safety of other residents. A new smoking assessment was not completed. A progress note, dated 3/19/25 at 3:07 AM, indicated staff smelled a strong odor of cigarette smoke in R19's room. A police report, dated 3/19/25 at 2:35 PM, indicated the facility called the police to report R19 had been smoking and vaping in R19's room. The responding police officer indicated R19 admitted to vaping in R19's room. A Social Services note, dated 3/19/25 at 1:49 PM, indicated the facility provided R19 with a 30-day discharge notice due to noncompliance with the facility's policies. A progress note, dated 4/1/25 at 12:54 AM, indicated staff responded to R19's room due to a strong odor of cigarette smoke and found a cigarette butt in R19's bathroom. A progress note, dated 4/1/25 at 6:34 AM, indicated staff found several cigarette butts in R19's bathroom, including a butt in R19's bathroom garbage that was still hot and had singed trash. Staff also noted cigarette ashes in R19's toilet. (Surveyor noted R19's bathroom was a shared bathroom between two adjoining resident rooms in which R19 and 3 other residents resided. In addition to R19, the other 3 residents had physical limitations which impaired their ability to evacuate in the event of a fire. One resident had Alzheimer's dementia and a fractured left hip. The other two residents required a Hoyer lift and the assistance of two staff to get out of bed.) A progress note, dated 4/1/25 at 8:02 AM, indicated the facility asked the police department to speak with R19 about staff finding a lit cigarette in R19's garbage. On 4/14/25 at 2:57 PM, Surveyor interviewed Police Officer (PO)-NN who indicated PO-NN had responded to a call to the facility on [DATE]. PO-NN indicated PO-NN interviewed R19 and counseled R19 not to smoke inside of the facility. On 4/7/25 at 12:11 PM, Surveyor interviewed R19 who indicated staff accused R19 of smoking in R19's room. R19 indicated the facility tried to make R19 a supervised smoker but that that did not last. R19 indicated staff tried to take R19's cigarettes away but R19 refused. During the interview, Surveyor noted R19 had a lighter on a lanyard and a pack of cigarettes. On 4/8/25 at 2:23 PM, Surveyor interviewed Social Services Director (SSD)-D who alleged R19 had previously caused a fire in an assisted living apartment due to unsafe smoking practices. On 4/9/25 at 10:52 AM, Surveyor interviewed R19 who confirmed there was a fire at an assisted living facility where R19 resided prior to admission to the facility. R19 indicated the fire started accidentally when R19 disposed of a lit cigarette butt in a plastic cigarette receptacle. R19 indicated someone had put paper in the cigarette receptacle and a fire started when R19 disposed of the cigarette butt. R19 alleged the fire melted the plastic container and damaged the exterior of the facility. R19 indicated the assisted living facility accused R19 of intentionally starting the fire due to an eviction notice. R19 alleged R19 was evicted from the facility due to the incident. On 4/10/25 at 9:08 AM, Surveyor interviewed SSD-D who indicated R19 was given a 30-day notice of discharge on 3/18/25 due to disruptive behavior such as smoking in R19's room and inappropriate sexual behavior. Example 2 - Elopement: The facility's Elopement Prevention and Missing Resident Policy, dated 12/20/24, indicates: .Elopement is defined as a situation where a resident with cognitive impairment who cannot recognize normal danger and hazard outside the facility leaves the facility without staff knowledge .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 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. All WanderGuards, safety devices, and door alarms shall be placed appropriately and maintained .Quality assurance for the prevention of missing residents and allotment: Should a resident attempt to elope, a review of the resident's care plan shall be conducted for possible adjustments and care practices or safety precautions period . From 4/7/25 to 4/10/25, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, hallucinations, and malnutrition. R27's MDS assessment, dated 2/25/25, indicated R27 had moderate cognitive impairment, unclear speech, and required partial assistance with ambulation. The MDS assessment also indicated R27 was capable of independently wheeling a manual wheelchair at least 150 feet. R27's care plan, initiated 5/9/24 and revised 4/6/25, indicated R27 is at risk for elopement and has a history of attempts to leave the facility unattended. R27 will look to go outside to go fishing. The care plan contained a goal that R27 will not leave the facility unattended and contained the following interventions: Apply WanderGuard. Monitor function and placement; Assess for fall risk; Monitor exit seeking behavior; Monitor for fatigue and weight loss (all initiated 5/9/24); Secure window to only allow partial opening (initiated 10/24/24) Behavior symptom monitoring for R27 indicated R27 had wandering behavior on six days in March 2025 and no wandering behavior in April 2025. No exit-seeking behaviors were documented for March and April 2025. R27's March 2025 Treatment Administration Record (TAR) indicated staff documented R27's WanderGuard was in place every shift except one. On R27's April 2025 TAR, staff did not document WanderGuard placement for the 4/1/25 night (NOC) shift and the 4/8/25 PM shift. A progress note, dated 12/30/24 at 5:37 PM, indicated R27 was redirected back into the facility after exiting out the front door. On 4/9/25 at 1:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-V who recalled the incident where R27 exited the building on 12/30/24. LPN-V indicated R27 frequently wanders the building and had increased restlessness, wandering, and exit seeking on 12/30/24. R27 repeatedly said R27 needed to attend a funeral and staff repeatedly directed R27 away from the doors to prevent R27 from leaving the building. LPN-V indicated the WanderGuard system alarmed. LPN-V observed R27 outside the facility but did not witness R27 leave the facility. LPN-V discovered R27 walking on a sidewalk toward the parking lot unsupervised. R27 told LPN-V that R27 had to get to a car to go to a funeral. LPN-V did not recall the time the incident occurred but indicated it was dark when R27 was redirected back into the building. LPN-V did not recall what R27 was wearing at the time. (Surveyor noted the National Weather Service documented the average temperature on 12/30/24 was 38 degrees Fahrenheit and sunset was approximately 4:26 PM.) On 4/8/25 at 3:08 PM, Surveyor observed R27 pace and wander by the central nurses' station and attempt to exit the facility's front doors. R27 exited through the first set of doors, however, staff redirected R27 back into the facility before R27 exited through the second set of doors. The WanderGuard system did not alarm when R27 went through the first set of doors. Surveyor noted R27 was not wearing a WanderGuard. R27 attempted to leave the facility for several more minutes, however, Infection Preventionist (IP)-C repeatedly blocked R27's path to the door. On 4/8/25 at 3:11 PM, Surveyor observed LPN-L ask if R27 was bored. R27 responded affirmatively. LPN-L asked why R27 was trying to go outside. R27 responded, Fishing. Surveyor interviewed LPN-L who confirmed R27 was not wearing a WanderGuard but should have a WanderGuard in place. LPN-L indicated R27 frequently attempts to remove the WanderGuard and has removed the device by chewing, cutting, and pulling at the strap. LPN-L indicated R27 has entered other residents' rooms and the activities room in search of scissors to cut the WanderGuard strap. LPN-L indicated R27 understands the purpose of the WanderGuard and does not want to wear it. LPN-L indicated staff have to check R27's WanderGuard every shift because R27 frequently removes the WanderGuard. LPN-L indicated the facility lost several WanderGuards because R27 removed the WanderGuard and threw it in the trash. On 4/8/25 at 3:12 PM, Surveyor interviewed IP-C who confirmed R27 was not currently wearing a WanderGuard. IP-C indicated IP-C noticed R27 was not wearing a WanderGuard earlier in the shift but had not had a chance to replace the WanderGuard. IP-C confirmed R27 removed WanderGuards on multiple occasions and indicated the facility had lost several WanderGuards due to R27 throwing them away. On 4/8/25 at 3:25 PM, Surveyor observed LPN-C put a WanderGuard on R27's right wrist. R27 immediately tried to remove the WanderGuard with a metal key R27 had found near the nurses' station. On 4/9/25 at 1:12 PM, Surveyor observed a widow directly above R27's bed that opened completely and was large enough for R27 to exit through. (This was contrary to the care plan revision that was made on 10/24/24.) On 4/9/25 at 1:15 PM, Surveyor interviewed CNA-U who was assigned to R27's unit (the B wing). CNA-U verified R27's window opened all the way and indicated some rooms have screws in the windowsills to prevent the windows from fully opening. CNA-U indicated R27 frequently tests doors in the building and attempts to exit the facility, however, staff usually catch R27 before R27 is able to exit. CNA-U was not aware R27 tries to remove R27's WanderGuard. CNA-U indicated CNA-U and CNA-F were providing care on the A wing approximately two weeks ago when they heard the WanderGuard system alarm. CNA-U and CNA-F finished the care they were providing and responded to the WanderGuard alarm on the B wing. CNA-U and CNA-F found R27 outside the B wing emergency exit door. CNA-U indicated R27 was several feet outside the building and the emergency exit door was closed. CNA-U estimated R27 had been outside for less than five minutes and said R27 was wearing a jacket. CNA-U indicated R27 said R27 was going fishing. CNA-U reported the incident to the nurse. CNA-U did not report the incident to administration and was not asked to write a statement about the incident. (Surveyor noted the Waupaca River was across the road and approximately 800 feet from the facility's entrance.) On 4/9/25 at 2:35 PM, Surveyor interviewed CNA-F who indicated R27 left the building on several occasions. CNA-F verified CNA-U's statement that R27 exited the building through the B wing emergency exit. CNA-F indicated CNA-F and CNA-U were providing care on the A wing approximately two weeks ago when they heard the WanderGuard system alarm. CNA-F responded to the alarm and discovered R27 in a wheelchair a few feet outside the B wing emergency exit. R27 indicated R27 was looking for a good fishing spot. CNA-F informed the nurse R27 had exited the building. CNA-F did not report the incident to administration and was not asked to write a statement about the incident. R27's medical record did not contain documentation in March or April 2025 about R27 exiting the building from the B wing emergency exit door. On 4/9/25 at 1:48 PM, Surveyor interviewed NHA-A who indicated R27 had never eloped. NHA-A confirmed R27 exited the building several times, but did not consider the incidents elopements because R27 was supervised when R27 exited the building. Surveyor requested all elopement investigations and assessments related to R27. On 4/9/25 at 2:20 PM and 3:30 PM, NHA-A indicated the facility did not have any incident reports regarding R27 eloping or exiting the building. NHA-A indicated the facility did not have documentation of investigations, interdisciplinary team (IDT) meetings, or care plan reviews related to R27 exiting the building unsupervised. NHA-A indicated staff are expected to document exit seeking behavior under behavior monitoring and write a progress note about the behavior. The facility's failure to provide supervision to ensure resident safety by failing to ensure R19 did not smoke in R19's room and to ensure that R27 did not or could not exit the facility (by failing to ensure R27's WanderGuard bracelet was in place or that R27's window could not open wide) created a reasonable likelihood for serious harm that led to a finding of immediate jeopardy. The jeopardy was removed on 4/10/25 when the facility implemented the following: 1. Removed smoking materials from R19's room and stored them in a locked area. 2. Reeducated R19 and had R19 sign the facility's smoking policy and behavior contract for smoking. 3. Placed R19 on 15 minute checks to ensure smoking materials are not found in R19's room. 4. Revised R19's care plan to reflect R19's current smoking plan. 5. Updated the facility's smoking policy to include information on where smoking materials will be kept to maintain safety and reduce the risk of unsafe smoking. 6. Educated residents who smoke on the facility's smoking policy, reviewed the designated smoking area, and collected all smoking materials for safe storage. 6. Educated staff on the facility's smoking policy and procedure. 7. Initiated audits to ensure all smoking materials remain locked and the smoking policy is being followed. 8. Placed a WanderGuard on R27 and reviewed R27's order to ensure staff check placement, location, and function daily. 9. Placed R27 on 15 minute checks to monitor R27's location and ensure safety. 10. Secured the window in R27's room. 11. Revised R27's care plan with updated interventions. 12. Reviewed residents at risk for elopement to ensure interventions are appropriate and in place. 13. Educated staff on the facility's elopement policy and the importance of monitoring for exit seeking behavior. 14. Educated staff on the importance of checking for WanderGuard placement and function. 15. Reviewed the facility's elopement policy to ensure information is included regarding what to do when a resident removes a WanderGuard. 16. Initiated audits to ensure WanderGuards are in place and functioning properly.

Based on resident and staff interview and record review, the facility did not ensure 3 residents (R) (R203, R24, and R300) of 3 residents reviewed for intravenous (IV) medication were free of significant medication errors. R203 was admitted to the facility on [DATE] with an order for IV antibiotics twice daily after a 42 day admission to the hospital for multiple infections and septic shock. Staff did not initially recognize a dosing error in R203's hospital discharge order for cefepime and entered the order incorrectly. On [DATE], Registered Nurse (RN)-P changed the order without consulting with a physician. Staff did not follow the IV medication order by the discharge physician or the facility's admitting physician. In addition, staff did not administer the IV antibiotic three times in four days. The facility's failure to clarify an IV antibiotic order with the physician, change the order without physician approval, and not administer all doses of the antibiotic led to a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 1:15 PM. The jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity level D (potential for no more than minimal harm/isolated) as evidenced by the following examples: R24 was not administered a dose of IV antibiotics on [DATE]. R24's physician was not notified that medication was not administered. R300 was not administered a dose of IV antibiotics on [DATE]. R300's physician was not notified that medication was not administered. Findings include: The facility's undated Medication Administration-General Guidelines policy indicates: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration) .4. Five Rights: Right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of the five rights is recommended at three steps in the process of preparation of a medication for administration: (1) When the medication is selected, (2) When the dose is removed from the container, and finally (3) Just after the dose is prepared and the medication put away .5. The Medication Administration Record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. If the label and the MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the current dosage schedule .Administration: .2. Medications are administered in accordance with written orders of the prescriber. 3. If a dose seems excessive considering the resident's age and condition, or medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to administration of the medication or if necessary contacts the prescriber for clarification .This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate . Findings include: 1. From [DATE] to [DATE], Surveyor reviewed R203's medical record. R203 was admitted to the facility on [DATE] and had diagnoses on admission including osteomyelitis of foot, bacteremia due to group B Streptococcus, acute kidney injury, and bilateral cellulitis of lower leg. R203's Admission Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R203 was not cognitively impaired. R203 was responsible for R203's medical decisions. Documentation in R203's medical record indicated the following timeline: ~ From ,d+[DATE]//25 to [DATE], R203 was hospitalized for osteomyelitis. R203 was administered IV antibiotics in the hospital to facilitate healing. ~ On [DATE], R203's hospital discharge paperwork contained an order from Hospital Discharge Physician (HDP)-S for IV cefepime 200 milligrams (mg)/milliliter (ml) injection (commonly known as Maxipime). Inject 20 ml into the vein every 12 hours for 6 days. ~ R203 was admitted to the facility on [DATE]. Facility Physician (FP)-R prescribed cefepime HCI intravenous solution 2 grams (gm)/100 ml. Use 20 ml intravenously two times/day related to osteomyelitis until [DATE]. (Surveyor noted the order from FP-R was different than the discharge order from HDP-S which was cefepime 200 mg/ml, 20 ml every 12 hours at 8:00 AM and 8:00 PM. Since there are 1000 milligrams in a gram, FP-R's order was ,d+[DATE]th of the dose of HDP-S' order.) Staff did not clarify the discrepancy in orders. ~ The initial IV cefepime order prescribed by FP-R was listed on R203's MAR as cefepime HCl intravenous solution 2 gm/100 ml. Use 20 ml intravenously two times a day (8:00 AM and 8:00 PM) related to osteomyelitis until [DATE] (Start date: [DATE] at 8:00 PM). ~ R203's MAR indicated the 8:00 PM dose of cefepime was not administered on [DATE]. There was no documentation to indicate the physician was notified that R203 did not receive cefepime. ~ R203's 8:00 AM dose of cefepime HCl 2 gm/100 ml, 20 ml was documented as administered on [DATE]. ~ R203's 8:00 PM dose of cefepime HCl 2 gm/100 ml, 20 ml was documented as administered on [DATE]. ~ On [DATE] at 11:01 PM, R203's cefepime HCl 2 gm/100 ml, 20 ml intravenously twice daily dose order was discontinued by Registered Nurse (RN)-P. ~ On [DATE], a new order was created by RN-P for cefepime HCl intravenous solution 2 gm/100 ml. Use 1 vial intravenously two times a day (8:00 AM and 8:00 PM) related to osteomyelitis until [DATE]. (Start date: [DATE] at 8:00 PM). (Surveyor noted the revised medication order from RN-P on R203's MAR was different from R203's hospital discharge order and the order from FP-R noted above. Surveyor also noted the start time of the order entred by RN-P was 8:00 PM on [DATE] which omitted a dose for R203 on [DATE] at 8:00 AM.) R203's medical record did not contain communication to or from the physician regarding the medication change. ~ R203's MAR indicated R203's 8:00 AM dose of IV cefepime was not administered on [DATE]. R203's medical record did not indicate the physician was notified that R203 did not receive cefepime. ~ Cefepime HCl 2 gm/100 ml, 1 vial intravenously two times a day was documented as administered at 8:00 PM on [DATE] and 8:00 AM on [DATE]. ~ R203's MAR indicated R203's 8:00 PM dose of IV cefepime was not administered on [DATE]. R203's medical record did not indicate the physician was notified that R203 did not receive cefipime. ~ Cefepime HCl 2 gm/100 ml, 1 vial intravenously two times a day was documented as administered at 8:00 AM and 8:00 PM on [DATE] and at 8:00 AM on [DATE]. ~ R203 had an appointment with Infectious Disease Physician (IDP)-Q on [DATE]. IV cefepime was discontinued and R203 was prescribed an oral antibiotic twice daily for 30 days. On [DATE], Surveyor compared the discharge order from HDP-S, the admission order from FP-R, and the adjusted order from RN-P and noted the following: ~ Order 1- Prescribed by HDP-S on [DATE]: cefepime 200 mg per ml. Give 20 ml twice daily. With a concentration of 200 mg per ml, this would be 4000 mg per dose resulting in a daily dose of 8000 milligrams per day. ~ Order 2 - Prescribed by FP-R on [DATE]: cefepime HCI 2 grams (gm) per 100 ml. Give 20 ml twice daily. There are 1000 mgs in a gram, so the dosing is equal to 2000 mg/100 ml. With a concentration of 20 mg/ml this would be 400 mg per dose resulting in a daily dose of 800 mg per day. This dose is 10% of the dose prescribed by HDP-S. ~ Order 3 - Not prescribed by a physician and amended autonomously by RN-P on [DATE]: cefepime HCI 2 gms per 100 ml. Give one vial intravenously twice daily. One vial is 2 gms of powder which is reconstituted in 100 ml of saline solution. Two gms is 2000 mg/100 ml for each dose resulting in a daily dose of 4000 mg per day. This dose is 50% of the dose prescribed by HDP-S and 500% (or five times) the dose prescribed by FP-R. On [DATE] at 3:32 PM, Surveyor interviewed RN-P who indicated RN-P was familiar with R203's IV medication orders. RN-P indicated RN-P changed R203's cefepime order on [DATE] because RN-P felt the order did not read right. RN-P stated the order sounded like staff should draw up 20 ml and inject it or insert it into something. RN-P stated RN-P had never seen an order like that before and changed it so it was easier to read. When asked if RN-P consulted with the physician before changing the order, RN-P indicated RN-P looked at the discharge paperwork. RN-P confirmed RN-P did not contact the physician or the pharmacy before changing R203's cefepime order. RN-P indicated RN-P did not notify anyone of the change because RN-P had just corrected the wording. RN-P indicated RN-P made an error when restarting R203's cefepime on [DATE]. RN-P indicated RN-P thought the order would start again at 8:00 AM on [DATE] but was made aware by R203 on [DATE] that R203 did not receive the 8:00 AM cefepime dose which was started at 8:00 PM on [DATE]. Surveyor and RN-P reviewed R203's cefepime in the medication cart. The label on the medication bag and medication read: Cefepime 2 gm in 100 ml 0.9 NS (normal saline). Infuse 100 ml (2 gm) over 30 minutes intravenously twice daily for osteomyelitis (rate 200 ml/hr). RN-P indicated the order on R203's hospital discharge paperwork, the initial order, the order RN-P changed, and the medication labels did not match and were confusing. Surveyor noted the medication packaging was 2 gms of powder in a vial with an attached bag of 100 ml of saline. The powder was to be reconstituted in the saline solution before administering the medication intravenously. On [DATE] at 4:53 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated if a medication is not initialed as administered on the MAR it means the medication was not given. DON-B indicated medications should be administered as ordered or documented why they are not. DON-B indicated the resident's physician should be notified if a medication is not administered and the notification should be documented in the resident's medical record. DON-B indicated medication orders transcribed by RNs must be written by a physician and a second RN should double check the order. DON-B indicated RNs should clarify with the physician and the pharmacy if an order contains an error or is unclear. DON-B indicated staff are not allowed to make changes to a physician order without the physician's knowledge or input. On [DATE] at 11:05 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated discharge orders are signed by the discharging physician. NHA-A indicated when a resident is admitted to the facility, the orders transfer to the resident's medical record and there is no way for FP-R to sign them electronically or otherwise. NHA-A indicated RN-P should have clarified the orders with a physician before making any changes. On [DATE] at 1:40 PM, NHA-A indicated NHA-A did not have documentation to provide to Surveyor that indicated R203's physician was notified that R203 missed three doses of IV cefepime between [DATE] and [DATE]. On [DATE] at 2:37 PM, Surveyor interviewed FP-R who indicated the discharge physician's orders are automatically placed under FP-R when a resident is admitted to the facility. FP-R was not aware of a discrepancy and stated the orders should have been transferred over as written by HDP-S. FP-R indicated FP-R had not seen R203 or reviewed R203's chart. FP-R indicated an RN should not alter a physician order without consulting the physician. FP-R indicated orders should be followed exactly as written and if an RN has an issue, the RN should contact FP-R or the discharge physician for clarification. FP-R indicated it is concerning that an order was changed by a nurse without consultation. FP-R indicated it was also concerning that a resident on IV antibiotics with significant infections had missed three doses of IV medication in four days. FP-R indicated staff should notify FP-R when a resident does not receive their medication. FP-R checked notifications for R203 while on the phone with Surveyor and indicated there was no communication regarding R203's missed antibiotic doses. On [DATE] at 8:29 AM, Surveyor interviewed HDP-S who indicated there was an error in the discharge cefepime medication order as it was listed in R203's hospital discharge paperwork. HDP-S indicated staff should have clarified the order with FP-R, IDP-Q, or HDP-S and should not have administered the medication as written. HDP-S indicated the order should have been written as 2 grams. HDP-S indicated it could be concerning for a resident to miss three doses of IV cefepime and stated the facility should have notified the current provider, IDP-Q, or HDP-S. On [DATE] at 12:37 PM, Surveyor interviewed NHA-A who indicated staff are trained on the facility's policies and procedures. NHA-A indicated a nurse cannot make changes to an order without consulting with a physician. NHA-A indicated s nurse should clarify an order if the order is unclear or if the nurse has questions. NHA-A indicated medication orders should be followed as written. On [DATE] at 12:44 PM, Surveyor interviewed DON-B who indicated DON-B had spoken to staff who administered R203's IV cefepime on [DATE] and indicated the full vial was administered for both doses, not the order as it was written at that time. DON-B indicated staff are trained on the facility's policies and should be aware of the expectations. DON-B indicated a nurse cannot change an order without consulting a physician. DON-B indicated RN-P does not work at the facility any longer. On [DATE] at 1:17 PM, Surveyor interviewed R203 who indicated R203 was administered the full dose of cefipime each time R203 received cefepime. R203 indicated R203 was still upset that R203 missed 3 doses of cefepime because R203 had almost died recently. R203 was upset staff did not administer the medication to R203 and was told staff did not have anything for R203 when R203 asked about a missed dose. R203 stated R203 was on the medication for a reason and the facility did not care. The facility's failure to question the discrepancies in R203's medication orders, staff changing the order without consulting a physician, and the facility's failure to ensure all scheduled doses of the ordered antibiotic were given created a reasonable likelihood for serious harm from a significant medication error. The jeopardy was removed on [DATE] when the facility began implementing the following: 1. Reviewed R203's medication orders for accuracy and availability and notified Infectious Disease (ID) of the missed doses. 2. Completed an audit of all residents on antibiotics and verified their medications are available and being administered. 3. Educated nursing staff on the facility's policy for administering medication per physician orders and what to do when medications are unavailable. 4. Educated nursing staff on confirming pharmacy orders with the physician and that nurses may not change medication orders without physician approval. 5. Initiated audits to ensure admission orders are transcribed correctly and have been received from the pharmacy. The deficient practice continues at a scope/severity level D (potential for no more than minimal harm/isolated) as evidenced by the following: 50467 2. From [DATE] to [DATE], Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including chronic pulmonary edema, pleural effusion, pneumonia, type 2 diabetes, asthma, morbid obesity, methicillin-resistant Staphylococcus aureus (MRSA) infection, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and diabetic foot ulcer. R24's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R24 was not cognitively impaired. R24 had a physician order for vancomycin HCL intravenous solution 1250 mg/250 ml at 12:00 PM for cellulitis. R24's medical record indicated R24 received vancomycin intravenously from [DATE] to [DATE]. R24's MAR indicated the following: ~ R24 received vancomycin at 12:03 PM on [DATE] in the right arm ~ R24 received vancomycin at 11:28 AM on [DATE] in the right arm ~ R24 received vancomycin at 11:59 AM on [DATE] in the left arm ~ R24 received vancomycin at 12:30 PM on [DATE] in the right arm ~ R24 received vancomycin at 11:26 AM on [DATE] in the right arm ~ R24 received vancomycin at 11:09 AM on [DATE] in the right arm ~ R24 received vancomycin at 11:13 AM on [DATE] in the right arm ~ R24 received vancomycin at 2:22 PM on [DATE] in the right arm ~ R24 received vancomycin at 8:43 PM on [DATE] in the right arm ~ R24 received vancomycin at 8:02 PM on [DATE] in the right arm R24's MAR did not indicate vancomycin was administered on [DATE]. A nursing note, dated [DATE] at 2:14 PM, indicated R24's Infectious Disease (ID) office was notified that vancomycin would be administered on the PM shift for the next 3 shifts. The ID office confirmed the change. On [DATE], the time for R24's vancomycin administration was changed on R24's MAR from 12:00 PM to 8:00 PM. The medication was not documented as administered on [DATE] and there was no documentation to indicate R24's ID office was updated on the missed dose. On [DATE] at 4:53 PM, Surveyor interviewed DON-B who indicated if a medication is not documented as administered on a resident's MAR, it means the medication was not administered. DON-B indicated medications should be administered as ordered or documented as to why they were not. DON-B indicated a resident's physician should be notified if a medication is not administered and the notification should be documented in the resident's medical record. 51043 3. From [DATE] to [DATE], Surveyor reviewed R300's medical record. R300 was admitted to the facility on [DATE] and had diagnoses including bacteremia, osteomyelitis of left ankle and foot, gangrene, diabetes, epilepsy, amputation of left toes, and right below-the-knee amputation. R300's MDS assessment, dated [DATE], had a BIMS score of 15 out of 15 which indicated R300 was not cognitively impaired. R300 was responsible for R300's medical decisions. On [DATE] at 2:02 PM, Surveyor reviewed R300's [DATE] MAR and noted R300's 10:00 AM 2 gm dose of ceftriaxone (an antibiotic medication) was not administered via R300's peripherally inserted central catheter (PICC) line on [DATE]. Code 2 was documented on R300's MAR which indicated away from home without medications. The order for 2 gm of ceftriaxone administered via PICC line daily was started on admission for osteomyelitis of the foot. R300's medical record did not indicate the physician was notified that R300 did not receive ceftriaxone. On [DATE] at 11:50 AM, Surveyor interviewed R300 who indicated R300 had a physician appointment on [DATE]. On [DATE] at 1:07 PM, Surveyor interviewed DON-B who indicated DON-B could not find any documentation to indicate R300's physician was notified that R300's dose of ceftriaxone was not administered on [DATE]. DON-B indicated R300's physician should have been updated when ceftriaxone was not administered. NHA-A verified R300 left the faciity on [DATE] at 8:30 AM and returned to the facility at 12:03 PM. On [DATE] at 2:35 PM, Surveyor interviewed Facility Physician (FP)-R who was not aware R300 did not receive a dose of ceftriaxone on [DATE]. FP-R indicated FP-R expects staff to notify FP-R if a dose of ceftriaxone is not administered. FP-R indicated if FP-R had been contacted on [DATE], FP-R would have ordered the dose of ceftriaxone to be administered when R300 returned from R300's physician appointment.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 49 residents residing in the facility. The facility's gastrointestinal illness (GI) outbreak line lists did not include last symptom dates or times for affected employees and residents. R24 should have remained on contact precautions related to GI illness until after 7:39 AM on 4/8/25. The facility removed R24 from contact precautions on 4/7/25. R44 should have remained on contact precautions related to GI illness until after 10:00 AM on 4/9/25. The facility removed R44 from contact precautions on 4/7/25. R22 was on enhanced barrier precautions (EBP) due to colonization of a multidrug-resistant organism (MDRO). Licensed Practical Nurse (LPN)-E did not wear a gown when LPN-E manipulated R22's clothing to administer a pain patch on 4/7/25. On 4/8/25, residents were not offered hand hygiene before or after breakfast in the main dining room. R23 was on EBP. On 4/8/25, staff did not follow the facility's infection control protocol when handling soiled linen and refuse and while providing high-contact care for R23. R402 was on EBP. On 4/8/25, staff did not ensure a mechanical lift was sanitized after a transfer for R402. R7 was on contact precautions. On 4/9/25, staff entered R7's room without donning personal protective equipment (PPE). Findings include: The facility's Infection Control-Norovirus policy, dated 2/4/21, indicates: The facility's policy ensures appropriate infection prevention and control measure are taken to prevent the spread of infection per state and federal regulations and national guidelines .To help control the spread of infection: 1. Close unit to visitors until symptoms have cleared for 48 hours .11. Use standard and droplet contact precautions with careful attention to hand hygiene .Use a mask when cleaning up diarrhea and vomit. 12. Contact precautions should always be used when caring for incontinent residents, during outbreaks, and when there is the possibility of splashes that might lead to contamination of clothing .When an outbreak is suspected or occurs: .5. Begin a line listing of ill individuals (staff and residents). a. Complete line listing for the duration of the outbreak (until you have no new cases for 48 hours) . An Action Plan attached to the policy indicates to implement contact precautions for all residents suspected or confirmed with acute gastroenteritis (AGE) and continue precautions for a minimum of 48 hours after the resolution of AGE symptoms .Monitor healthcare personnel absenteeism due to diarrhea and/or vomiting symptoms and exclude those with gastroenteritis symptoms from patient care for at least 48 hours after resolution of symptoms .Use soap and water for hand hygiene (instead of antibacterial hand rub) after providing care or having contact with residents with AGE symptoms. The facility's Infection Control-Linen Management policy, dated 2/4/21, indicates: The facility's policy is to ensure lines are handled to prevent cross-contamination and the spread of infection per state and federal regulations and national guidelines. Guidelines: .4. Dirty linens are contained in a closed container or bag. 5. Dirty linens are to be handled in a way to prevent aerosolizing infectious agents. The facility's Infection Control-Cleaning and Disinfection/Non-Critical and Shared Equipment policy, dated 2/4/21, indicates: .5. Any equipment used in rooms must be cleaned with a disinfectant wipe immediately after use/upon exit of the room .C. Mechanical lift equipment. 1. On 4/9/25, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had a diagnosis of congestive heart failure (CHF). R24's Minimum Data Set (MDS) assessment, dated 3/16/25, stated R24's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R24 was not cognitively impaired. R24 was responsible for R24's healthcare decisions. On 4/925, Surveyor reviewed R44's medical record. R44 was admitted to the facility on [DATE] and had a diagnosis of diabetes mellitus. R44's MDS assessment, dated 3/9/25, stated R44's BIMS score was 11 out of 15 which indicated R44 had moderate cognitive impairment. R44 was responsible for R44's healthcare decisions. On 4/7/25 at 10:30 AM, Surveyor observed R24's room door which contained an EBP sign but not a contact precautions sign. On 4/9/25, Surveyor reviewed the facility's Norovirus outbreak documents which included emails to/from Infection Preventionist (IP)-C and a County Health Nurse, dated 4/7/25, that indicated at 10:34 AM, the County Health Nurse informed the facility that 2 of 3 samples from the facility tested positive for Norovirus. At 10:44 AM, IP-C informed the County Health Nurse via email that the facility opened the A wing due to infection is not spreading through the facility anymore. Included in the outbreak documents was a typed timeline that indicated the facility shut down the A wing on 3/31/25 for possible Norovirus due to 4 residents with active GI symptoms and contacted the County Health Department. A timeline indicated the facility opened the A wing on 4/7/25 and received an email from the County Health Nurse confirming 2 of 3 tests sent out were positive for Norovirus. The timeline indicated there were 3 new positive residents in the facility on 4/8/25, 2 on the A wing and 1 on the B wing. Surveyor reviewed the facility's Norovirus outbreak line lists, including 1 list for staff and a separate list for residents. The line lists indicated a staff member was the first person with symptoms on 3/24/25. The staff list included the date of onset, signs/symptoms, and a return to work date for each affected staff. The staff line list did not include the date/time of the last symptom (needed to determine how long to stay off of work as indicated in the facility's policy). The resident line list included the date of onset, signs/symptoms, room numbers, and resolved dates. The resident line list did not include the date/time of last symptom (needed to determine how long to keep the resident on transmission-based precautions as indicated in the facility's policy). On 4/9/25 at 8:52 AM, Surveyor interviewed IP-C who indicated Certified Nursing Assistant (CNA)-N, whose name was on the staff line list with no additional information, had called in on 4/9/25. IP-C was not aware of CNA-N's symptoms yet. On 4/9/25, Surveyor reviewed the resident line list which indicated R24 had an onset date of 4/5/25 with diarrhea. The line list indicated R24's illness was resolved on 4/7/25. Surveyor reviewed R24's medical record which contained CNA documentation that indicated R24's last loose stool was on 4/6/25 at 7:39 AM. The resident line list also indicated R44 had an onset date of 4/4/25 with diarrhea. The line list indicated R44's illness resolved on 4/7/25. Surveyor reviewed R44's medical record which contained a note, dated 4/3/25 at 8:47 AM, that indicated R44 continued to have looser stool than normal into this morning from last night. A note, dated 4/7/25 at 9:30 AM, indicated R44 was removed from contact precautions due to no signs/symptoms of nausea, vomiting, or diarrhea for 48 hours. R44's medical record contained CNA documentation that indicated R44 had watery stools on 4/5/25 and 4/6/25. CNA documentation indicated R44's last loose stool was on 4/7/25 at 10:00 AM. On 4/9/25, Surveyor reviewed the facility's call-in list used by Human Resources (HR). The HR list did not include signs/symptoms, end dates, or return to work dates. Examples included the following: ~ CNA-F had an onset date of 3/25/25 with symptoms of fever, cough, body aches, and congestion. The HR call-in list did not contain symptom resolution or return to work dates. ~ CNA-G had an onset date of 3/26/25 with symptoms of diarrhea and lethargy. The HR call-in list did not contain symptom resolution or return to work dates. ~ CNA-H had an onset date of 3/30/25 with symptoms of congestion and fever. The HR call-in list did not contain symptom resolution or return to work dates. Surveyor reviewed the facility's employee line list which included the following examples: ~ Physical Therapy Assistant (PTA)-K had an onset date of 3/30/25 with symptoms of vomiting, diarrhea, and light headedness. The HR call-in list contained a return to work date of 4/3/25 but no symptom resolution date ~ Certified Occupational Therapy Assistant (COTA)-M had an onset date of 3/30/25 with symptoms of vomiting and diarrhea. The HR call-in list contained a return to work date of 4/2/25 but no symptom resolution date In addition, comparison of the facility's outbreak staff line list with the HR call-in list revealed the following: ~ CNA-I had an onset date of 3/24/25 with symptoms of vomiting, fever, and diarrhea. The staff line list contained a return to work date of 3/28/25 but no symptom resolution date. CNA-I was not on the HR call-in list. ~ CNA-J had an onset date of 3/24/25 on the staff line list. The HR call-in list indicated CNA-J had an onset date of 3/25/25. ~ CNA-G had an onset date of 3/24/25 on the staff line list. The HR call-in list indicated CNA-G had an onset date of 3/26/25. ~ LPN-L had an onset date of 4/3/25 with symptoms of fever, chills, vomiting, and diarrhea. The staff line list had a return to work date of 4/7/25 but no symptom resolution date. LPN-L was not on the HR call-in list. On 4/9/25 at 10:55 AM, Surveyor interviewed COTA-M who verified the illness listed on the staff line list and indicated COTA-M's symptoms ended in the early morning hours of 3/31/25. COTA-M could not recall the specific time of COTA-M's last loose stool. COTA-M indicated COTA-M returned to work on 4/2/25 at 7:00 AM. On 4/9/25 at 11:18 AM, Surveyor interviewed IP-C who indicated the GI outbreak was identified on 3/31/25. IP-C indicated IP-C, Nursing Home Administrator (NHA)-A, and HR determined the outbreak status together. IP-C indicated IP-C noticed the first resident with signs/symptoms of GI illness on 3/31/25. IP-C indicated multiple residents then displayed symptoms of illness and the facility closed the A wing because all of the residents who were sick on that date resided on that wing. IP-C indicated IP-C uses a report from the facility's electronic medical record system that shows if a resident had any symptoms (per nursing progress notes) for the previous 72 hours to determine when residents can come off of contact precautions. IP-C indicated employees must update the facility daily on how they are feeling. Either DON-B or HR determines when 48 hours has passed since the employee's last symptom of illness. Following a discussion of the above information for R24's GI illness, IP-C verified R24 should have remained on contact precautions until after 7:30 AM on 4/8/25. IP-C indicated CNA documentation does not pull to the report IP-C uses to determine symptom resolution for the resident line list. IP-C verified there should have been a contact precautions sign on R24's door at the time of the observation noted above. Following a discussion of the above information for R44's GI illness, IP-C verified R44 should have remained on contact precautions until after 10:00 AM on 4/9/25. IP-C indicated IP-C removed R44 from contact precautions too soon. Following a discussion of the above discrepancies and lack of information on the staff line list, IP-C verified the missing information was relevant to monitor the facility's outbreak status. IP-C indicated there were still 3 residents on contact precautions, 2 on the A wing and 1 on the B wing. When asked if the County Health Department was notified of the new cases, IP-C indicated the most recent update to the County Nurse was on 4/7/25 via the emails listed above. IP-C indicated IP-C had not updated the County Health Department on the new cases. On 4/9/25 at 12:02 PM, Surveyor interviewed IP-C who indicated the difference between the staff line list and the HR call-in list is that the staff line list indicates the date of staffs' first symptom and the HR call-in list indicates the date the employee called in sick. IP-C indicated the employee (CNA-N) that was added to the line list that day (4/9/25)had called in on 4/9/25 for nausea and diarrhea with symptoms that started on 4/7/25. IP-C was unsure of when CNA-N last worked. On 4/9/25 at 12:18 PM, Surveyor interviewed PTA-K via phone. PTA-K verified the illness listed on the staff line list and indicated PTA-K was pretty sure PTA-K's symptoms ended on 4/1/25 when PTA-K had a last loose stool in the morning. PTA-K could not recall the time of PTA-K's last loose stool and indicated PTA-K returned to work on 4/3/25 at 8:30 AM. On 4/9/25 at 12:32 PM, Surveyor reviewed CNA-N's time card report which indicated CNA-N last left work on 4/6/25 at 6:12 AM prior to CNA-N's illness onset on 4/7/25. 2. The facility's Enhanced Barrier Precautions policy, dated 3/25/24, indicates: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention and transmission of multidrug-resistant organisms (MDROs) .EBP refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident care activities .4. High-contact care activities include: a. Dressing .Table 1 of the policy indicates a resident who is colonized with a CDC-targeted MDRO should be placed on EBP. On 4/7/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia and history of urinary tract infection with extended-spectrum beta-lactamase (ESBL) bacteria (ESBLs are considered MDROs and contain enzymes which break down certain antibiotics making infections difficult to treat). R22's MDS assessment, dated 4/2/25, stated R22's BIMS score was 4 out of 15 which indicated R22 had severe cognitive impairment. R22 had a Power of Attorney for Healthcare (POAHC) who was responsible for R22's healthcare decisions. On 4/7/25 at 9:29 AM, Surveyor observed LPN-E enter R22's room to apply a lidocaine patch to R22's left lower back. Surveyor observed a sign on R22's door that indicated staff must wear gloves and a gown for high-contact resident care activities such as dressing. Surveyor observed LPN-E lift R22's shirt with gloved hands while R22 leaned slightly forward in R22's wheelchair. LPN-E applied the lidocaine patch to R22's left lower back, removed gloves, and completed hand hygiene. LPN-E then obtained tape from the medication cart, dated the tape with a marker, applied the tape to the lidocaine patch on R22's back, adjusted R22's shirt back, and transported R22 to the activity room. LPN-E did not wear a gown during the observation. On 4/7/25 at 9:31 AM, Surveyor interviewed LPN-E who indicated R22 was on EBP due to a history of MDRO infection. LPN-E indicated staff should wear a gown and gloves when completing invasive care. LPN-E indicated if staff dealt with R22's urine, they needed to gown and glove. On 4/7/25 at 2:18 PM, Surveyor interviewed IP-C who thought staff only needed to gown and glove for R22 when providing cares related to urine. IP-C indicated that was how IP-C was taught by the facility's previous IP and IP-C educated staff the same way. IP-C verified the facility's policy states gown and gloves should be worn for high-contact cares such as dressing. IP-C indicated IP-C educated staff to read the EBP sign on a door prior to entering the room. IP-C verified LPN-E should have worn a gown to apply R22's lidocaine patch because the adjustment of clothing was involved. 49010 3. The Centers for Disease Control and Prevention (CDC) About Handwashing information from CDC.gov, dated 2/16/24, indicates: Many diseases and conditions are spread by not washing hands with soap and clean, running water. Hand washing with soap is one of the best ways to stay healthy. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surface to person when you: Touch your eyes nose and mouth with unwashed hands; Prepare or eat food and drinks with unwashed hands; Touch surfaces or objects that have germs on them; Blow your nose, cough, or sneeze into hands and touch other people's hands or common objects. You can keep yourself and your loved ones healthy by washing your hands often, especially during key times when you are likely to get and spread germs: Before, during, after preparing food; Before and after eating food . From 4/7/25 to 4/10/25, the facility was in an active Norovirus outbreak. On 4/8/25 at 7:48 AM, Surveyor observed breakfast in the main dining room and noted CNA-DD was the only staff in the dining room with 7 residents. Surveyor observed CNA-DD pour drinks, offer napkins, deliver and prepare food, and assist with condiments, however, CNA-DD did not offer residents hand hygiene before or after the meal. Surveyor noted R23 and R402 required feeding assistance and were seated at different tables. Surveyor observed CNA-DD assist R23 and R402, however, CNA-DD did not offer R23 and R402 hand hygiene before or after assisting them with eating. On 4/8/25 at 8:14 AM, Surveyor interviewed R41 who stated R41 was not offered hand hygiene. On 4/8/25 at 8:26 AM, Surveyor interviewed CNA-DD who indicated CNA-DD had to work alone because no other staff came to the dining room. CNA-DD stated CNA-DD did not offer or assist any of the residents in the dining room with hand hygiene because CNA-DD was the only staff in the dining room. 4. The facility's Infection Control Linen Management policy, dated 2/4/21, indicates: The facility's policy is to ensure linens are handled to prevent cross-contamination and the spread of infection per state and federal regulations and national guidelines .5. Dirty linens are contained in a closed container or bag. 6. Dirty linens are to be handled in a way to prevent aerosolizing infectious agents (i.e., Do not shake linens). Procedure: .5. Carry linen by holding it away from your body . On 4/9/25 at 5:17 AM, Surveyor observed CNA-Y enter a resident's room on the E wing with an EBP sign at the entrance. CNA-Y donned the appropriate personal protective equipment (PPE) to assist the resident. At 5:39 AM, Surveyor observed CNA-Y exit the room. CNA-Y was not wearing a gown or gloves and was carrying a clear plastic bag of items which CNA-Y held tightly to CNA-Y's chest with both arms. Surveyor observed a brown blanket on top of the plastic bag. The blanket was not in the bag and touched CNA-Y's arms, chest, and under CNA-Y's chin as CNA-Y carried the bag and blanket across the hall to the utility room. Following the observation, Surveyor interviewed CNA-Y who verified CNA-Y carried soiled linens from a resident's room to the utility room and put them into a designated laundry container. When Surveyor asked CNA-Y if the blanket had been on the resident's bed, CNA-Y stated yes but it was an extra blanket so CNA-Y removed it and put it in the dirty laundry to be washed. On 4/10/25 at 12:44 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects staff to be aware of and follow the facility's infection control policies and practices. 50467 5. On 4/8/25 at 5:07 AM, Surveyor observed CNA-CC exit R23's room in a gown and gloves and carry unbagged clothing and linens down the hallway to a soiled linen cart. R23 was on EBP and had an EBP sign on R23's door. CNA-CC disposed of the soiled items and then reached under her CNA-CC's gown with soiled gloves. CNA-CC retrieved a walkie talkie and called for assistance to transfer R23. CNA-CC then put the walkie talkie back under R23's gown, walked down the hallway, and re-entered R23's room wearing the same PPE. On 4/8/25 at 5:11 AM, Surveyor observed CNA-Y assist with a transfer for R23. CNA-Y donned gloves for the transfer but did not don a gown. On 4/8/25 at 5:11 AM, Surveyor entered R23's room to observe CNA-CC and CNA-Y transfer R23. When Surveyor asked if R23 was on EBP, CNA-CC indicated a resident down the hall was sick and that is why a gown and gloves were needed. When Surveyor mentioned the EBP sign on R23's door, CNA-CC looked at the sign and confirmed R23 was on EBP. CNA-CC indicated CNA-CC and CNA-Y should be wearing PPE. On 4/8/25 at 5:23 AM, Surveyor interviewed LPN-AA who confirmed staff should not be in the hallway with unbagged soiled clothing and linens. LPN-A indicated all soiled items should be bagged if they are being carried in the hallway. On 4/8/25 at 5:31 AM, Surveyor observed CNA-CC exit R23's room again with soiled linens while wearing PPE. CNA-CC then walked back and re-entered R23's room. On 4/8/25 at 5:43 AM, Surveyor interviewed CNA-CC who confirmed soiled linens and clothing should be bagged prior to transporting them in the hallway. 6. On 4/8/25 at 7:34 AM, Surveyor observed LPN-T and CNA-QQ transfer R402 via mechanical lift. Following the transfer, LPN-T wheeled the lift into the hallway and walked away. When Surveyor asked LPN-T if the lift should be sanitized, LPN-T stated, I guess, if I can find wipes. LPN-T found wipes and sanitized the lift. 7. On 4/9/25 at 10:52 AM, Surveyor observed CNA-F enter R7's room without donning PPE. R7 was on contact precautions and had a contact precautions sign on R7's door. On 4/9/25 at 1:07 PM, Surveyor observed again CNA-F enter R7's room without donning PPE. When CNA-F exited the room, Surveyor asked if CNA-F should have worn PPE. CNA-F indicated CNA-F just plugged in a cord. When Surveyor asked if R7 was on contact precautions, CNA-F looked at R7's door and confirmed R7 was on contact precautions. CNA-F then confirmed CNA-F should have worn PPE when CNA-F entered the room. On 4/10/25 at 12:57 PM, Surveyor interviewed IP-C who confirmed staff should wear PPE during direct cares such as dressing, changing, and transfers. IP-C confirmed soiled linens and clothing should not be transported in the hallway if not bagged or in a linen container. IP-C also confirmed staff should don PPE prior to entering a resident's room and remove PPE prior to exiting a resident's room. IP-C indicated all equipment should be sanitized between use per the facility's policy.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 49 residents residing in the facility. Kitchen staff did not complete appropriate hand hygiene. Logs for testing the parts per million (PPM) of the sanitizing solution in the sanitizer buckets were not completed. Staff did not appropriately test and maintain dishwasher temperatures. Staff completed unsanitary dishwashing. Findings include: On 4/8/25 at 9:03 AM, Dietary Manager (DM)-FF indicated the facility follows the Food and Drug Administration (FDA) Food Code as their standard of practice. Hand Hygiene: The Centers for Disease Control and Prevention (CDC) About Handwashing information from CDC.gov, dated 2/16/24, indicates: Many diseases and conditions are spread by not washing hands with soap and clean, running water. Hand washing with soap is one of the best ways to stay healthy. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surfaces to person when you: Touch your eyes, nose, and mouth with unwashed hands; Prepare or eat food and drinks with unwashed hands; Touch surfaces or objects that have germs on them; Blow your nose, cough, or sneeze into hands and then touch other peoples' hands or common objects. You can keep yourself and your loved ones healthy by washing your hands often, especially during key times when you are likely to get and spread germs: Before, during, after preparing food; Before and after eating food . Surveyor requested the kitchen's hand hygiene policy but received the facility's Certified Nursing Assistant (CNA)/Nurse hand hygiene policy on two occasions. From 4/7/25 to 4/10/25, the facility was in an active Norovirus outbreak. Multiple staff and residents tested positive and/or experienced symptoms, including kitchen staff. On 4/8/25 at 8:56 AM, Surveyor observed [NAME] (CK)-HH wash dishes. After handling dirty plates and silverware used by residents, CK-HH dipped CK-HH's hands in a bucket of water in which dirty silverware were soaking. After dipping both hands into the bucket, CK-HH wiped CK-HH's hands with a cloth. On 4/9/25 at 9:00 AM, Surveyor interviewed CK-HH who indicated CK-HH thought CK-HH's hands in the bucket of water was equal to washing CK-HH's hands. When Surveyor asked about the facility's Norovirus outbreak, CK-HH agreed there could be germs on the silverware and stated CK-HH had not thought of that. CK-HH then walked into the kitchen to retrieve items and returned to the dishwashing area. CK-HH did not complete hand hygiene. On 4/9/25 at 9:08 AM, Surveyor interviewed DM-FF who indicated staff should be aware of and practice good hand hygiene which they were trained on numerous times. DM-FF indicated staff should wash their hands in the hand washing sink, not in a bucket of dirty water. Surveyor informed DM-FF of the hand hygiene breach right away as the facility was in an active Norovirus outbreak and the clean dishes that CK-HH was putting away could be contaminated. DM-FF indicated DM-FF would ensure the dishes were rewashed and hand hygiene was completed. On 4/9/25 at 11:21 AM, Surveyor observed CK-GG wash dishes in the dish room. At 11:28 AM, CK-GG left the dish room and entered the kitchen. CK-GG pulled the covers off food on the steam table and prepared to obtain temperatures and serve the lunch meal. After CK-GG picked up plates, Surveyor asked if CK-GG completed hand hygiene after touching the dirty dishes. CK-GG indicated CK-GG should have cleansed hands after touching dirty dishes, but forgot. CK-GG then washed hands in the handwashing sink. Sanitizing Solution: The 2022 FDA Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions. The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The Ecolab Oasis 146 Multi-Quat Sanitizer data sheet indicates the sanitizing solution should be tested for effectiveness by measuring the PPM dilution range. The Hydrion Quat test strips are the appropriate testing strips. The sanitizer solution temperature should be tested and be within 65-75 degrees Fahrenheit. The effective PPM range is 150 to 400 PPM. Surveyor requested a policy on testing the sanitizing solution. An applicable policy was not provided. During an initial kitchen tour that began at 8:17 AM on 4/7/25, Surveyor observed sanitizer buckets and the three-compartment sink. The three-compartment sink contained Oasis 146 Multi Quat Sanitizer which was used to fill the sanitizing section of the sink and the sanitizer buckets. Surveyor requested to see the three-compartment sink and sanitizer bucket testing logs. CK-GG indicated staff test the three-compartment sink sanitizing solution with Hydrion test strips and showed Surveyor the log which included PPM of the sanitizing solution and temperature of the water. CK-GG indicated sanitizer buckets are not tested and do not have a testing log. On 4/8/25 at 8:43 AM, Surveyor observed Dietary Aide (DA)-II use a rag from the sanitizer bucket. When Surveyor asked DA-II if the PPM for the solution had been tested for effectiveness, DA-II indicated DA-II had not tested the sanitizing solution. DA-II indicated there was no log for testing the sanitizer buckets. On 4/8/25 at 9:39 AM, Surveyor interviewed DM-FF who indicated staff are supposed to test the sanitizer buckets for water temperature and PPM of the sanitizing solution. DM-FF indicated the facility did not have a log for testing the sanitizer buckets. Dishwasher Temperatures: The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual Warewashing: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 Celsius (C) (160 Fahrenheit (F)). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). The 2022 FDA Food Code documents at 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures: The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multi-use utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 160 degrees F as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 194 degrees F at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 165 degrees F for a stationary rack, single temperature machine, and 180 degrees F for other machines are based on the sanitizing rinse contact time required to achieve the 160 degree F utensil surface temperature. The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing (B): In hot water mechanical warewashing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the utensil surface temperature. The facility's undated Cleaning Dishes/Dish Machine policy indicates: All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machine will be checked prior to meals to ensure proper functioning and appropriate temperatures for cleaning and sanitizing .Staff will follow these procedures for washing dishes: 1. Prior to use, verify proper temperatures and machine function .Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitization. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify the actual temperatures . On 4/8/25 at 8:48 AM, Surveyor observed CK-HH wash dishes. Surveyor and CK-HH observed three dish cycles. The wash temperature for each cycle was appropriate at 166 degrees F, however, the rinse temperature only reached 172 degrees on the first two cycles and 174 degrees on the third cycle. On 4/8/25 at 8:49 AM, DM-FF walked by the dishwashing area and stated, That machine has been off on temps since we got it. On 4/8/25 at 8:50 AM, Surveyor observed CK-HH run a temperature test strip and temperature disk through the dishwasher on a flat rack. The temperature disk measured 171.6 degrees F. CK-HH was unable to find the test strip which was lost in the machine. CK-HH indicated the disk block temperature was not good and should be 180 degrees. At 8:53 AM, CK-HH again ran the temperature disk with a load of dishes. The temperature disk read 167.7 degrees. CK-HH indicated the temperature was lower because the disk was run with dishes. On 4/8/25 at 9:07 AM, Surveyor interviewed DM-FF who indicated the temperature gauge on the dish machine does not work. DM-FF indicated the dishmachine company attempted to fix it in the past and maintenance tried to fix it as well. DM-FF indicated the temperature gauge does not read what it it supposed to read and the temperature disk does not get up to temp, but a paper test strip does. On 4/8/25, Surveyor viewed the dishwashing temperature logs which documented rinse temperatures for every meal with varying temperatures of 180 degrees and above. On 4/8/25 at 9:33 AM, Surveyor interviewed CK-GG who indicated CK-GG runs a temperature test strip every shift but does not keep them. CK-GG indicated the test strips are used to record the temperature on the dishwashing temperature logs. When Surveyor asked how CK-GG is able to get a number for the log when the test strip does not provide a temperature but just turns orange if the temperature is over 180 degrees, CK-GG stated CK-GG did not know, and Surveyor should ask DM-FF. On 4/8/25 at 9:34 AM, Surveyor interviewed DM-FF who indicated the dishwashing temperature paper strips should be run every meal. DM-FF indicated staff do not keep a log of the test strips. DM-FF indicated the former kitchen manager used to keep the test strips on a calendar due to the ongoing issue with dishwasher temperatures. When Surveyor asked if DM-FF keeps the paper strips since the facility is still experiencing dishwashing temperature issues, DM-FF stated when DM-FF was hired, DM-FF was not instructed to do so. DM-FF indicated there was previous communication with maintenance about a booster to keep the dishwasher temperature levels in compliance, but a booster was not obtained. When asked how temperatures on the log are recorded as 180, 181, 182, and 183 degrees and above when staff indicate the dishwasher does not reach 180 degrees, DM-FF indicated DM-FF was aware that staff falsely write numbers at 180 degrees and above and that the temperature strip does not provide a number to record. DM-FF indicated DM-FF is aware the temperatures on the log are not accurate temperatures. DM-FF verified DM-FF has not addressed the issues and verified the temperature of the dishmachine needs to reach 180 degrees or above to sanitize the dishes. On 4/8/25 at 9:39 AM, Surveyor interviewed DM-FF who indicated DM-FF had proof the dishwashing machine was an ongoing issue. DM-FF indicated the facility has a company that comes monthly to look at the entire kitchen for regulatory compliance. DM-FF indicated DM-FF receives a report of how the facility does each month and the report is presented at the facility's monthly Quality Assurance Performance Improvement (QAPI) meeting. DM-FF provided Surveyor with a copy of the report from 10/22/24. The report indicated the dishwasher rinse temperature needs to reach 180 degrees but only reached a maximum of 170.9 degrees in three cycles. DM-FF indicated the information was provided at the next QAPI meeting, but no changes had been made. On 4/8/25 at 9:48 AM, Surveyor interviewed CK-HH who indicated CK-HH records temperatures over 180 degrees on the dishwashing log because everyone else does. On 4/8/25 at 9:56 AM, Surveyor interviewed Maintenance Director (MD)-JJ who indicated MD-JJ does not believe the temperature gauge on the dishwasher works, which is an ongoing problem. MD-JJ indicated MD-JJ previously requested a booster but was told a booster cannot be put on the machine. MD-JJ indicated a company checked the machine, and they said the machine is working correctly. MD-JJ indicated MD-JJ did not have any paperwork or a receipt to indicate to the facility the dishmachine was working correctly and reached the appropriate temperature. MD-JJ indicated MD-JJ usually uses the temperatures staff write on the log when MD-JJ checks the dishmachine for compliance. MD-JJ reiterated MD-JJ does not think the temperature gauge works correctly. On 4/8/25 at 10:36 AM, Surveyor observed MD-JJ run a paper test strip through the dishwashing machine. The strip turned orange which indicated a temperature of 180 degrees or above, however, the gauge on the dishmachine read 168 degrees. Surveyor reviewed the results of the facility's previous recertification survey and noted the dishwasher temperature gauge was not working appropriately at that time and the facility relied on paper test strips. Unsanitary Dishwashing Practice: The 2022 FDA Food Code documents at 2-301.14 When to Wash. Food Employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles, and: .(E) After handling soiled equipment or utensils; .(H) Before putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. The facility's undated Cleaning Dishes/Dish Machine policy indicates: .2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes. On 4/8/25 at 8:56 AM, Surveyor observed CK-HH wash dishes. After handling dirty plates and silverware used by residents, CK-HH did not complete hand hygiene and was not wearing an apron. CK-HH began to put clean dishes away without washing hands. On 4/9/25 at 9:00 AM, Surveyor interviewed CK-HH who did not realize CK-HH could be contaminating clean dishes. Surveyor observed CK-HH continue to put away clean dishes without rewashing them. On 4/8/25 at 9:07 AM, Surveyor interviewed DM-FF who indicated staff should wash their hands before going from dirty dishes to clean dishes. DM-FF indicated staff are well trained on the procedure and should be following it. On 4/10/25 at 12:37 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated kitchen staff should be aware of and follow the facility's policies and procedures.

Based on observation, staff and resident interview, and record review, the facility did not ensure the provision of sufficient nursing staff to meet residents' needs. This practice had the potential to affect more than 4 of the 49 residents residing in the facility. R24, R29, R44, R3, and R53 expressed concerns with staffing and call light response times. In addition, R24's call light was activated for 1 hour and 19 minutes on 4/9/25. Two other residents' call lights were activated for 35 minutes and 55 minutes. On 4/8/25, Certified Nursing Assistant (CNA)-DD was the only staff present in the dining room. R23 and R402 require feeding assistance and had to wait until all other residents were served. R41 asked for water twice but was not provided water. The facility did not ensure sufficient staffing levels were maintained to meet residents' needs in accordance with the Facility Assessment and resident acuity. Findings include: 1. On 4/7/25 at 10:30 AM, Surveyor interviewed R24 who indicated R24 had waited up to 3 hours for staff to respond to R24's call light. R24 indicated staff are not efficient and it is not acceptable to wait 2 to 3 hours to use a urinal. R24 indicated R24 takes a water pill and holding R24's urine for 3 hours is too long. On 4/7/25 at 11:00 AM, Surveyor interviewed R29 who indicated it can take staff 2 to 3 hours to answer a call light. On 4/7/25 at 11:42 AM, Surveyor interviewed R44 who indicated staff might respond to a call light timely, however, they turn the call light off and state they will come back later because they are busy. R44 indicated one staff on the NOC shift says they will return but does not and then gets upset when R44 has a wet bed and a full urinal. R44 indicated there is also a staff on the NOC shift who gets upset because R44 can not use the toilet. R44 indicated R44 is unable to use the toilet due to a recent right above-the-knee amputation and has fallen twice already. R44 indicated R44 needs assistance with toileting. On 4/7/25 at 12:39 PM, Surveyor interviewed R3 who indicated CNAs have told R3 to soil R3's self because they do not have enough staff to get R3 up. R3 stated staff let R3 sit in a soiled brief for an hour. R3 indicated R3 gets so upset that R3 pulls the brief off and throws it on the floor so R3 does not have to sit in urine. R3 indicated R3 was told multiple times that R3 has a pad and should just wet R3's self. On 4/8/25 at 10:38 AM, Surveyor interviewed R53 via phone. R53 stated staffing was terrible at the facility, especially on the NOC shift. R53 stated one night R53 had diarrhea and activated the call light for assistance. R53 stated it took staff an hour and a half for staff to respond. R53 stated R53 was incontinent due to the long response time and felt humiliated. On 4/9/25 at 9:50 AM, Surveyor observed call light response times and noted 3 residents had call lights activated. The wait times were 35 minutes, 55 minutes, and 1 hour and 19 minutes. At 11:09 AM, Surveyor observed CNA-W exit R24's room. When Surveyor asked if R24's needs had been met and indicated R24's call light had been on for 1 hour and 19 minutes, CNA-W indicated R24's needs had been met but R24 was still waiting for DON-B and wanted to keep the call light on until DON-B arrived. 49010 2. On 4/8/25 at 7:48 AM, Surveyor observed breakfast in the main dining room and noted CNA-DD was the only staff in the dining room with 7 residents. Surveyor observed CNA-DD pour drinks, offer napkins, prepare and deliver food, and assist with condiments. Surveyor noted R23 and R402 were seated at different tables and needed assistance with eating. Surveyor noted R23 and R402 waited until the rest of the residents were served and assisted before R23 and R402 received assistance with their meals. Since CNA-DD was only able to feed 1 resident at a time, R23 waited for assistance until CNA-DD finished feeding R402. R23 and R402's food was not kept warm while they waited. On 4/8/25 at 8:07 AM, Surveyor observed R41 ask twice for water and state R41 would really like some. R41 did not receive water because CNA-DD was assisting other residents. On 4/8/25 at 8:14 AM, Surveyor interviewed R41 who indicated the facility does not have enough staff. R41 indicated food is cold by the time it is delivered. R41 indicated R41 always has to wait for things and sometimes does not get them. On 4/8/25 at 8:26 AM, Surveyor interviewed CNA-DD who indicated CNA-DD worked alone because no other staff came to the dining room. CNA-DD indicated another CNA was scheduled to be in the dining room but most likely had to stay on the unit and provide care. CNA-DD indicated when CNA-DD walked by the dining room, CNA-DD saw residents in the dining room and food on the cart waiting to be delivered so CNA-DD started assisting residents. CNA-DD indicated there are often not enough staff in the dining room because CNAs are supposed to cover the dining room in addition to resident units. CNA-DD indicated residents have to wait for assistance when there is only 1 staff in the dining room. 50467 3. On 4/8/25, Surveyor reviewed the Facility Assessment (last revised 8/1/24). The Assessment indicated there should be 5 to 9 licensed nurses and 8 to 15 CNAs providing direct care per day. On 4/9/25 at 11:43 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A needed to revise the Facility Assessment because the facility currently scheduled nursing staff according to resident acuity. When asked about staffing numbers, NHA-A indicated for a census of 45-52 residents there should be: ~ Licensed staff: 3 on the AM shift; 2 to 3 on the PM shift; 1 on the NOC shift ~ CNAs: 4 to 6 on the AM and PM shifts; 2 to 3 on the NOC shift The information provided by NHA-A indicated the staffing hour ratio (staffing hours per day divided by the census) should be between 2.84 and 3.38. Surveyor reviewed the daily nursing staff schedules and census for 10/3/24 to 10/6/24, 11/28/24 to 12/1/24, and 12/26/24 to 12/29/24 and noted the following: ~ The 10/5/24 schedule contained a census of 51 residents. The staffing hour ratio was 2.80. ~ The 11/29/24 schedule contained a census of 52 residents. The schedule indicated there was only 1 CNA and 1 Licensed Practical Nurse (LPN) on the NOC shift (10:00 PM to 6:00 AM) from 11:00 PM to 2:00 AM. The staffing hour ratio was 2.55. ~ The 12/1/24 schedule contained a census of 52 residents. The staffing hour ratio was 2.82. ~ The 12/26/24 schedule contained a census of 54 residents. The staffing hour ratio was 2.51. On 4/9/25 at 11:43 AM, Surveyor interviewed NHA-A confirmed there were only 2 staff for 52 residents on 11/29/24 which was below staffing levels and resident acuity.

Based on staff and Ombudsman interview and record review, the facility did not ensure 2 residents (R) (R11 and R18) of 5 sampled residents received a written transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. In addition, the facility did not notify Ombudsman (OMB)-PP of hospital transfers and an involuntary 30-day discharge notice for 5 residents (R11, R18, R19, R24, and R49) of 5 sampled residents. R11 was transferred to the hospital on [DATE] and 1/3/25. R11 was not provided with a written transfer notice for either transfer. In addition, OMB-PP was not notified of the transfers. R18 was transferred to the hospital on 2/17/25. R18 was not provided with a written transfer notice. In addition, OMB-PP was not notified of the transfer. R19 was transferred to the hospital on 1/23/25. OMB-PP was not notified of the transfer. In addition, R19 was provided an involuntary 30-day discharge notice on 3/18/25. A copy of the discharge notice was not provided to OMB-PP or R19's provider. R24 was transferred to the hospital on 2/22/25. OMB-PP was not notified of the transfer. R49 was transferred to the hospital on 1/23/25. OMB-PP was not notified of the transfer. Findings include: The facility's Transfer and Discharge Policy, dated 2/13/24, indicates: It is the facility's policy to ensure residents are treated equally regarding transfer or discharge .a. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met at the facility .c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .1. Documentation in the resident's medical record should include: a. The basis for the transfer .b. In the case of inability to meet resident needs, the specific resident need(s) that cannot be met, the facility's attempts to meet the resident needs .2. Information provided to the receiving facility must include the following: a. Contact information of the practitioner responsible for the care of the resident; b. Resident representative information, including contact information; .f. All other necessary information, including a copy of the resident's discharge summary and any other documentation, as applicable, to ensure a safe and effective transition of care. (Of note: The policy does not state what documentation should be provided to residents or their representatives.) 1. On 4/9/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including chronic pain, venous insufficiency, anxiety, diabetes, and chronic venous hypertension with ulcer of right lower extremity. R11's Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 had intact cognition. R11 made R11's own medical decisions. R11's medical record indicated R11 was transferred to the hospital on [DATE] for facial cellulitis. R11 was not provided with a written transfer notice. R11 was also transferred to the hospital on 1/3/25 for facial cellulitis and was not provided with a written transfer notice. In addition, OMB-PP was not notified of either transfer. On 4/10/25 at 10:56 AM, Surveyor interviewed Social Services Director (SSD)-D who indicated a transfer notice should have been provided for both transfers. SSD-D also indicated OMB-PP should have been notified of the transfers. 2. On 4/9/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including traumatic spinal cord dysfunction, pyelonephritis, neurogenic bladder, and diabetes. R18's MDS assessment, dated 3/11/25, had a BIMS score of 15 of 15 which indicated R18 had intact cognition. R18 made R18's own medical decisions. R18's medical record indicated R18 was transferred to the hospital on 2/17/25 for a urinary tract infection (UTI), influenza, and pneumonia. R18 was not provided with a written transfer notice. In addition, OMB-PP was not notified of the transfer. On 4/10/25 at 10:56 AM, Surveyor interviewed SSD-D who indicated a transfer notice should be provided for each transfer. SSD-D also indicated OMB-PP should have been notified. 3. On 4/10/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including diabetes, adjustment disorder with depressed mood, peripheral vascular disease, and surgical ambulation of left leg below the knee. R19's MDS assessment, dated 2/9/25, had a BIMS score of 13 out of 15 which indicated R19 had intact cognition. R19 made R19's own medical decisions. R19's medical record indicated R19 was transferred to the hospital on 1/23/25. R19 was provided with a transfer notice, however, the facility did not notify OMB-PP of the transfer. In addition, the facility provided R19 with an involuntary 30-day discharge notice on 3/19/25 for failure to follow the facility's policies, verbal aggression toward staff, and inappropriate sexual touching of staff. OMB-PP and R19's provider were not provided with a copy of the 30-day discharge notice. On 4/10/25 at 10:44 AM, Surveyor interviewed SSD-D who indicated OMB-PP was not notified of R19's hospital transfer on 1/23/25 and was not provided a copy of the 30-day discharge notice provided to R19 on 3/19/25. 4. On 4/7/25, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including heart failure, pneumonia, and diabetes. R24's MDS assessment, dated 3/16/25, had a BIMS score of 15 out of 15 which indicated R24 had intact cognition. R24 made R24's own medical decisions. R24's medical record indicated R24 was admitted to the hospital on [DATE] for sepsis, cellulitis, hemorrhagic shock, and heart failure. R24 received a written transfer notice, however, OMB-PP was not notified of the transfer. On 4/10/25 at 10:44 AM, Surveyor interviewed SSD-D who indicated OMB-PP was not notified of R19's hospital transfer. 5. On 4/9/25, Surveyor reviewed R49's medical record. R49 was admitted to the facility on [DATE] and had diagnoses including bacterial infections and major depression. R49's MDS assessment, dated 1/23/25, had a BIMS score of 8 out of 15 which indicated R49 had moderately impaired cognition. R49 had an activated Power of Attorney for Healthcare (POAHC) who assisted R49 with medical decisions. R49's medical record indicated R49 transferred to the hospital on 1/23/25 due to fever and lung congestion. R49 did not return to the facility after discharge from the hospital. OMB-PP was not notified of the transfer. On 4/9/25 at 12:33 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated discharge notices were completed for R49 but were currently being scanned and not able to be located. On 4/11/25 at 7:55 AM, Surveyor interviewed OMB-PP who indicated the facility had not provided discharge or transfer notices since at least August of 2023.

Based on staff interview and record review, the facility did not ensure adequate monitoring and administration for 1 resident (R) (R7) of 3 sampled residents who received psychotropic medication. R7 had an order for clozapine 25 milligrams (mg) twice daily (BID) for psychosis related to Parkinson's disease and a weekly complete blood count (CBC) with differential (diff) for monitoring. On 11/19/24, staff did not ensure the correct lab was drawn. R7 did not receive clozapine from 11/23/24 to 11/26/24 and was sent to the emergency room (ER) on 11/26/24 for symptoms of psychosis. Findings include: The facility's Laboratory, Radiology, and Other Diagnostic Services policy, dated 1/11/21, indicates the facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for quality and timeliness of the services. From 1/13/25 to 1/14/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, anxiety, hallucinations, and malnutrition. R7's most recent Minimum Data Set (MDS) assessment, dated 12/22/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderate cognitive impairment. R7 had an activated Power of Attorney for Healthcare (POAHC) since admission. Surveyor reviewed R7's physician orders and noted the following: ~ Clozapine 25 mg 1 tablet by mouth two times per day for psychosis for Parkinson's disease (start date 9/16/24) ~ Weekly CBC with diff for monitoring while on clozapine, one time a day every Tuesday (start date 10/1/24) Surveyor reviewed R7's November 2024 Treatment Administration Record (TAR) and noted R7's CBC with diff lab was not signed out on 11/19/24. Surveyor reviewed R7's laboratory results for November 2024 and noted on 11/19/24, Registered Nurse (RN)-I completed a lab form and checked the box for a CBC lab draw rather than a CBC with diff. Surveyor reviewed the lab results sheet and verified the lab ran a CBC without differential. Surveyor reviewed R7's November 2024 Medication Administration Record (MAR) and noted R7's clozapine was not administered from 11/23/24 through 11/26/24 for a total of 8 missed doses. Nursing staff documented the medication was on hold/see progress notes. Surveyor reviewed R7's progress notes from 11/23/24 through 11/26/24 and noted several instances where the facility documented they were waiting for a refill from pharmacy. A progress note, dated 11/24/24, indicated the physician would not re-order R7's clozapine until a CBC with differential was drawn. An ER visit note indicated on 11/26/24 at approximately 1:30 AM, facility staff observed R7 standing on R7's bed, reaching up the wall, and appearing to have ingested an unknown amount of aloe vera lotion. R7 had excessive drooling and frothing from the mouth. R7 was sent to the ER and was noted to be confused and anxious. R7 received intravenous glycopyrronium bromide (a medication used to treat ulcers, excessive drooling/sweating, and chronic obstructive pulmonary disorder (COPD) symptoms). R7 returned to the facility at approximately 5:00 AM on 11/26/24. On 1/14/25 at 9:55 AM, Surveyor interviewed RN-I regarding R7's lab draw. RN-I indicated RN-I thought the order stated a CBC without differential and was not aware that the incorrect lab was drawn. RN-I did not recall receiving education about ensuring labs are drawn per the physician's order. On 1/14/25 at 12:07 PM, Surveyor interviewed Consultant Pharmacist (CP)-W regarding clozapine and lab monitoring. CP-W verified after 36-48 hours the medication would have been out of R7's system which would increase the likelihood of psychosis symptoms. On 1/14/25 at 12:41 PM, Surveyor interviewed Neurology RN-N regarding R7's missed lab and medication. RN-N stated the Neurologist was not aware that R7 had missed 8 doses of clozapine. RN-N verified weekly monitoring was required for clozapine due to potential blood cell abnormalities. RN-N indicated a regular CBC was not adequate to monitor for that side effect. RN-N verified missing 8 doses of clozapine would greatly increase the likelihood of psychosis symptoms. RN-N also indicated R7 did not have a history of ingesting non-food items or other psychosis symptoms since starting clozapine. On 1/14/25 at 1:20 PM, Surveyor interviewed RN-M regarding R7's missed clozapine and change in behavior. RN-M verified R7 did not have a history of ingesting non-food items or climbing on R7's bed. RN-M verified R7's clozapine had been on hold from the pharmacy due to an incorrect lab draw on 11/19/24. On 1/14/25 at 1:31 PM, Surveyor interviewed CNA-O regarding R7's behaviors. CNA-O verified CNA-O worked regularly with R7 and had never observed R7 try to ingest non-food items or climb on R7's bed. On 1/14/25 at 1:43 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R7's missed clozapine and incorrect lab draw. NHA-A verified an incorrect lab was drawn on 11/19/24 and the facility was unable to re-order R7's clozapine until the correct lab was drawn.

Based on staff interview and record review, the facility did not ensure appropriate care and treatment was provided consistent with N6 Wisconsin Nurse Practice Act when 1 resident (R) (R2) of 9 sampled residents experienced a change of condition. On 5/16/24, R2 experienced a change of condition and indicated to staff that R2 was having difficulty breathing and felt like R2 was having a stroke. Certified Nursing Assistant (CNA)-D and CNA-J reported R2's change of condition to nursing staff on 5/16/24. Registered Nurse (RN)-C and Licensed Practical Nurse (LPN)-K did not adequately assess R2 or report R2's concerns to a physician. In addition, R2's change of condition was not reported to night shift staff on 5/16/24. On 5/17/24 at approximately 5:45 AM, R2 passed away at the facility due to diastolic congestive heart failure (left-sided heart failure that causes symptoms that include difficulty breathing, dizziness, fatigue, increased urination, and confusion). The facility's failure to adequately assess, monitor, and notify a physician for a resident who reported difficulty breathing and felt like they were having a stroke created a finding of immediate jeopardy that began on 5/16/24. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 7/17/24 at 3:44 PM. The immediate jeopardy was removed on 7/17/24; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement an action plan. Findings include: The facility's Physician and Family Notification-Change in Condition policy, revised 5/1/24, states the facility will inform the resident, consult with the resident's physician or nurse practitioner, and notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). According to the Wisconsin Nurse Practice Act, N6.03(1), A RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPN's or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the LPN shall, under the general supervision of an RN or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an RN provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. From 7/16/24 to 7/17/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (bone infection) of the right foot, chronic respiratory failure, history of stroke, hypertension (high blood pressure), dysphasia (difficulty swallowing), and anxiety. R2's most recent Minimum Data Set (MDS) assessment, dated 3/4/24, stated R2 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 had intact cognition. The MDS assessment also indicated R2 was independent with set-up assistance for activities of daily living (ADLs) such as transferring and toileting. R2's care plan, initiated on 1/26/24, stated to monitor and document R2's respiratory rate, depth, and quality each shift or as ordered. R2's care plan also stated R2's anxiety increased when R2 was unable to get out all secretions from R2's trach. R2's last documented vital signs were on 5/15/24 at 7:04 PM and indicated the following: ~ Pulse: 54 beats per minute ~ Blood pressure: 128/54 mmHg (millimeters of mercury) ~ Oxygen saturation: 96% ~ Respiratory rate: 22 breaths per minute ~ Temperature: 97.6 degrees Fahrenheit (F) R2's medical record did not contain any vital signs or assessments after 5/15/24 at 7:04 PM. A progress note, dated 5/15/24 at 6:08 PM, indicated Nurse Practitioner (NP) was aware of R2's weight loss and ordered Med pass TID (three times per day). R2's medical record did not contain any progress notes on 5/16/24. A progress note, dated 5/17/24 at 2:30 AM, indicated R2 was awake in bed at approximately 12:30 AM and voiced no complaints of pain or discomfort at that time. R2's lung sounds were clear. (The progress note was entered on 5/17/24 at 8:31 AM by Registered Nurse (RN)-G after R2 passed away.) A progress note, dated 5/17/24 at 4:30 AM, indicated R2 was sleeping well with no complaints of shortness of breath or dyspnea. R2 was awake earlier on the night shift. No signs of increased restlessness were noted. (The progress note was entered on 5/17/24 at 6:31 AM by RN-G after R2 passed away.) A progress note, dated 5/17/24 at 6:32 AM, indicated R2 had no pulse, respirations, or audible heart tones. RN-G entered R2's room to administer R2's scheduled medication and noted R2 was unresponsive with no respirations or heartbeat noted upon auscultation and no pupillary response to light. R2's time of death was pronounced as 5:45 AM. On 7/16/24 at 1:15 PM, Surveyor interviewed CNA-D who stated CNA-D had taken care of R2 for a long time and knew R2 well. CNA-D stated CNA-D worked the AM shift on 5/16/24 and noticed R2's call light was on at the start of the shift. CNA-D answered R2's call light and noted R2 was incontinent which was unusual for R2. While CNA-D assisted R2 with cares, R2 mouthed, I can't breathe. CNA-D stated R2 was grabbing at CNA-D while repeating, I can't breathe. CNA-D also stated R2 was weaker, required more assistance with cares than usual, and looked pale. CNA-D reported the concerns to RN-C multiple times during the AM shift and reported the concerns to CNA-J on the PM shift. CNA-D indicated that was not the first time CNA-D thought RN-C did not respond appropriately to a resident's change of condition. CNA-D reported the concerns to management and was told to document the concerns in R2's medical record. On 7/17/24 at 8:45 AM, Surveyor interviewed RN-C who could not recall if RN-C assessed R2 related to a change of condition during the AM shift on 5/16/24. RN-C stated RN-C reviewed R2's vital signs and they were normal. RN-C could not recall which vital signs had been obtained or what the results were. RN-C stated it was normal for R2 to mouth that R2 couldn't breathe. On 7/17/24 at 8:58 AM, Surveyor interviewed RN-G who did not recall anything in report from the PM shift about R2's change of condition. RN-G could not remember specifics but stated RN-G did not recall doing any assessments on R2 during the night and wasn't aware of any concerns. On 7/17/24 at 9:11 AM, Surveyor interviewed CNA-F who stated R2 had less energy, needed more help with cares and transfers, and was more confused than usual on the 5/16/24 AM shift. CNA-F stated CNA-F did not report the concerns to anyone because RN-C was already aware. On 7/17/24 at 10:30 AM, Surveyor interviewed RN-H who completed wound rounds for R2 on the 5/16/24 AM shift. RN-H stated R2 did not look like R2's self. RN-H indicated R2 was not as talkative, was more lethargic looking, and was more gray than usual. RN-H knew that RN-C had been informed of the changes but was unsure if there was any follow-up completed. On 7/17/24 at 10:35 AM, Surveyor interviewed CNA-J who stated CNA-J was told in report by CNA-E about R2's concerns from the AM shift. CNA-J checked on R2 early in the shift due to the concerns and stated R2 mouthed to CNA-J that R2 felt like R2 was having a stroke and didn't feel well. CNA-J reported the information to LPN-K. CNA-J stated LPN-K did vital signs, however, LPN-K could not recall which vital signs had been checked or what the results were. CNA-J stated R2 was routinely anxious and some staff did not take R2's concerns seriously because of it. On 7/17/24 at 10:51 AM, Surveyor interviewed LPN-K who verified CNA-J reported concerns about R2. LPN-K stated LPN-K went to see R2 but could not recall what type of assessment had been completed or if the assessment was documented. LPN-K checked R2's oxygen saturation and stated it was normal, however, LPN-K could not recall the exact value. LPN-K also placed a humidifier on R2's trach collar. On 7/17/24 at 11:32 AM, Surveyor interviewed Medical Examiner (ME)-P who verified R2's cause of death was documented as diastolic congestive heart failure. On 7/17/24 at 11:45 AM, Surveyor interviewed CNA-I who stated CNA-I did not work with R2 in the days prior to R2's passing and indicated RN-C was not good at responding to CNA or resident concerns. CNA-I recalled an instance in which CNA-I reported to RN-C that R2 had difficulty breathing and clearing secretions. RN-C told CNA-I to tell R2 to suction R2's self and did not assess R2. On 7/17/24 at 11:53 AM, Surveyor interviewed CNA-M who assisted CNA-E with R2's cares on 5/16/24 which was unusual because R2 was fairly independent with ADLs. CNA-M verified R2 mouthed that R2 could not breathe and looked more pale than usual. CNA-M stated R2 came out of R2's room a lot to look for staff and seemed anxious and confused. CNA-M stated RN-C was not always responsive to resident changes. On 7/17/24 at 12:25 PM, Surveyor interviewed Nurse Practitioner (NP)-O was who not working during R2's change of condition but was familiar with R2. NP-O stated R2 was sick overall and NP-O last saw R2 on 5/13/24 with no concerns. NP-O verified NP-O wanted to be notified if a resident voiced concerns that they couldn't breathe and felt like they were having a stroke. On 7/17/24 at 12:29 PM, Surveyor interviewed CNA-N who worked the 5/16/24 night shift but was not assigned to R2's unit. CNA-N stated CNA-J said in report that R2 was more anxious than usual and that CNA-E had concerns about R2 being able to breathe. CNA-N stated R2 used R2's call light more than usual during the night which was unusual because R2 was fairly independent. CNA-N indicated RN-C did not respond to CNA concerns regarding residents and changes of condition. On 7/17/24 at 12:50 PM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B regarding R2's change of condition. DON-B stated DON-B expects nursing staff to document assessments in the medical record and report back to CNA staff regarding the concerns. DON-B stated RN-C had been verbally reprimanded in the past regarding documenting assessments and was recently written up for the same concern for a different resident. DON-B verified if a resident or a CNA on behalf of a resident reported breathing concerns, nursing staff should do a full respiratory assessment including a check of the resident's oxygen saturation, respiratory rate, and lung sounds. DON-B also verified if a resident or a CNA on behalf of a resident reported stroke concerns, nursing staff should notify the physician or NP due to timeframes for stroke medications that could be administered. DON-B stated nursing staff should also assess a resident's neurological status including vital signs, responsiveness, orientation, hand grasps, and facial droop. On 7/17/24 at 2:58 PM, Surveyor interviewed Family Member (FM)-Q regarding R2's change of condition. FM-Q verified FM-Q was not notified of any concerns for R2 on 5/16/24 and was notified on 5/17/24 that R2 passed away. FM-Q stated R2 had a lot of paranoia and anxiety about dying. The failure to assess, monitor, and notify a provider for a resident who reported breathing and stroke concerns led to serious harm for R2 which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 7/17/24 when it had completed the following: 1. Educated nursing staff on change of condition policies and procedures, how to conduct a physical head-to-toe assessment, completing change of condition documentation, family and provider notification, and a change of condition form. One-to-one education was completed with nurses who were directly involved. 2. Initiated daily monitoring of nursing and CNA shift-to-shift reports. 3. Completed a change of condition audit and initiated daily shift change audits. 4. Held a quality assurance performance improvement (QAPI) meeting with the Medical Director to discuss the event and corrective measures to be taken.

Based on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well being for 1 Resident (R) (R1) of 3 sampled residents. A Dermatology recommendation, faxed to facility on 6/13/23, recommended R1's provider consider discontinuing medications that could be causing bullous pemphigoid (BP) (a rare skin condition that mainly affects older people and usually starts with an itchy, raised rash. As the condition develops, large blisters can form on the skin.) The facility did not contact R1's provider, and R1's condition worsened. During a follow-up Dermatology appointment on 9/6/23, a second recommendation was issued to consider discontinuing medications that could be causing BP. The second recommendation was sent to R1's provider who implemented some of the recommendations, and R1's condition improved. Findings include: The facility's Physician Orders-Entering and Processing policy, revised 1/31/18, contained the following information: Purpose: To provide guidelines when receiving, entering, and confirming physician or prescriber's orders. Guidelines: Notify the resident's physician (if not the prescribing physician), for verification if applicable. R1 was admitted to the facility on [DATE] and had diagnoses that included bullous pemphigoid, schizophrenia, obesity, anxiety, and depression. R1's Minimum Data Set (MDS) assessment, dated 9/4/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 discharged from the facility on 10/9/23. Surveyor reviewed R1's medical record and noted the following orders prior to R1's Dermatology appointment on 6/5/23: ~ Gabapentin Capsule 100 mg (milligrams) Give 2 capsules by mouth three times a day related to low back pain ~ Losartan Potassium Tablet 50 mg Give 1 tablet by mouth in the morning related to essential primary hypertension ~ Furosemide tablet 40 mg Give 1 tablet by mouth in the morning for fluid retention related to lymphedema On 4/20/23, R1's wound care provider referred R1 for a Dermatology consult for what appeared to be psychogenic scratching (an itch disorder where itch is at the center of the symptomatology and where psychological factors play an evident role in the triggering, intensity, aggravation, or persistence of the itching.) On 6/5/23, R1 saw Dermatology and had a skin biopsy. On 6/13/23 at 1:56 PM, the facility received a 10 page fax from Dermatology. Page 2 of the fax indicated: I am writing in regards to (R1.) (Named physician) or (Nurse Practitioner (NP)-D) please see attached medical records and letter from provider in regards to (R1's) care. Page 8 of the fax indicated: (R1) has biopsy proven bullous pemphigoid. This may be drug induced and could be due to (R1's) gabapentin which was started in November. (R1) is not of the typical age for this disease and I would consider (discontinuing) this medication prior to us escalating treatment to dapsone (an anti-infective medication used to treat numerous systemic and dermatologic conditions) or immunosuppressives. (R1) is also on losartan (an anti-hypertensive medication) and furosemide (a diuretic medication) which can also be causes of BP. On 9/6/23, R1 saw a different provider at the same Dermatology office. The facility's wound care nurse (Licensed Practical Nurse (LPN)-E) sent a letter for R1's 9/6/23 appointment that indicated: To whom it may concern: I am writing to inform you of the extensive lengths myself and others have gone to manage and aid in wound healing for (R1.) (R1) is self-limiting, stays up in a wheelchair for long periods of time, picks and scratches at all open areas, creates new open areas with excoriation, and some spontaneously appear. (R1) removes dressings after they are applied and is non-compliant with all interventions. Every morning, (R1) is found with all areas (open to air) because (R1) removed the dressings, and with blood all over the bed and under (R1's) fingernails. (R1) uses special shampoo and body wash provided by family. Staff redirects, educates and uses positive reinforcement with (R1) .We have had therapy consults for positioning in the wheelchair, have tried pressure reducing cushions, (R1) is on an air mattress, and we have provided several pairs of gloves to (R1) to wear especially on night shift, but every pair disappeared or, if used, were covered in blood in the morning. (R1) had a psych consult and follow-up to review medications, and had a consult with your clinic. R1 was also followed by a wound specialist that contracts with our facility. We have used many topical creams/ointments .We have been using betamethasone (a topical steroid used to treat inflammation) to the lesions on (R1's) bilateral upper extremities, chest, abdomen, etc. (R1's) bilateral posterior thighs are very concerning with the deterioration we have seen. New blisters appear every day. (R1) continues on the oral antibiotic and niacin (a B vitamin) that was ordered after R1's initial consult with Dermatology. R1 is on anti-anxiety medication and an anti-histamine as well. We are unsure of any further measures we can take at this time .The areas to each thigh measure about 22 x 22 x .1 cm (centimeter) and present as a large cluster of skin and granulation tissue. Moderate to heavy serosanguineous (drainage with small amounts of blood) exudate . On 9/6/23, a Dermatology Report of Consultation indicated: This is the first time I saw (R1) and am unsure what if anything has been done for (BP). Diagnosis: Biopsy proved BP; possibly drug induced - Previous notes suggested discontinuing gabapentin and possibly losartan or Lasix. This was suggested before escalating treatment to dapsone or immunosuppressives. High dose steroids are the most common treatment for this disease. Unless the underlying disease process of BP is addressed, (R1) will continue to blister and have open sores. 1. First has medication been stopped: gabapentin, losartan, Lasix (furosemide). 2. If medication has been stopped without improvement, next step would be high dose steroids (dapsone or immunosuppressant). On 11/1/23 at 1:27 PM, Surveyor interviewed LPN-E who indicated LPN-E measured the BP induced blistered areas on R1's body. On 11/1/23, Surveyor reviewed R1's weekly wound notes and noted the following wound measurements and medication adjustment dates: Right Posterior Thigh: 6/7/23 - Immeasurable 6/14/23 - Immeasurable 6/21/23, 6/28/23, 7/5/23, 7/12/23 - 7.2 cm x 11 cm x .1 cm 7/19/23 - 10 cm x 20 cm x .1 cm 7/26/23, 8/2/23, 8/9/23 - 13.5 cm x 20 cm x .1 cm 8/16/23 - 12 cm x 20 cm x .1 cm 8/23/23, 8/30/23 - 20 cm x 20 cm x .1 cm 8/30/23 - 20 cm x 20 cm x .1 cm 9/6/23 - 22 cm x 22 cm x .1 cm 9/7/23 - R1's gabapentin was discontinued. On 9/8/23, a gabapentin reduction was ordered with a discontinue date of 9/17/23. 9/8/23 - R1's losartan was discontinued. On 9/9/23, a reduced dose of losartan was ordered. 9/13/23 - 21 cm x 28 cm x .1 cm 9/20/23, 9/27/23, 10/4/23 - 18 cm x 18 cm x .1 cm Left Posterior Thigh: 6/7/23, 6/14/23 - .7 cm x 4.5 cm x .2 cm 6/21/23, 6/28/23, 7/5/23, 7/12/23 - 1.5 cm x 3 cm x .2 cm 7/19/23 - 8 cm x 13 cm x .1 cm 7/26/23, 8/2/23, 8/9/23 - 12.7 cm x 7 cm x .1 cm 8/16/23 - 18 cm x 10 cm x .1 cm 8/23/23, 8/30/23 - 20 cm x 20 cm x .1 cm 9/6/23 - 22 cm x 22 cm x .1 cm 9/7/23 - R1's gabapentin was discontinued. On 9/8/23, a gabapentin reduction was ordered with a discontinue date of 9/17/23. 9/8/23 - R1's losartan was discontinued. On 9/9/23, a reduced dose of losartan was ordered. 9/13/23, 9/20/23 - 21 cm x 18 cm x .1 cm 9/27/23, 10/4/23 - 14 cm x 14 cm x .1 cm On 11/1/23 at 1:27 PM, Surveyor interviewed LPN-E who indicated when a provider makes a recommendation, the nurse who receives the recommendation should contact the resident's physician. On 11/1/23 at 2:10 PM, Surveyor interviewed LPN-E who reviewed Surveyor's timeline of R1's wound measurements and medication adjustments. LPN-E confirmed R1's wounds appeared to improve and indicated it was probably the medications that caused R1's BP. On 11/1/23 at 3:33 PM, Surveyor interviewed LPN-H and showed LPN-H the note that was faxed to the facility from Dermatology on 6/13/23. When asked what LPN-H would do if LPN-H saw or received a similar note, LPN-H indicated LPN-H would ensure the information was given to R1's provider. On 11/1/23 at 2:00 PM, Surveyor interviewed Regional Consultant (RC)-F and Nursing Home Administrator (NHA)-A who indicated Nurse Practioner (NP)-I wrote a note after the June recommendation from Dermatology that addressed R1's skin and medications. Surveyor reviewed the 6/27/23 progress note written by NP-I that indicated under History of Present Illness: Skin seems to be very gradually healing .meds/charts/labs reviewed. During the same interview on 11/1/23 at 2:00 PM, NHA-A indicated the facility made follow-up calls to Dermatology, but could not leave a voicemail. A progress note, dated 6/13/23 at 1:15 PM, indicated: Call to Dermatology to follow up on message for orders to be faxed to (facility). Office closed and no option for voicemail. Surveyor noted the fax from Dermatology to the facility on [DATE] was time stamped 6/13/23 at 1:56:30 PM (41 minutes after the note was written). Surveyor did not note any documented follow-up to the physician regarding Dermatology's recommendation to consider discontinuing gabapentin, losartan, and furosemide to see if one was causing R1's BP. On 11/1/23 at 2:52 PM, Surveyor interviewed NP-I who indicated NP-I was R1's nurse through insurance. NP-I indicated NP-I collaborated regularly with NP-D (R1's NP at the facility). NP-I indicated NP-I was not notified of Dermatology's recommendation in June to consider discontinuing medications that may have been causing R1's BP. NP-I indicated NP-I didn't know about R1's BP diagnoses until after NP-I was notified of the recommendation to discontinue the medications after R1's 9/6/23 Dermatology appointment. When NP-I wrote the 6/27/23 progress note mentioned above, NP-I was not aware of the Dermatology recommendation to discontinue the medications. NP-I indicated if NP-I was notified of the recommendation, NP-I would have collaborated with NP-D and considered discontinuing the medications, but was unsure if they would have changed some or all of them. NP-I indicated since NP-I was R1's provider through insurance, NP-I wasn't updated on everything; however, NP-I expected R1's provider at the facility to be updated of the Dermatology recommendation. On 11/1/23 at 2:18 PM, Surveyor interviewed NP-D who indicated NP-D was not notified of the Dermatology recommendation in June to consider discontinuing medications to improve R1's BP. NP-D also indicated NP-D and NP-I collaborated regularly. NP-D stated NP-D and NP-I were both made aware of the June recommendation to discontinue medications after R1's Dermatology appointment in September. NP-D verified NP-D probably would have followed the recommendation, but would have also consulted with NP-I. NP-D indicated after NP-D and NP-I became aware of the recommendation in September, NP-D and NP-I collaborated and altered R1's medications.

Based on interview and record review the facility did not ensure one Resident (R) R1, received treatment and care in accordance with professional standards of practice or as instructed by R1's representative resulting in R1 being transferred to the hospital where R1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] At the time of admission to the facility, R1's representative (RR)-I and family member (FM)-J instructed licensed practicing nurse (LPN)-C, that R1 was to have soft foods and was to utilize an adaptive cup for drinking. Facility dietary staff as well as nursing staff were not aware of these instructions. Staff reported observations of R1 having issues with swallowing to nurse(s). R1's physician was not updated regarding the swallowing issues nor was R1's diet altered to prevent aspiration (a condition in which food, liquids, saliva is breathed into the airways). Findings Include: On 10/4/21, the Surveyor conducted a review of R1's medical record. R1 was admitted to the facility on [DATE] for a planned respite stay (a short-term break for primary caregiver) of 5 days. At the time of admission, R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was dependent on a wheelchair for transport and required staff assistance for activities of daily living (ADLs) including extensive assistance of staff for eating. R1's cognitive status was documented to be severely impaired and R1's medical record indicated that R1 rarely/never made decisions. On 9/10/21, a pre-admission chest x-ray was completed on R1. Results indicated no acute chest disease suspected. On 9/15/21 at 10:57 AM, LPN-C documented an Admission Summary which read: Resident arrived at 10:20 from home with care taker (Rep-I) and (FM-J). R1 is here for respite care until Monday . R1 takes meds (medications) whole, in food. Does not tolerate orange juice. Requires soft foods. Has a special cup that drinks from . Is non-verbal, staff to anticipate needs On 9/16/21 at 12:06 PM, Registered Dietician (RD)-F documented a Nutrition/Dietary Note which indicated, RD Referral: Per nsg (nursing), res (resident) is to receive a general, regular diet - ground meats. No orange juice. Res to be fed by staff in DR (dining room). FM-J provided a list of food consistencies R1 prefers, for example ground meats . Monitor intakes/diet tolerance per facility protocol. Refer RD as needed. On 9/17/21 in AM, Nurse Practitioner (NP)-N seen R1, NP-N's documentation read: Chief complaint: Concern for aspiration. Subjective: Patient is seen today as requested by nursing who reports concern for possible aspiration as patient was noted to be coughing today. Caretaker is in room at time of visit and reports that patient does have history of pneumonia Patient appears comfortable and in no acute distress. (R1) remains nonverbal which is per (R1's) baseline Assessment/Plan: .Continue modified diet. Staff to make sure patient is alert during meals. Continue to monitor as (R1) remains high risk for aspiration. Follow-up: Dysphagia (difficulty with swallowing), respiratory distress. On 10/4/21 at 12:09 PM, the Surveyor interviewed Dietary Manager (DM)-D. DM-D indicated, No one told me or the kitchen staff to give R1 soft foods; only that R1 was general diet with ground meats. On 10/4/21 at 12:25 PM, the Surveyor interviewed, LPN-C. LPN-C indicated that on the day R1 was admitted , LPN-C met with Rep-I and FM-J who informed LPN-C to give R1 soft foods and to make sure if R1 did not eat a meal to give R1 a supplement and also that R1 could not tolerate orange juice. LPN-C indicated, I put the information about the orange juice on R1's diet card (a tool utilized in the kitchen which provides resident-specific instructions on dietary needs and /or preferences). They (Rep-I/FM-J) gave me a special cup that R1 took fluids from. LPN-C added that FM-J came back Thursday morning (9/16) and on Friday (9/17). On Friday, R1 was laying down and FM-J asked LPN-C to come in to check R1's breathing. LPN-C explained that R1 was mouth breathing and with R1's sleep apnea, LPN-C did not feel there was anything to be concerned about but NP-N was in the building so to make FM-J feel better, NP-N did an assessment and R1's lungs were clear. It seemed this is how R1 would breath with laying down, I had no concerns. On 10/4/21 at 12:53 PM, the Surveyor interviewed Speech Therapist (ST)-E. ST-E indicated that on Saturday (9/18) and Sunday (9/19) ST-E worked in the dinning to assist the facility due to low staffing. ST-E fed R1 breakfast. While feeding R1 Saturday, R1 was coughing. R1 demonstrated signs of aspiration with thin liquids and with solid foods seemed weak and really didn't chew them (solid foods). I got R1 thickened liquids and yogurt and it went better. I notified DON-B, who was working as a floor nurse, that I noticed R1 did better with pureed diet and honey thick liquids and I also let DON-B know that nursing was able to down-grade (change to a more cautious form of food (e.g thickened liquids, pureed food)) a diet without a recommendation from Speech Therapist or without a doctor order. ST-E indicated that again on Sunday morning when feeding R1, R1 was having difficulties swallowing and ST-E notified R1's nurse, LPN-L. ST-E indicated that again on Sunday, ST-E explained that nursing could down-grade R1's diet. ST-E confirmed that on Saturday or Sunday, R1's diet was not changed/down-graded to pureed foods or thickened liquids nor any other sort of modification was made. ST-E explained that ST-E was not working in a ST capacity on the weekend and that nursing had the ability to adjust the diet consistency. ST-E stated, R1 was showing signs of aspiration on Saturday morning; R1 was coughing and throat-clearing both Saturday and Sunday. ST-E indicated that ST-E thinks R1 had some chest congestion prior to feeding R1 Saturday morning. On 10/4/21 at 1:28 PM, the Surveyor interviewed DON-B who confirmed working as a floor nurse on Saturday (9/18). DON-B indicated, ST-E came up to me after the meal and reported R1 sounded gurgly and was concerned R1 was aspirating with eating. I listened to R1's lungs. R1's lungs were clear to auscultation. It did sound like R1 was pharyngeal gurgly and I used toothettes (devices used to for oral care) and that cleared it (the sounds heard in R1's throat/airway area) up. DON-B explained that DON-B then reported to LPN-H, R1's nurse for the day, that ST-E had approached DON-B and was questioning R1's diet. DON-B confirmed that DON-B did not change R1's diet and did not contact the NP or a doctor. DON-B confirmed that DON-B did not instruct LPN-H to update the NP or doctor or modify R1's diet. On 10/4/21 at 1:40 PM, Surveyor interviewed, Certified Nursing Assistant (CNA)-G. CNA-G reported that on Thursday, CNA-G was in the dining room helping other residents and observed who CNA-G believed to be FM-J feeding R1. CNA-G noted that R1 was coughing a lot when being fed soup during the lunch meal. The following day at supper, CNA-G fed R1 and R1 was not doing too good. CNA-G explained that R1 was awake and alert as much as R1 could be and willing to eat and drink, but CNA-G said, it was the same thing, got chicken soup again and seemed the broth was making R1 cough and choke. Because of this, CNA-G asked the kitchen for thickened liquids and thicker food. CNA-G indicated, R1 did well with those thicker foods and thickened liquids and ate everything. CNA-G stated, I thought maybe Thursday was a one time thing, a fluke but then it happened again on Friday. It seemed like it (food) was going down the wrong tube. R1 had constant coughing every time R1 tried to swallow. Same with drinking fluids, R1 didn't seem to understand the concept of drinking out of a straw. CNA-G was asked if R1 had a special cup and CNA-G said, yes, R1 did better with R1's own cup. CNA-G confirmed R1 was getting regular facility cups on R1's meal tray. CNA-G indicated CNA-G reported R1's coughing and swallowing issues to a nurse on Thursday but does not recall the nurse's name. CNA-G indicated telling someone else on Friday at supper time between 4:40 and 5 PM as well about R1's swallowing difficulties, but does not recall who. CNA-G recalls the person saying something along the lines that they were not taking R1 on for evaluation due to R1's short stay (referring to respite stay). On 10/4/21 at 1:57 PM, the Surveyor reviewed R1's hospital records. history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Appearance: .ill-appearing and toxic-appearing. Assessment/Plan: . being treated with antibiotics for aspiration pneumonia and [CONDITION(S)]. Discharge/Death Summary indicated R1 date of death was 9/21/21 at 5:45 AM. Brief Hospital Summary: POA (power of attorney) goal of comfort care, therefore no more aggressive interventions pursued. Cause of death and interval between onset and time of death: Respiratory failure. On 10/4/21 at 2:50 PM, the Surveyor reviewed R1's baseline care plan (a tool which outlines care instructions that staff are to follow), ground meats were indicated, the care plan did not mention soft foods. The adaptive cup which R1 was to drink from per RR-I/FM-J's instructions was also not listed. Review of R1's diet card instructions included ground meats, general diet and no orange juice; there was no documentation on R1's diet card related to giving R1 soft foods and no mention of an adaptive cup. On 10/4/21 at 3:04 PM, DON-B reported to Surveyor that it is a standard of practice that a nurse can always down-grade but not up-grade a diet. On 10/4/21 at 3:06 PM, the Surveyor interviewed LPN-H. LPN-H confirmed being R1's nurse on Sunday 9/19/21, when R1 was sent out to the Emergency Department (ED). LPN-H explained that a CNA noticed R1 to be congested when taking R1 to the dining room for lunch on Sunday and that R1's oxygen saturation was dropping. LPN-H called the on-call doctor and got an order to suction R1's airway, which LPN-H reported to have helped a little bit, and oxygen saturations came up to 89 or 90 percent. LPN-H indicated it sounded like something came up but also sounded like there was more (related to sounds in throat/airway area). LPN-H also got an order to give R1 oxygen in an attempt to get R1's oxygen saturation rates up. The on-call doctor also ordered a chest x-ray and labs; however, RR-I came to the facility and requested R1 be sent to the ED which occurred prior to conducting the lab or X-ray. LPN-H confirmed that no one ever mentioned prior to that date that R1 was having problems eating or drinking; LPN-H stated, I know I tried to give R1 pills with pudding Sunday morning, I don't think R1 would have swallowed it (the pudding with pills in). Even with me putting spoon on R1's tongue, it didn't trigger R1's reflex to swallow. So I did not give the pills On 10/4/21 at 3:54 PM, the Surveyor interviewed DON-B further. DON-B explained that when reporting to LPN-H on Saturday about ST-E's report of R1 having swallowing issues and concerns about aspiration that DON-B's expectation would be that LPN-H would call family or the NP to see if they wanted to do anything else; DON-B listing examples of NPO (nothing per mouth) or pureed diet. DON-B confirmed being the only Registered Nurse (RN) on duty on Saturday as the other nurses were LPNs. DON-B confirmed that DON-B did not instruct the LPNs to down-grade/change R1's diet. DON-B confirmed ST-E told DON-B that R1 could be aspirating and nursing could down-grade the diet. DON-B indicated DON-B could have down-graded R1's diet,I could have called the NP and informed the NP. DON-B confirmed if a resident is coughing at a meal, the expectation would be for staff to tell the nurse and the nurse would then call family or NP.

Based on record review and staff interview, the facility did not notify the physician of changes in resident condition in a timely manner that may have altered treatment for 1 Resident (R) (R73) of 21 sampled residents R73 was admitted to the facility with multiple comorbidities on 1/8/21. R73 exhibited potential symptoms of COVID-19 and a change in condition on 2/1/21. The physician/nurse practitioner was not notified of R73's change of condition for medical intervention. R73 was found in respiratory distress and sent to the hospital on 2/2/21 where R73 was diagnosed with COVID-19. R73 passed away at hospital on 2/4/21. Facility failure to provide timely notification of the physician when the resident had a change in condition that indicated potential COVID-19 infection delayed medical intervention and created a finding of Immediate Jeopardy (IJ) that began on 2/1/21. Surveyor notified Nursing Home Administrator of IJ on 3/10/21 at 4:30 PM. The IJ was removed on 3/10/21. However, the deficient practice continues at scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility undated policy titled Notification of change in resident health status stated: The facility will consult the resident's physician, nurse practitioner or Medical Director and when indicated notify the resident's legal representative or an interested family member when there is: (B) Acute illness or a significant change in the resident's physical, mental or psychosocial status (i.e. deterioration in health, mental , psychosocial status in either life-threatening conditions or clinical complications). Criteria: Life threatening conditions are such things as a [CONDITION(S)] or respiratory distress. Clinical complications are such things as development of stage 2 pressure ulcer, onset or recurrent periods of [CONDITION(S)], urinary tract infection, or persistent decline in psychosocial status. Notification time: immediate. Definition of Immediate: As soon as possible no longer than 24 hours. Nursing judgement is an integral part of the skilled care provided in this facility; therefore, such judgement must applied in a case by case basis in keeping with acceptable nursing practice. Findings include: R73 was a [AGE] year-old resident admitted to the facility from an acute care hospital on 1/8/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R73's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/15/21, documented R73's BIMS (Brief Interview of Mental Status) to be 10/15, which indicated moderate cognitive impairment. R73's 1/15/21 MDS documented R73's height to be 72 inches and weight to be 311 pounds. R73's BMI (Body Mass Index) was 42.2. R73 was on preventative isolation with contact and droplet prevention for unknown COVID-19 status from 1/8/21-1/22/21. On 1/22/21 R73 was moved to a unit with no isolation prevention in place. On 1/26/21, R73 was seen by NP (Nurse Practitioner)-E in the facility for a follow up visit for multiple medical conditions. NP-E visit note dated 1/26/21, documented R73 was seen for; blood pressure, blood sugar, and therapy progression. NP-E's 1/26/21 visit note documented interventions and orders for [MEDICATION(S)] (expectorant which helps loosen congestion in chest making it easier to cough out) 400 mg prn (as needed) and plan of care discussed with nursing staff. NP-E's 1/26/21 visit note subjective information documented: Patient is seen in biweekly follow up. [R73] is seen lying in bed at time of visit. [R73] reports [R73] had some congestion over night but has cleared. [R73] denies fever, chills, nausea, vomiting, diarrhea or constipation. Nursing offers no further concerns. NP-E's visit note dated 1/26/21, documented a complete physical assessment for R73 to include a respiratory assessment which documented: Clear to auscultation (action of listening to lungs with stethoscope) bilaterally. No wheezing, rales or rhonchi (all examples of abnormal lung sounds). Normal expansion, no accessory muscle use. NP-E's 1/26/21 physical assessment documented no abnormal findings. R73's medical record did not include any additional lung assessments documented in R73's medical record while in the facility from 1/26/21 until discharge on [DATE]. On 1/26/21, R73 nurses notes documented the following: Spoke with NP today about elevated temp (temperature). NP was aware of this incident. No s/sx (signs or symptoms) of infection noted. Has since been afebrile (free of fever). No rapid COVID test is indicated per NP. Per NP WBC (White Blood Cell) is elevated, however this is as a result of steroid medication. NP states no need for isolation at this time. The facility uses a form titled, Change of Condition as a tracking tool for all residents with an issue or concern related to change of condition. On 1/26/21, R73 was added to the document with an issue/concern of cough, 99.3 degrees Fahrenheit (F) temperature. On 1/30/21, at 10:44 A.M., Skilled daily documentation was completed for R73 by LPN (Licensed Practical Nurse)-C. The document vital signs section indicated: A. Most recent temperature 97.8 - route tympanic taken 1/29/21 at 3:11 P.M. Most recent pulse 82, pulse type regular taken 1/28/21 at 2:30 P.M. Most recent respiration 24 taken 1/27/21 at 12:39 P.M. On 1/31/21, at 10:46 A.M., Skilled daily documentation was completed for R73 by LPN-C. The document vital signs section indicated: A. Most recent temperature 97.3 - route tympanic taken 1/31/21 at 10:24 A.M. Most recent pulse 82, pulse type regular taken 1/28/21 at 2:30 P.M. Most recent respiration 24 taken 1/27/21 at 12:39 P.M. Most recent blood pressure 140/74 taken 1/28/21 at 2:30 P.M. C. Skilled note related to cardiac - Resident given prn [MEDICATION(S)] for increase congestion. Afebrile, O2 sat >92% on room air (oxygen saturation - amount of oxygen in the blood normal level of oxygen is usually 95% or higher. Some people with chronic lung disease or sleep apnea can have normal levels around 90%.) HOB (head of bed) up and also effective. On 3/10/21 at 9:57 A.M., the Surveyor interviewed LPN-C who stated vital signs automatically pull into the skilled daily documentation report from the last time the vitals were taken. LPN-C confirmed LPN-C did not take R73's vitals on 1/30/21 and 1/31/21, at the time the skilled daily documentation was completed, and they were automatically pulled into the report from the most recent date and time vitals were taken. On 1/31/21 at 10:46 A.M., LPN-C documented the following in R73's medical record: Resident given prn [MEDICATION(S)] for increased congestion. Afebrile. O2 sat> 92% on room air. HOB up and also effective. On 2/1/2021 at 4:38 P.M., SSD (Social Service Designee)-D documented the following in R73's medical record: Went in by resident to do [R73's] assessments. Resident seem very [NAME] (sic) and short of breathe (sic). Resident stated [R73] was ok, but when I was in there Friday [R73] sounded weezy (sic) but not short of breath. I checked [R73's] O2 (oxygen saturation) and it was at 90 and [R73's] pulps (sic) was 65. I informed nurse of this. Nurse stated she will check on [R73]. Surveyor interviewed SSD-D on 3/10/21 at 10:10 A.M., who confirmed the information documented in the nurse's note dated 2/1/21 at 4:38 P.M. SSD-D confirmed she informed a nurse of the information documented in the 2/1/21 nurses note at 4:38 P.M. SSD-D stated the nurse was on the way down to R73's room. SSD-D stated the nurse she informed was RN-F who no longer works in the facility. The Surveyor reviewed R73's medical record and R73's medical record did not include documentation or evidence of any assessment performed by an RN in the facility on 2/1/21 when SSD-D reported concerns related to R73 to RN-F. There is no evidence staff consulted with a physician regarding R73's significant change in symptoms. On 2/2/2021 at 10:45 A.M., LPN-C documented the following in R73's medical record: Writer was called into residents room, c/o (complained of) difficulty breathing with O2 sat at 72% on room air. Afebrile. O2 (oxygen) started at 3 LPM (liters per minute) via nasal cannula, NP was in facility and asked her to assess resident, with orders to transport to ER (emergency room ). Resident signed bed hold and transfer form, and resident requested [R73's family] be notified, writer notified by voice message. Writer called 911, transported out at 0720 (7:20 A.M.). ER called with report by writer, DON aware. At 1045 (10:45 A.M.) writer called ER to get update, they were transporting resident to a hospital in the valley d/t (due to) resp (respiratory) distress and positive covid. DON notified of update from ER. On 2/2/21, the facility completed a form titled, SNF/NF to Hospital Transfer Form, which documented R73 was transferred to emergency roiagnom on [DATE] at 7:36 A.M. R73 was transferred to a different hospital due to R73's acute condition. R73 was admitted to the second hospital with the following reason for admission: acute hypoxemia respiratory failure secondary to COVID-19 infection. R73's discharge summary from the acute care hospital documented R73's date of admission 2/2/21 and date of death [DATE]. R73's hospital discharge summary documented, Other significant conditions contributing to death but not resulting in the underlying cause: 1. Acute hypoxic respiratory failure secondary to COVID-19 infection 2. Superimposed pseudomonas bacterial pneumonia 3. DVT (Deep vein thrombosis: a medical condition that occurs when a blood clot forms in a deep vein.) 4. AKI (Acute Kidney Injury) on CKD (Chronic Kidney Disease) stage 4 5. Type 2 DM (Diabetes Mellitus) 6. Stroke On 3/10/21 at 9:01 A.M., the Surveyor conducted an in-person interview with NP-E regarding R73. NP-E informed the Surveyor NP-E had seen R73 on 1/26/21 and ordered [MEDICATION(S)] as needed for congestion which R73 had overnight and had now cleared. NP-E did not receive any notification from the facility regarding R73's change of condition at any point from 1/27/21 until NP-E walked in R73's room on 2/2/21. When NP-E entered R73's room on 2/2/21, R73 was observed to be in respiratory distress. NP-E informed staff to send R73 to the hospital emergency department. NP-E stated no other provider was notified about R73's change of condition from 1/27/21 until 2/2/21. If a different on-call provider was notified NP-E would have received a notification alerting NP-E of the communication to a provider from the facility regarding R73. NP-E stated if NP-E was notified of R73's condition sooner a COVID-19 test, lab work, and a chest X-ray could have been ordered to get R73 medical intervention sooner. The failure to provide timely notification of the physician when the resident had a change in condition that indicated potential COVID-19 infection, created a finding of Immediate Jeopardy. The facility removed the jeopardy on 03/10/2021 when it had completed the following: A RN assessment was completed for each resident in the facility for any signs or symptoms of COVID-19 on 3/10/21. The MD was notified of any residents with symptoms and results of rapid covid tests if completed. The resident and or resident representative will be notified of symptoms and or testing results. Licensed staff were educated on the policy for notification of change in resident health status and re-educated on the signs and symptoms of COVID-19. LPNs were educated on the following: The LPN will document clinical findings and notify the RN if a clinical change is noted that may indicate a need for Physician intervention. Under the general supervision of a RN the LPN can collect clinical data and report directly to the physician pertinent findings that may necessitate a change in the physicians' plan of care. The LPN will report significant findings to the RN or RN on call for any necessary assessment or intervention. Licensed staff were educated on concerns that may require additional assessment and RN or MD notification. The management team was educated on reporting any symptoms they may see directly to the RN DON or the RN ADON. The policy for notification of change in resident health status was reviewed and remains appropriate. The facility drafted guidelines for LPNs to follow when identifying a change in condition. The RN will be notified when further assessments are necessary or further direction is needed. A list of concerns requiring RN and or MD notification were provided to licensed staff. The progress notes will be reviewed daily by clinical management to assure the MD has been notified timely of any change in condition. The facility will audit documentation for physician notification of changes in resident status daily. The RNC will audit findings weekly and report to the NHA/QAPI committee for any revisions to the plan and need for continued monitoring.

Based on record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practical well-being for 1 Resident (R) (R73) of 21 sampled residents and did not provide care consistent with professional standards of practice (N6, Nurse Practice Act, Wisconsin). R73 was admitted to the facility with multiple comorbidities on 1/8/21, making R73 at increased risk for severe illness from COVID-19. R73 exhibited potential symptoms of COVID-19 infection on 1/31/21 and 2/1/21 and did not have a thorough physical assessment completed. R73's condition deteriorated and R73 was later found in respiratory distress. R73 was sent to the hospital on 2/2/21 where R73 subsequently tested positive for COVID-19. R73 passed away at the hospital on 2/4/21. Facility failure to provide nursing care consistent with the Wisconsin Nurse Practice Act (N6) and to perform a timely assessment on a medically compromised resident who displayed symptoms of COVID-19 infection created a finding of Immediate Jeopardy (IJ) that began on 1/31/21. Surveyor notified Nursing Home Administrator of IJ on 3/10/21 at 4:30 PM. The IJ was removed on 3/10/21. However, the deficient practice continues at scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: According to the CDC (Center of Disease Control and Prevention) People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19: - Fever or chills - Cough - Shortness of breath or difficulty breathing - Fatigue - Muscle or body aches - Headache - New loss of taste or smell - Sore throat - Congestion or runny nose - Nausea or vomiting - Diarrhea This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. Adults of any age with certain underlying medical conditions are at increased risk for severe illness from the virus that causes COVID-19. Severe illness from COVID-19 is defined as hospitalization , admission to the ICU, intubation or mechanical ventilation, or death. Adults of any age with the following conditions are at increased risk of severe illness from the virus that causes COVID-19: - Chronic kidney disease - [CONDITION(S)] (chronic obstructive pulmonary disease) - Heart conditions, such as heart failure, coronary artery disease, or [CONDITION(S)] - Immunocompromised state (weakened immune system) from solid organ transplant - Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2) - Severe Obesity (BMI = 40 kg/m2) - Smoking - Type 2 diabetes mellitus Based on what we know at this time, adults of any age with the following conditions might be at an increased risk for severe illness from the virus that causes COVID-19: - Asthma (moderate-to-severe) - [CONDITION(S)] disease (affects blood vessels and blood supply to the brain) - Hypertension or high blood pressure - Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines - Neurologic conditions, such as dementia - Liver disease - Overweight (BMI > 25 kg/m2, but < 30 kg/m2) - Pulmonary fibrosis (having damaged or scarred lung tissues) Wisconsin regulation, entitled Chapter N6 Standards of Practice for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) states: Definitions: Basic nursing care means care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable Basic patient situation as determined by an R.N., physician . means the following 3 conditions prevail at the same time in a given situation: (a) The patient's clinical condition is predictable; (b) Medical or nursing orders are not changing frequently and do not contain complex modification; and, (c) The patient's clinical condition requires only basic nursing care. Complete Patient situation as determined by the R.N means any one or more of the following conditions exist in a given situation: (a) The patient's clinical condition is not predictable; (b) Medical or nursing orders are likely to involve frequent changes or complex modifications (c) The patient's clinical condition indicates care that is likely to require modification of nursing procedures in which the response of the patient to the nursing care are not predictable. Delegated act means acts delegated to a registered nurse or licensed practical nurse. Direct supervision means immediate availability to continually coordinate, direct and inspect at first hand the practice of another. General supervision means regularly to coordinate, direct and inspect the practice of another. N6.03 - Standards of practice for registered nurses - (1) - General nursing procedures. An R.N shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. The standard is met thorough performance of each of the following steps of the nursing process: (a) Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (c) Intervention us the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation is the determination of a patient progress or lack of progress towards goal achievement which may lead to modification of the nursing diagnosis. Standards of practice for licensed practical nurses: (1) In the performance of acts in basic patient situations, the L.P.N. shall under the general supervision of an R.N or the direction of a provider: (a) Accept only patient care assignments which the L.P.N is competent to perform (b) Provide basic nursing care (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated acts may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data . The facility education dated 3/10/21 stated: LPNs will perform nursing acts in basic patient situations. The LPN will document clinical findings and notify the RN if a clinical change is noted that may indicate a need for physician intervention. Under the general supervision of the RN the LPN can collect clinical data and report directly to the physician pertinent findings that may necessitate a change in the physicians' plan of care. The LPN will report significant findings to the RN or RN on call. Patients that have a high probability of a significant change will have a Complex medical condition may require direct supervision by the RN. LPN and RN should notify the RN on call for the following situations: ~ Acute illness or change of condition ~ Signs or symptoms that may indicate COVID 1. R73 was a [AGE] year-old resident admitted to the facility from an acute care hospital on 1/8/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R73's admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 1/15/21, documented R73's BIMS (Brief Interview of Mental Status) to be 10/15 which indicated moderate cognitive impairment. R73's 1/15/21 MDS documented R73's height to be 72 inches and weight to be 311 pounds. R73's BMI (Body Mass Index) was 42.2. R73's weight and multiple comorbidities put R73 at increased risk of severe illness from COVID-19. R73 was on preventative isolation with contact and droplet prevention for unknown COVID-19 status from 1/8/21-1/22/21. On 1/22/21 R73 was moved to a unit with no isolation prevention in place. On 1/26/21, R73 was seen by NP (Nurse Practitioner)-E in the facility for a follow up visit for multiple medical conditions. NP-E visit note, dated 1/26/21, documented R73 was seen for; blood pressure, blood sugar, and therapy progression. NP-E's 1/26/21 visit note documented interventions and orders for [MEDICATION(S)] (expectorant that helps loosen congestion in chest making it easier to cough out) 400 mg prn (as needed) and plan of care discussed with nursing staff. NP-E's 1/26/21 visit note subjective information documented: Patient is seen in biweekly follow up. [R73] is seen lying in bed at time of visit. [R73] reports [R73] had some congestion over night but has cleared. [R73] denies fever, chills, nausea, vomiting, diarrhea or constipation. Nursing offers no further concerns. NP-E's visit note dated 1/26/21 documented a complete physical assessment for R73 which included a respiratory assessment that documented: Clear to auscultation (action of listening to lungs with stethoscope) bilaterally. No wheezing, rales or rhonchi (all examples of abnormal lung sounds). Normal expansion, no accessory muscle use. NP-E's 1/26/21 physical assessment documented no abnormal findings. R73's medical record did not include any additional lung assessments documented in R73's medical record while in the facility from 1/26/21 until discharge on [DATE]. On 1/26/21, R73 nurses notes documented: Spoke with NP today about elevated temp (temperature). NP was aware of this incident. No s/sx (signs or symptoms) of infection noted. Has since been afebrile (free of fever). No rapid COVID test is indicated per NP. Per NP WBC (White Blood Cell) is elevated, however this is as a result of steroid medication. NP states no need for isolation at this time. Surveyor noted the facility form entitled Change of Condition was a form used by the facility as a tracking tool for all residents with an issue or concern related to change of condition. On 1/26/21, R73 was added to the document with an issue/concern of cough, 99.3 temp (temperature degrees Fahrenheit (F). On 1/30/21, at 10:44 A.M., Skilled daily documentation was completed for R73 by LPN (Licensed Practical Nurse)-C. The document vital signs section indicated: A. Most recent temperature 97.8 - route tympanic taken 1/29/21 at 3:11 P.M. Most recent pulse 82, pulse type regular taken 1/28/21 at 2:30 P.M. Most recent respiration 24 taken 1/27/21 at 12:39 P.M. On 1/31/21, at 10:46 A.M., Skilled daily documentation was completed for R73 by LPN-C. The document vital signs section indicated: A. Most recent temperature 97.3 - route tympanic taken 1/31/21 at 10:24 A.M. Most recent pulse 82, pulse type regular taken 1/28/21 at 2:30 P.M. Most recent respiration 24 taken 1/27/21 at 12:39 P.M. Most recent blood pressure 140/74 taken 1/28/21 at 2:30 P.M. C. Skilled note related to cardiac - Resident given prn [MEDICATION(S)] for increased congestion. Afebrile, O2 sat >92% on room air (oxygen saturation - amount of oxygen in the blood normal level of oxygen is usually 95% or higher. Some people with chronic lung disease or sleep apnea can have normal levels around 90%.) HOB (head of bed) up and also effective. On 3/10/21 at 9:57 A.M., the Surveyor interviewed LPN-C who stated vital signs automatically pull into the Skilled daily documentation report from the last time the vitals were taken. LPN-C confirmed LPN-C did not take R73's vitals on 1/30/21 and 1/31/21, at the time the skilled daily documentation was completed, and they were automatically pulled into the report from the most recent date and time vitals were taken. LPN-C informed the Surveyor LPN-C did not listen to R73's lungs. As a result, staff gathered no data regarding R73's condition for futher assessment. LPN-C confirmed to the Surveyor that on 1/30/21 and 1/31/21 on the day shift, an RN was not in the facility and there were three LPNs working in the facility. LPN-C stated an RN is available by phone to report data to if needed. LPN-C stated no call was placed to DON-B who was the RN on call and who is also in charge of infection of infection control to report R73's symptoms of congestion. On 2/1/2021 at 4:38 P.M., SSD (Social Service Designee)-D documented the following in R73's medical record: Went in by resident to do [R73's] assessments. Resident seem very [NAME] (sic) and short of breathe (sic). Resident stated [R73] was ok, but when I was in there Friday [R73] sounded weezy (sic) but not short of breath. I checked [R73's] O2 (oxygen saturation) and it was at 90 and [R73's] pulps (sic) was 65. I informed nurse of this. Nurse stated she will check on [R73]. On 3/10/21 at 10:10 A.M., the Surveyor interviewed SSD-D who confirmed the information documented in the nurse's note dated 2/1/21 at 4:38 P.M. SSD-D confirmed she informed a nurse of the information documented in the 2/1/21 nurses note at 4:38 P.M. SSD-D stated she noted the nurse was on the way down to R73's room. SSD-D stated the nurse she informed was RN-F who no longer works in the facility. The Surveyor reviewed R73's medical record and R73's medical record did not include documentation or evidence of any assessment performed by an RN in the facility on 2/1/21 when SSD-D reported concerns related to R73 to RN-F. On 3/11/21, at 11:14 A.M., the Surveyor interviewed RN-N by phone regarding care provided to R73. RN-N confirmed working with R73 on the night shift starting on 2/1/21. RN-N stated RN-N was in R73's room during the shift because R73's roommate had an IV (Intravenous therapy) for which RN-N was responsible. RN-N stated RN-N got a glass of ice water for R73 during the night shift starting on 2/1/21, and does not recall providing any additional cares or tasks for R73 during the shift. RN-N stated the previous shift did not report any concerns regarding R73. On 2/2/2021 at 10:45 A.M., LPN-C documented the following in R73's medical record: Writer was called into residents room, c/o (complained of) difficulty breathing with O2 sat at 72% on room air. Afebrile. O2 (oxygen) started at 3 LPM (liters per minute) via nasal cannula, NP was in facility and asked her to asses resident, with orders to transport to ER (emergency room ). Resident signed bed hold and transfer form, and resident requested [R73's family] be notified, writer notified by voice message. Writer called 911, transported out at 0720 (7:20 A.M.). ER called with report by writer, DON aware. At 1045 (10:45 A.M.) writer called ER to get update, they were transporting resident to a hospital in the valley d/t (due to) resp (respiratory) distress and positive covid. DON notified of update from ER. On 2/2/21, the facility completed a form titled, SNF/NF to Hospital Transfer Form, which documented R73 was transferred to emergency roiagnom on [DATE] at 7:36 A.M. R73's 2/2/21, Emergency Department (ED) note documented R73's chief complaint to be difficulty breathing and R73's primary impression to be pneumonia due to COVID-19 virus. R73's ED (Emergency Department) Clinical Impression documented: ~ Pneumonia due to COVID-19 virus ~ Acute hypoxemia (low oxygen in the blood) respiratory failure due to COVID-19 ~ Urinary tract infection without hematuria (blood in urine), site specified ~ Acute congestion heart failure, unspecified heart failure type ~ [CONDITION(S)] R73 was transferred to a different hospital due to R73's acute condition. R73 was admitted to the second hospital with the following reason for admission: acute hypoxemia respiratory failure secondary to COVID-19 infection. R73's discharge summary from the acute care hospital documented R73's date of admission 2/2/21 and date of death [DATE]. R73's hospital discharge summary documented, Other significant conditions contributing to death but not resulting in the underlying cause: 1. Acute hypoxic respiratory failure secondary to COVID-19 infection 2. Superimposed pseudomonas bacterial pneumonia 3. DVT (Deep vein thrombosis: a medical condition that occurs when a blood clot forms in a deep vein.) 4. AKI (Acute Kidney Injury) on CKD (Chronic Kidney Disease) stage 4 5. Type 2 DM (Diabetes Mellitus) 6. Stroke On 3/10/21 at 11:06 A.M., DON-B informed the Surveyor that LPNs are able to collect data and are not able to complete assessments on residents. DON-B stated LPNs are expected to call the on call RN and report the data collected and the RN would be responsible for completing a thorough in-person assessment for the resident. DON-B informed the Surveyor a complete respiratory assessment should have been completed on R73 when R73 presented with congestion (1/31/21) which was a change of condition for R73, and a potential symptom of COVID-19. DON-B informed the Surveyor R73 should have had a complete assessment done on 2/1/21 when SSD-D reported R73's concerns to RN-F on 2/1/21. On 3/10/21 at 11:06 A.M., DON-B confirmed on 1/30/21 and 1/31/21 on the A.M. shift three LPNs were working with no RN in the building. DON-B stated DON-B was the on call nurse on the weekend of 1/30/21-1/31/21, and did not receive a call regarding residents in the facility. DON-B stated DON-B is also responsible for the facility's infection control program and R73's symptoms of congestion would require a call to DON-B because of the current COVID-19 concerns. On 3/10/21 at 9:01 A.M., the Surveyor conducted an in-person interview with NP-E regarding R73. NP-E informed the Surveyor NP-E had seen R73 on 1/26/21 and ordered [MEDICATION(S)] as needed for congestion which R73 had overnight and had now cleared. NP-E did not receive any notification from the facility regarding R73's change of condition at any point from 1/27/21 until NP-E walked in R73's room on 2/2/21. When NP-E entered R73's room on 2/2/21, R73 was observed to be in respiratory distress. NP-E informed staff to send R73 to the hospital emergency department. The failure to perform a timely assessment on a medically compromised resident who displayed symptoms of COVID-19 infection prevented timely medical intervention and created a finding of Immediate Jeopardy. The facility removed the jeopardy on 03/10/2021 when it had completed the following: Residents who have signs or symptoms of covid have the potential to be affected. A RN assessment was completed for each resident in the facility for any signs or symptoms of COVID-19. Assessment results were documented in the medical record. Residents with signs or symptoms that may indicate covid will be placed on droplet/contact precautions and a rapid COVID-19 test will be completed. the facility will continue to monitor for signs or symptoms of COVID-19 every shift including temp and pulse oximetry. Licensed staff were educated on the policy for notification of change in resident health status and re-educated on the signs and symptoms of COVID-19. LPNs were educated on the following: The LPN will document clinical findings and notify the RN if a clinical change is noted that may indicate a need for Physician intervention. Under the general supervision of a RN the LPN can collect clinical data and report directly to the physician pertinent findings that may necessitate a change in the physicians' plan of care. The LPN will report significant findings to the RN or RN on call for any necessary assessment or intervention. Licensed staff were educated on concerns that may require additional assessment and RN or MD notification. The management team was educated on reporting any symptoms they may see directly to the RN DON or the RN ADON. The policy for notification of change in resident health status was reviewed and remains appropriate. The facility drafted guidelines for LPNs to follow when identifying a change in condition. The RN will be notified when further assessments are necessary or further direction is needed. The progress notes will be reviewed daily by clinical management for any signs or symptoms of covid or any change in condition requiring further assessment or follow up. Residents that may have signs or symptoms that may indicate a change in condition will be noted for alert charting and follow up documentation of clinical data collection and assessment. The facility will audit documentation for signs and symptoms of COVID-19 daily. The RNC will audit findings weekly and report to the NHA and QAPI committee for any revisions to the plan.

Based on observation, Resident (R) interview, staff interviews, and record review, the facility did not ensure pressure injury monitoring and treatment were completed in accordance with standards of practice and physician orders [REDACTED]. R20 was admitted to the facility with a stage 2 pressure injury which progressed to a stage 3 by 8/7/19 and stage 4 by 10/8/19. Staff did not monitor the wound weekly in (MONTH) 2019, did not change the [DEVICE] three times a week as ordered, and did not assist with repositioning in bed every two hours and as needed. Facility failure to appropriately monitor and treat R20's pressure injury created a finding of immediate jeopardy that began on 8/7/19. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 10/30/19 at 3:21 PM. The immediate jeopardy was removed on 10/31/19. However, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan. Findings include: Advancing Excellence notes that Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: o Decrease in bowel and bladder function o More incontinence o Decrease in ability to move without help o Decrease in mental capacity o Increase in pain o Increased risk for infection o Less participation in activities http://www.nhqualitycampaign.org/files/factsheets/Staff%20Fact%20Sheet%20-%20Reducing%20Pressure%20Ulcers.pdf Mayo Clinic's website describes the complications of pressure injuries, including: Sepsis:[MEDICAL CONDITION] occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure. [MEDICAL CONDITION]: [MEDICAL CONDITION] is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. [MEDICAL CONDITION] can lead to life-threatening complications. Bone and joint infections: An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteo[DIAGNOSES REDACTED]) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications. http://www.mayoclinic.org/diseases-conditions/bedsores/basics/risk-factors/con- 848 On 10/28/19 at 8:46 AM, Surveyor observed R20 had an air mattress and a [DEVICE] and proceeded to interview R20. R20 explained struggling with pressure injuries recurring on the buttocks, which R20 expected to heal slowly each time because of a [DIAGNOSES REDACTED]. R20 indicated the pressure injury currently being treated with a [DEVICE] was present when R20 was admitted to the facility. R20 indicated the [DEVICE] was started after the only wound clinic visit R20 had during residence at the facility, which happened earlier in October. R20 explained that while living at a previous, sister facility (owned by same corporation) a flap surgery was performed and healing was going well until R20 attempted a slide board transfer which opened the wound and began a new struggle with healing the pressure injury. R20 revealed staff were not doing [DEVICE] changes as frequently as ordered by the physician. R20 indicated the [DEVICE] was last changed last Tuesday (10/22/19). R20 shared staff were frequently not prompt in responding to the call light which R20 used to summon staff for repositioning assistance. On 10/29/19, Surveyor reviewed R20's medical record which included Minimum Data Set (MDS) information at the time of admission documenting one stage 2 pressure injury was present upon admission on 7/11/19. R20's admission MDS, dated [DATE], and most recent quarterly MDS, dated [DATE], both documented R20 required 2 people to extensively assist with bed mobility. R20's skin integrity care plan, initiated the day of admission (7/11/19), included encouraging good nutrition and hydration, following facility protocols for treatment, pressure relieving devices (examples given were air mattress and offloader boots), and turn and position as necessary. Surveyor noted there were no revisions since the plan was initiated. (See F657 for related citation.) The Certified Nursing Assistant (CNA) version of R20's care plan documented, resident very aware of need to turn and position and will call for staff to assist with bed mobility. Surveyor was not able to locate wound clinic documentation and physician visit notes in R20's medical record. (Refer to F712 for related citation.) The most recent measurements available for R20's left gluteal fold pressure injury were dated 10/1/19. Wound documentation was as follows: 7/11/19 - Admission Skin Assessment - gluteal cleft circled with no annotation for which side and documented as, sore 2.6 x 4.5 x 0.5 A right gluteal fold pressure injury was documented from 7/16/19 through resolution on 8/13/19. 8/7/19 - Wound Documentation - Left gluteal crease - stage 3 - all measurements in Length x Width x Depth in centimeters (cm) - 3.8 cm x 7 cm x 1.7 cm - tunneling/undermining 3 cm at 1100. - Comment Current treatment regime in place and appropriate (Surveyor noted left pressure injury treatment was not in place before this date per Treatment Administration Record (TAR).) 8/7/19 - treatment order for left gluteal crease - cleanse with normal saline and gauze, apply calcium alginate dressing, secure with foam border dressing daily and as needed until resolved (Surveyor noted this was the same order entered for right gluteal crease stage 2 pressure injury on 7/16/19). Surveyor noted the actual signed order provided to the survey team for 8/7/19 was not for the left gluteal. The order documented, right gluteal crease - cleanse with normal saline and gauze, apply zinc and cover with foam border dressing daily and as needed until resolved. No documentation was provided showing the physician was notified of a new pressure injury on the left gluteal crease. 8/13/19 - Wound Documentation - Left gluteal crease - stage 3 - 2.5 cm x 5.5 cm x 1.2 cm - tunneling/undermining 3 cm at 1100 8/20/19 - Wound Documentation - Left gluteal crease - stage 3 - 3.8 cm x 3.8 cm x 1.1 cm - tunneling/undermining 2.5 cm at 1100 8/27/19 - Wound Documentation - Left gluteal crease - stage 3 - 3 cm x 3.5 cm x 1.5 cm - tunneling/undermining 2.8 cm at 1100 9/4/19 - Wound Documentation - Left gluteal crease - stage 3 - 5.8 cm x 3 cm x 1 cm - tunneling/undermining 1 cm at 1100 9/11/19 - Wound Documentation - Left gluteal crease - stage 3 - 2.5 cm x 6.5 cm x 1.2 cm - tunneling/undermining 1.2 cm at 1100 - comment New orders for possible wound vac have been requested 9/11/19 - Physician response was a referral to surgery consult 9/11/19 - Physician Visit Note: (R20) asking for a wound vac which (R20) has used previously with good results. I have suggested (R20) have a surgical consultation. (R20) does have a large unstageable wound. 9/18/19 - Wound Documentation - Left gluteal crease - stage 3 - 4.3 cm x 6.5 cm x 1.3 cm - tunneling/undermining 3.1 cm at 1100 9/25/19 - Wound Documentation - Left gluteal crease - stage 3 - 3.2 cm x 4.5 cm x 3.2 cm - tunneling/undermining 3.7 cm at 0100 (possible typo in location) 10/1/19 - Wound Documentation - Left gluteal crease - stage 3 - 3.3 cm x 4.3 cm x 2.4 cm - tunneling/undermining 2.7 cm at 1100 Comment appropriate treatment in place at this time 10/8/19 - Wound Clinic Notes - Left ischial area open wound - stage 4 - no measurements provided except undermining rim of 1 to 1/2 cm. [DEVICE] instructions provided. 10/8/2019 13:42 Nurses Note - Returned from wound appointment with orders for wound vac. Change 3 times a week, see me prn (as needed) per wound team. 10/11/2019 17:14 Nurses Note - Vac supplies and unit arrived today. Vac dressing applied to left ischial ulceration and bridged to top of right thigh per resident request. Suction on at 125mmhg. Resident tolerated procedure well. (Note: no measurements between 10/1/19 and 10/30/19) 10/30/19 - Wound Documentation - Left gluteal crease - stage 4 - 2.8 cm x 6 cm x 2 cm - tunneling/undermining 4.5 cm at 1100 On 10/30/19 at 3:01 PM, Surveyor interviewed DON-B in person with WCCLPN-C via phone to determine the start date of R20's left ischial pressure injury. WCCLPN-C recalled R20 had both a right and left wound at one point in time. WCCLPN-C was not certain but believed the left pressure injury was present on admission as a stage 2. DON-B verified R20's admission MDS documented one pressure injury and perhaps there were supposed to be two. [DEVICE] not changed as ordered: On 10/30/19 at 9:03 AM, DON-B reviewed R20's TAR with Surveyor and verified R20's [DEVICE] changes were not completed on 10/18/19 and 10/25/19 as ordered. R20's wound vac change scheduled for 10/21/19 was not completed related to a progress note on 10/20/19 which documented Wound vac was off since yesterday so replaced this am. R20's wound change scheduled for 10/23/19 was not completed related to a progress note on 10/22/19 documenting the wound vac dressing was changed on 10/22/19. (This verified the accuracy of R20's interview above that no [DEVICE] change was completed from Tuesday, 10/22/19, until after the interview on Monday, 10/28/19.) DON-B indicated R20 had not complained about the wound change not being completed and Wound Care Certified Licensed Practical Nurse (WCCLPN)-C also had not brought up any concerns. DON-B explained having a practice of auditing TARs for completion but audits were not completed in the past two weeks. Monitoring not completed weekly: National Pressure Ulcer Advisory Panel 2014 Quick Reference Guide documents Pressure Ulcer Assessment: 1. Assess the pressure ulcer initially and re-assess it at least weekly . 3. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. October Measurements: 10/1/19 - Wound Documentation - Left gluteal crease - stage 3 - 3.3 cm x 4.3 cm x 2.4 cm - tunneling/undermining 2.7 cm at 1100 Comment appropriate treatment in place at this time 10/30/19 - Wound Documentation - Left gluteal crease - stage 4 - 2.8 cm x 6 cm x 2 cm - tunneling/undermining 4.5 cm at 1100 On 10/30/19 at 11:15 AM, Surveyor interviewed WCCLPN-C. WCCLPN-C verified wound measurements were not taken since 10/1/18. WCCLPN-C explained personal leave was taken for two weeks prior to survey and explained WCCLPN-C expected someone to complete treatments and assessments when WCCLPN-C was not available. WCCLPN-C also revealed having difficulty completing all the treatments and monitoring required because of other nursing duties. (See F725 for related staffing concerns.) WCCLPN-C verified R20's skin integrity care plan was not updated since admission (See F657 for care plan revision concerns) and explained R20's physician was notified and a [DEVICE] requested when R20's wound deteriorated. WCCLPN-C indicated there was no time to look over TARS and ensure treatments were completed. At 1:58 PM, WCCLPN-C indicated R20 spent too much time in wheelchair depending if there were fun activities going on and R20 could reposition self in wheelchair. WCCLPN-C believed R20 was educated on the risks of staying in the chair too long it education would be documented on the wound documentation. (Surveyor located one note on right gluteal crease (resolved pressure injury) documentation, dated 7/23/19, Resident has recently been non-compliant with offloading and repositioning. DON did talk to resident regarding (R20's) wound increasing in measurement over the past week. Surveyor was unable to locate nursing notes, a care plan, or other documentation to indicate R20 was non-compliant with offloading or repositioning.) Repositioning not done every two hours and as needed: On 10/30/19 at 12:02 PM, during Surveyor's follow-up interview with R20, R20 explained spending about three hours per day up in electric wheelchair with specialty, custom-made pressure redistribution cushion. R20 indicated phone alarms were utilized by R20 to ensure the call light was activated every two hours for repositioning assistance, even at night. R20 explained R20 requires staff assistance to reposition in bed. R20 stated being able to reposition self a bit in wheelchair but used a timer to ensure no more than three hours in the wheelchair. R20 revealed during the PM shift on 10/28/19, staff did not respond promptly to a call light R20 activated for repositioning assistance. At the time of interview, R20 opened laptop computer and read time notes off to Surveyor, alleging at 6:45 PM, two hours were up so R20 activated the call light. No one responded so eventually R20 utilized a cell phone to call the nurse station. R20 called four times before Licensed Practical Nurse (LPN)-K answered the phone. LPN-K arrived at R20's room at 8:31 PM to assist with repositioning. (3.75 hours since previous repositioning). (Refer to F725 for related staffing concerns.) On 10/30/19 at 1:50 PM, Surveyor interviewed LPN-K, who verified knowing R20 from previous, sister facility and knowing R20 was cognizant. LPN-K verified answering R20's call light on 10/28/19 after receiving a call at the nurse station. LPN-K indicated LPN-K recognized R20's phone number. LPN-K verified R20 complained about the long call light wait time and alleged the wait was 1.5 hours. LPN-K believed R20 was accurate because R20 watches the clock to get repositioned. LPN-K denied being the nurse directly responsible for R20's care on 10/28/19 and explained R20's nurse was busy helping another resident. On 10/30/19, Surveyor reviewed (MONTH) 2019 CNA documentation in task tracking for Resident repositioned self or was assisted with repositioning every 2 hours and as needed during shift? (3 shifts daily) and noted: 10/2/19 - no entries for 3 shifts 10/3/19 - no entries for 2 shifts 10/4/19 - no entries for 3 shifts 10/5/19 - no entries for 2 shifts 10/6/19 - no entries for 2 shifts 10/7/19 - no entries for 1 shift 10/8/19 - no entries for 1 shift 10/9/19 - no entries for 2 shifts 10/10/19 - no entries for 2 shifts 10/11/19 no entries for 3 shift 10/12/19 - no entries for 2 shifts 10/13/19 - no entries for 1 shift 10/16/19 - no entries for 1 shift 10/17/19 - no entries for 1 shift 10/18/19 - no entries for 3 shifts 10/19/19 - no entries for 2 shifts 10/20/19 - no entries for 2 shifts 10/21/19 - no entries for 3 shifts 10/22/19 - no entries for 3 shifts 10/23/19 - no entries for 1 shift 10/24/19 - no entries for 2 shifts 10/25/19 - no entries for 2 shifts 10/26/19 - no entries for 2 shifts 10/28/19 - no entries for 1 shift 10/29/19 - no entries for 2 shifts The failure to appropriately monitor and treat R20's pressure injury created a finding of Immediate Jeopardy. The facility removed the jeopardy on 10/31/19 when it had completed the following: Resident's wound was assessed by a RN. Documentation of assessment was completed. The resident was repositioned. The resident's plan of care was updated to reflect current interventions to prevent decline in the wound status. The resident's repositioning schedule was reviewed to identify the frequency of repositioning. Barriers to positioning were reviewed with the resident. Residents with pressure injuries have the potential to be affected. Residents with pressure injuries were evaluated for turning and repositioning, frequency of implementation of repositioning, pressure relieving devices and pressure prevention interventions. Each resident with pressure injuries plan of care was reviewed to reflect prevention interventions. Residents with pressure injuries had an audit of the provision of current treatments to assure the current MD orders were followed. Licensed staff were educated on the current wound management and pressure ulcer prevention program. Licensed staff were educated to assist CNA staff with repositioning and interventions to promote healing. Any regular, agency or casual licensed staff that are working will be educated prior to the start of their next scheduled shift. CNAs were educated on pressure ulcer prevention, using the resident's Kardex to direct the current resident specific interventions for treatment and prevention strategies. Two nurses will complete the initial skin assessment on new admissions. The baseline care plan and Kardex will reflect interventions to promote healing including pressure reduction devices and resident specific repositioning schedule. New admissions will be reviewed by the DON and or designee for interventions to promote wound healing. The wound 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 will review all pressure injuries weekly and document the wound evaluation in the medical record. The DON will review the wound evaluations and documentation with the wound nurse for any changes in wound status. The 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. New admissions will be audited for care plan interventions to prevent and heal pressure injuries within 48 hours of admission. Weekly wound meetings will include an audit of all pressure injuries wound status, current interventions for healing, proper repositioning schedule and adherence, nutritional interventions, and current treatment. Results of the audits will be reviewed in QAPI for any further education or modifications to the plan of correction.

Based on observation, interview and record review, the facility did not ensure the environment for 3 Residents (R) (R54, R30, and R56) of 24 sampled residents remained free of accident hazards. On 9/20/19, R54's manual wheelchair was struck by R30's electric wheelchair causing R54 to fall and sustain a fracture. Facility was aware of R30's unsafe driving of the electric wheelchair on 9/16/19 but did not assess R30's ability to safely use the electric wheelchair until after the incident on 9/20/19. (This example is being cited at scope/severity G; actual harm.) R30 is a resident who smokes. The smoking evaluation indicated R30 could smoke independently with facility storage of tobacco and fire material. The facility did not ensure R30 was turning in the smoking materials to staff for storage in between smoking times. R56 is a resident who smokes. The smoking evaluation indicated R56 could smoke independently with facility storage of tobacco and fire material. The facility did not ensure R56 was turning in the smoking materials to staff for storage in between smoking times. Findings include: 1. R54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/29/19 at 11:42 AM, Surveyor reviewed facility investigation related to the above stated incident. Facility documents indicated that on 9/20/19, R54's manual wheelchair was struck by R30's electric wheelchair causing R54 to fall from the wheelchair. R54 was assessed by staff for injuries and sent to a hospital Emergency Department for evaluation. Hospital records indicated R54 sustained a fracture to the sacrococcygeal junction with distal fragment displaced on half shaft diameter anteriorly (pelvic fracture in the region of the sacrum and coccyx 'tailbone'.) Therapy staff assessed R30 for safety in electric wheelchair. Therapy assessment concluded that R30 was not able to use electric wheelchair safely and provided R30 with a manual wheelchair. On 10/29/19 at 11:53 AM, Surveyor reviewed R30's medical record which contained the following progress notes: 9/16/2019 18:47 (6:47 PM) Behavior Note describe behavior, notifications: Res. (resident) driving through lobby of facility at quick pace in electric scooter, swearing under breath, muttering speaking in rapid fashion asking where female CNA (Certified Nursing Assistant) was. Sped through nurses lobby at fast speed past writer at med (medication) cart and other res. nearby narrowly missing hitting writer and other res. in w/c. Social worker present on seen (sic). Writer asked if res. wanted medications. Res. stated rapidly 'you can bring them to my room,' Res. flew past writer down to A wing swearing and threatening to cause harm. Res. came back from A wing and was about to pass writer. Writer stated, 'I will give your meds here.' Res. asked why. Writer, stated 'because I don't feel safe being in your room.' Writer took pills. Res. went down to (R30's) room with nursing assistant and lift. 9/18/2019 05:36 (5:36 AM) Nurses Note: Writer did talk to resident this morning regarding recent behaviors . In the interim, resident was asked to slow down (R30's) power wheelchair as it is a safety risk at facility-(R30) verbalized understanding, and will follow through with this request. 9/20/2019 16:07 (4:07 PM) Nurses Note: This resident has been deemed unsafe by physical therapy due to event where (R30) exhibited unsafe behavior as early as this morning when (R30) propelled (R30's) wheelchair at moderate speed into another stationary wheelchair which had a resident sitting in it. (R30) has attempted to propel (R30's) wheelchair into staff members who are able to move out of (R30's) way more quickly . On 10/30/19 at 9:28 AM, Surveyor interviewed NHA (Nursing Home Administrator)-A, who indicated belief that charting on 9/18/19 above was in regards to the incident on 9/16/19. NHA-A verified there was no documentation which indicated what the staff did on 9/16/19 in response to R30's unsafe driving on 9/16/19. NHA-A verified no staff education was done as a result of the investigation. NHA-A expressed understanding and agreement that if staff would have requested therapy screen regarding incident on 9/16/19 the event causing R54's injury on 9/20/19 may not have occurred. 2. On 10/28/19 at 8:17 AM, Surveyor interviewed R30. Surveyor observed a cigarette lighter on R30's overbed table in R30's room. R30 verified R30 smoked and did not always give smoking supplies back to staff. On 10/29/19 at 9:56 AM, Surveyor reviewed R30's medical records which contained the following the following progress notes: 8/24/2019 05:23 (5:23 AM) Nurses Note: CNA (Certified Nursing Assistant) reported to writer that it smelled of cigarette smoke in res room,writer entered res room with the smell of cigarette smell noted ,when writer asked res if he was smoking, (R30) just blinked (R30's) eyes et (and) told writer to get out of room,empty pack of cigarettes on bedside table noted .Writer called DON (Director of Nursing) per (DON) explain to (R30) smoking policy ,writer did this et ask if i could have lighter which was in a cigarette pack with a cigarette put out inside ,(R30) said to writer I don't care what the [***] you do . 9/18/2019 05:36 (5:36 AM) Nurses Note: Writer did talk to resident this morning regarding recent behaviors . In addition, the smoking policy was also reviewed with this resident as he was not in the designated area for smoking. Resident stated ' I did not know this,why.' . In addition, R30's medical record contained a Smoking assessment dated [DATE] which indicated R30 could smoke independently with facility storage of tobacco and fire material. Throughout survey dates of 10/28, 10/29 and 10/30/19, Surveyor noted a resident who wandered halls. Staff and other residents reported this resident would wander into other resident rooms and take items at times. Staff verified this resident was diagnosed with [REDACTED]. On 10/30/19 at 7:50 AM, Surveyor interviewed DON-B who indicated facility process was to conduct smoking assessments annually and as needed with changes of condition. DON-B verified facility would conduct smoking assessment [MEDICAL CONDITION] occur. When asked, DON-B stated, We call the administrator (NHA (Nursing Home Administrator-A) and (NHA-A) gets involved. When asked about R30 having smoking supplies in R30's room, DON-B stated, (R30) has people who bring (R30) smoking materials, we talk to (R30) about facility storing materials, (R30) says its (R30's) right to smoke. DON-B indicated smoking materials are supposed to be kept in facility medication storage room and stated, It does not always happen. DON-B verified awareness R30 kept tobacco items in R30's room. On 10/30/19, Surveyor reviewed facility provided document titled Resident Smoking Policy Notification which stated the following: Smoking is only permitted in designated areas, located outside the building. Smoking is not allowed inside the building under any circumstances. Smoking restrictions shall be strictly enforced in all nonsmoking areas. The facility may check periodically to determine if residents have any smoking articles in violation of our smoking policies. This facility maintains the right to confiscate smoking articles found in violation of our smoking policies. Smoking at this facility is a privilege and any non-compliance with our smoking policy may result in loss of smoking privilege while at the facility or involuntary discharge from the facility. The document did not contain how frequently or under what circumstances smoking assessments were to be conducted. 3. On 10/28/19, the Surveyor reviewed R56's medical record. R56 was admitted [DATE] with [DIAGNOSES REDACTED]. R56's quarterly MDS (Minimum Data Set) indicated R56 was cognitively intact. R56's smoking care plan dated 7/11/19, stated The resident is a smoker, instruct resident about the facility policy on smoking; locations, times and safety. A smoking evaluation dated 7/12/19 indicated under the intervention section: resident could smoke independently with facility storage of tobacco and fire material. On 10/28/19 at 9:34 AM, the Surveyor entered R56's room for an initial interview. R56 stated R56 was going outside to have a cigarette (showing the Surveyor the cigarettes and lighter). The Surveyor asked R56 where R56 keeps the cigarettes and lighter, R56 stated they are either kept in R56's coat pocket or in R56's room. On 1030/19 at 7:55 AM, the Surveyor interviewed DON (Director of Nursing)-B regarding R56 keeping the cigarettes and lighter either in R56's coat pocket or in R56's room. DON-B stated the smoking materials are supposed to be kept in the med room in between smoking times. DON-B verified this is not always happening and stated this is something we need to improve on.

Based on record review and staff interview, the facility did not ensure 1 Resident (R) (R10) of 25 residents was free from physical abuse. Additionally, the facility did not ensure 2 Residents (R19 and R21) as well as 13 to 15 unnamed residents of 66 residents who resided in the facility on 7/27/19 were free from neglect. R8 was admitted to the facility with known combative behaviors such as scratching and biting. R8 did not have a plan in place for staff to monitor R8's behaviors on the unit. On 7/13/19 R8 was involved in an altercation with R10 in which R8 bit R10. R8's bite caused R10 to bleed and R10 was ordered five days of antibiotic therapy and a tetanus immunization as a result of being bitten by R8. (This example is being cited at a scope/severity of G (actual harm/isolated) R18 and R60 were not served meals on 7/27/19. In addition, two complaints submitted to the State Agency on 7/29/19 and 7/31/19 stated 15 residents missed breakfast and lunch on 7/27/19. One complaint stated NHA (Nursing Home Administrator)-A was aware of the complaint and did nothing to assist getting the residents their meals. Findings include: 1. R8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R8 had a care plan in placed dated 7/14/19 which had the following interventions in place: ~ Resident has history scratching and biting during cares - reproach as needed - per past caregivers, he is more cooperative with personal cares when in bed (intervention added 7/15/19). On 8/1/19, the Surveyor reviewed R8's medical record. R8 nurses notes documented the following entries: 7/10/19 at 3:00 AM., Resident did scratch (CNA) during cares and did create a small, approximately 0.3 x 0.3 cm (centimeter) scratch. 7/10/19 at 12:10 PM., Writer attempted to administer TB ([MEDICAL CONDITION] skin test). (R8) was cooperative at first however upon seeing the needle coming towards his forearm, resident began squeezing writers arm and digging claws into writer's skin. 7/10/19 at 1:36 PM., (R8) scratched CNA while attempting cares 7/12/19 at 1:59 AM., (R8) grabbing, pinching and attempting to bite staff during incontinent cares. 7/13/19 at 3:54 PM., (R8) had an incident with another resident and (R8) ended up biting (R10). (R8) did open skin. A review of a self-report submitted to the State Agency by the facility stated, During the evening shift of 7/13/19, it was observed by the activity aide that while doing an activity by the nursing station, (R8) had wheeled self away and was going toward the water cooler by the nursing station. (R10) followed (R8) and stood in front of (R8). (R8) then grabbed onto (R10's) left hand and bit it. (R10) immediately called out and was bleeding. According to the self-report both residents were separated immediately after the incident. On 8/1/19, the Surveyor reviewed R10's medical record. R10 had the following physician orders [REDACTED]. ~ On 7/13/19, R10 had a nurses order in place to cleanse skin teat to left hand and place Band-Aid if needed in the evening for wound care. ~ On 7/16/19, R10 physician orders [REDACTED]. ~ On 7/16/19 R10 physician orders [REDACTED]. On 8/1/19., at 11:00 AM., the Surveyor interviewed DON (Director of Nursing)-B related to R8 biting R10. DON-B stated that the facility was aware R8 had combative behaviors (scratching and biting) when R8 was admitted to the facility. DON-B confirmed to the Surveyor no plan was available for staff to be aware of how to manage R8's behaviors and prevent resident-to-resident incidents such as this one. DON-B stated a care plan was not developed instructing staff how to care for R8's behaviors or how to prevent R8 from injuring other residents at the facility. DON-B informed the Surveyor when the care plan was developed on 7/15/19, it did not instruct staff how to prevent R8 from injuring other residents. The facility policy entitled Abuse Prevention Program, Facility Procedures, Training Program and Staff Materials with an effective date of (MONTH) 28, (YEAR) and (MONTH) 4, (YEAR), indicated each resident will be free from abuse/neglect. 2. On 8/1/19 at 9:23 AM, the Surveyor interviewed R19 after R19 requested to speak to the Surveyor regarding meals. R19 stated if R19 does not fill out a menu, R19 is not served food. R19 stated R19 was not served breakfast or lunch on 7/27/19. R19 does not like going without meals. On 8/1/19 at 9:34 AM, the Surveyor interviewed R21 after R21 requested to speak to the Surveyor regarding meals. R21 stated on 7/27/19, R21 roomed with R60 and stated R60 did not receive breakfast or lunch because staff forgot about R60. R21 requested staff provide cares/food for R60 who does not speak, but staff did not provide food for R60 as R21 stayed to observe R60 received food and cares. R21 verified staff were aware R60 had not been served breakfast or lunch on 7/27/19. On 8/1/19 at approximately 10:00 AM, the Surveyor requested meal intakes for residents on 7/27/19 from NHA-[NAME] NHA-A indicated NHA-A would provide the meal intakes to the Surveyor. At approximately 10:30 AM, NHA-A advised the Surveyor that the facility did not have meal intakes documented for any residents on 7/27/19. It was unknown if residents were served food on 7/27/19. On 8/5/19 at 2:09 PM, the Surveyor interviewed DM (Dietary Manager)-K regarding meals served on 7/27/19. DM-K verified there were 13 to 15 residents that did not eat breakfast on 7/27/19. Dietary staff went to find out why the residents were not at breakfast and were told the residents were not up. It was unknown why the residents were not up. DM-K did not remember names of residents not served breakfast as meal tickets were not saved and does not remember if lunch was served to them. This was reported to the NHA on 7/27/19. On 8/5/19 at 2:13 PM, the Surveyor interviewed NHA-A regarding meals served on 7/27/19. NHA-A stated NHA-A was made aware of 13 to 15 residents that were not served meals on 7/27/19 at approximately 1:00 PM. NHA-A stated, Some (residents) were in bed yet and hadn't refused meals. NHA-A verified NHA-A did not assist the residents with receiving any meals on 7/27/19 after NHA-A was notified the residents had not received meals. NHA-A verified the facility did not report this incident to the State Agency though this incident could have been considered neglect because 13 to 15 residents were not served breakfast or lunch. Additionally, NHA-A verified once NHA-A was made aware 13 to 15 residents were not served food at approximately 1:00 PM on 7/27/19, NHA-A did not investigate why the residents were not served food, and did not make any changes to prevent potential neglect from occurring in the future until after speaking with the Surveyor on 8/1/19. NHA-A stated the change made to prevent neglect in the future related to residents not receiving meals was started this morning (8/5/19.) The change indicated dietary staff are to make a copy of meal intakes because the intake sheet could not be found for 7/27/19.

Based on observations, staff, resident and family interviews and record review, the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 3 residents (R7, R8, and R1) of 5 sampled residents. R7 changed rooms on 02/06/17. R8 moved into the room on 02/16/17. Staff indicated they shared concerns about R7 and R8 sharing a room prior to the placement, but R7 and R8 were placed as roommates. R7 has a history of tearfulness, but staff and R7 indicated R7 has been crying more and spending more time out of her room related to roommate incompatibility. Staff indicated R7 and R8 have multiple disagreements and everyone is aware of incompatibility, but no action is being taken to resolve the situation. R8 was forced to sign the facility admission agreement on the day of admission without allowing the request that R8 would like to wait until a family member was coming to the facility the following day and would review the agreement with R8. R1 entered the facility for short term stay rehabilitation and then required to stay long term at the facility. The resident was moved off the rehab unit from a single room to a double room without the resident's consent. The resident had indicators of unhappiness related to the room change. The facility had not advocated for the resident's right to choice. Example 1 is a scope/severity level deficiency of G (actual harm/isolated). Example 2 and 3 are a scope/severity deficiency of level D (potential for harm/isolated). Findings include: 1. Surveyors and were investigating a concern that was sent to the state agency regarding room changes without consent at the facility. Facility staff indicated R7 and R8 recently received a room change. On 02/21/17 at 7:45 a.m., Surveyor interviewed R7. R7 stated she was forced to move to a different room but did not want to change rooms. R7 indicated a few weeks ago she was informed of the upcoming room change and was told by NHA (Nursing Home Administrator)-A that everyone had to have a roommate. R7 stated that one day NHA-A stated it was moving day and R7 indicated she informed NHA-A that she did not want to change rooms. R7 indicated NHA-A told R7's son that R7 begged him (NHA) to move, but R7 did not. R7 stated she cannot stand her roommate. R7 indicated when she is in her room, R8 says all the time that, I want this and I want that and began to cry during the interview. R7 stated she cries often these days because of R8 and indicated she used to spend more time in her room, but because of R8 she spends time sitting by the nurses station. R7 stated MR (Medical Records)-L knows I do not want to be in that room and MR-L said she was going to get me out of there. On 02/21/17 at 8:05 a.m., Surveyor interviewed MR-L regarding R7's room situation. MR-L stated this past weekend R7 was seated by the nurses station and verified R7 was teary eyed and upset. MR-L stated she did not specifically ask why R7 was crying, but assumed it was because of her roommate. MR-L stated R7 told her that R7 does not sleep well anymore. MR-L indicated R7 was told of the room change prior to changing and agreed. MR-L stated a few weeks after the change, then R8 was moved into the room and R7 did not like her roommate. MR-L stated R7 has been upset and teary since R8 moved into the room. On 02/21/17 at 8:50 a.m., Surveyor interviewed CNA (Certified Nursing Assistant)-E regarding R7's room change and roommate concerns. CNA-E stated at first R7 was hesitant to the room change, but agreeable. CNA-E indicated staff wanted to move R7 closer to the nurses station due to breathing concerns. CNA-E stated R7 did adjust to the room and did become happy with the room change, but then R8 was moved into the room and there have been problems ever since. CNA-E indicated R7 and R8 fight and R7 has been crying ever since. CNA-E stated R7 is now under a lot of stress and believes the increased stress is related to sharing a room with R8. CNA-E indicated all staff say R7 and R8 need to be separated, but NHA-A does not address the concern. CNA-E reiterated R7 and R8 do not get along. CNA-E indicated staff will be assisting R7 with cares, and R8 will start saying how she needs assistance and becomes very demanding. CNA-E stated NHA-A kept saying at the time of the room changes, we need to move her over and over again. CNA-E indicated R7 has become withdrawn and depressed since the addition of R8 to the room. On 02/21/17 at 8:30 a.m., Surveyor interviewed NHA-A regarding the roommates R7 and R8. NHA-A stated R7 wanted the room change to be closer to the nurses station because of her breathing concerns and R7 was fine until R8 became her roommate. NHA-A indicated R8 just became R7's roommate last Thursday (02/16/17). NHA-A stated there have been issues between R7 and R8, but the facility has been trying to resolve the concerns. NHA-A verified the facility has not offered any room changes to either R7 or R8. On 02/21/17 at 9:00 a.m., Surveyor interviewed RN (Registered Nurse)-B regarding R7 and R8 sharing a room. RN-B stated she does not work with R7, but has frequently heard R7 telling other residents that she does not like her roommate. RN-B also indicated she has heard from other staff that R7 does not like R8 and is very upset. RN-B stated the situation is discussed in the morning meeting all the time, but nothing is done. On 02/21/17 at 9:30 a.m., Surveyor conducted a telephone interview with the previous SW (Social Worker)-F regarding R7 and R8 sharing a room. SW-F stated NHA-A does not ask residents about the room changes, but just tells them they will be moved. SW-F stated residents cry, to include R7, and then NHA-A told me (SW-F) to take care of it. SW-F indicated NHA-A stated R7 would be moved and then R8 can move into that room. SW-F indicated NHA-A is moving residents like cattle and I have told him this is against regulations, but NHA-A did not want to hear about it. SW-F stated NHA-A just tells staff to move them and there is no discussion. SW-F indicated R7 was upset with the room change, but I left employment right after that, because of what was happening. SW-F stated has not spoken to R7 since the move. On 02/21/17 at 10:30 a.m., Surveyor conducted a telephone interview with CNA (Certified Nursing Assistant)-H regarding R7 and R8 sharing a room. CNA-H stated R8 is very mean to R7. CNA-H indicated R8 does not want R7 to go past her bed into the bathroom and then R8 starts to yell at R7. CNA-H stated R7 used to stay in her room and enjoyed reading, but now R7 stays out of her room because she does not want to be in the room with R8. CNA-H indicated she comes to work at 5:30 a.m. and R7 wants to get up and out of the room, and prior to R8 being in the room, R7 would stay in the room. CNA-H stated R7 cries frequently because of R8. CNA-H indicated R7 and R8 are not compatible roommates and all staff are aware, but nothing gets done. On 02/21/17 at 10:40 a.m., Surveyor interviewed RN-M regarding R7 and R8's roommate concerns. RN-M stated when staff were informed R7 and R8 were to be roommates, staff had voiced concerns about R7 and R8 being placed as roommates, but staff were told to place them together anyway. RN-B indicated it was like a trial and error situation. RN-B stated staff did not think it would work because of R8's personality. RN-B indicated R8 is mean to R7 and stated R7 does continue to cry if staff talk about the issue with her so I do not like to talk about the roommate concerns with R8 because I know it will make her cry. RN-B indicated R7 used to enjoy staying in her room watching television, doing a puzzle or reading, but now she won't stay in her room because of the roommate issue. RN-B stated there was a big issue that occurred over the past weekend with R7 and R8, but I don't know what was said. LPN (Licensed Practical Nurse)-N was working that day. RN-M indicated nothing has been done, as there is no talk about changing rooms for R7 or R8. On 02/21/17 at 10:55 a.m., Surveyor conducted a telephone interview with LPN-N regarding an alleged incident that occurred over the previous weekend. LPN-N stated the roommate situation for R7 and R8 has negatively impacted R7. LPN-N stated when staff were told R8 and R7 were to be roommates, staff voiced concerns it was not a good fit, but R7 and R8 were put together anyway. LPN-N indicated there has been problems since R7 and R8 were initially placed together. LPN-N indicated R8 gets verbally mean to R7 and an example is if R7 goes past R8's curtain that separates them, R8 will call staff to have R7 removed. LPN-N indicated if staff are providing cares to R7, then R8 will start saying she needs assistance. LPN-N stated last weekend, R8 was yelling at staff in front of R7 because staff were taking care of R7, as R7 was having breathing concerns and needed assistance. LPN-N indicated R7's anxiety has escalated and her breathing appears to be affected. LPN-N stated R7 will not stay in her room anymore because of R8. LPN-N indicated she called NHA-A last weekend and told him R7 and R8 should not be roommates, but nothing gets done. LPN-N stated she was going to separate R7 and R8 herself, but it appeared the situation had settled and R7 appeared better. LPN-N indicated prior to R7 and R8 being placed as roommates, R7 was happy and would talk, but now R7 appears to be reserved and keeps to herself. Surveyor reviewed R7's medical record and was unable to locate nursing or CNA behavior documentation regarding what is being voiced from staff regarding R7's unhappiness with roommate. On 02/21/17 at 1:05 p.m., Surveyor and RN-M reviewed R7's medical record. RN-B verified there was no documentation and stated the roommate situation apparently is not being documented, and only discussed amongst staff. On 02/21/17 at 3:40 p.m., Surveyor interviewed LPN-K, who stated R7 has anxiety and her anxiety has significantly increased since the room change and the addition of R8 to the room. LPN-K indicated the night of the room change, R7 was crying and with the increase in anxiety her breathing worsens. LPN-K indicated staff expressed concerns that R7 and R8 would not get along prior to being placed together, but they were put together anyway. LPN-K stated there have always been problems between R7 and R8. On 02/22/17 at 8:20 a.m., Surveyor interviewed NHA-A. NHA-A stated he was unaware of any continuing concerns between R7 & R8. NHA-A indicated there have been a few concerns, but the issues were resolved. NHA-A stated staff have not expressed concerns regarding placement of R7 and R8 sharing a room. NHA-A indicated the facility holds twice daily meetings and was never informed of ongoing concerns regarding R7 and R8's placement together. NHA-A stated it has only been four days since they have been together and time to adjust is needed. NHA-A stated there was an issue last weekend that was reported and that was about R8's television being too loud, so R8 was given a headset to wear while watching television and that seemed to resolve the situation. On 02/22/17 at 9:15 a.m., Surveyor interviewed R7 in her room. R8 was watching television without the use of a headset and the television was very loud. R7 had her television on, but the sound of her television was barely heard due to R8's television volume set very loudly. R7 stated her roommate's television is very loud and she cannot hear her TV set. R7 indicated R8 is suppose to wear a headset, but she doesn't. Surveyor interviewed R8 at that time and R8 verified a headset was given to her, but only worked a few days so the facility took the headset away. R7 again, reiterated that she did not ask for a room change and NHA-A keeps saying she did. R7 again reiterated that she spends a lot of time by the nurses station because she hates being in her room now, because of R8. R7 stated yesterday Hskg (Housekeeping)-O brought her back to her room after lunch and the door was closed. R7 stated she told Hskg-O she cannot go into her room because R8 was getting washed up and wanted privacy, so R7 would be required to stay in the hall until R8 was done. R7 stated things like that happen all the time. On 02/22/17 at 9:25 a.m., Surveyor interviewed Hskg-O regarding what R8 had reported. Hskg-O verified she assisted R7 to her room after lunch and the door was closed. Hskg-O stated R7 told her she could not go into the room because the door was closed and R8 was getting washed up. Hskg-O stated she went to interim DON (Director of Nursing)-C and asked if R7 was required to stay out of the room while R8 was receiving cares. Hskg-O stated DON-C indicated no, and R7 could be placed in the room. Hskg-O stated she returned to the room, but the door was open and staff had completed R8's cares. Hskg-O indicated she went and spoke with the CNA and told her staff cannot keep R7 out of her room when R8 was receiving cares. Hskg-O stated she did not know the reason why, but it was possible CNA staff were keeping R7 out of the room during cares to keep R8 happy. On 02/22/17 at 10:30 a.m., Surveyor interviewed NHA-A regarding the observation of the television being loud and R8 without the use of a headset. NHA-A stated the maintenance man came to him on 02/21/17 and stated the headset was no longer working and removed the headset from the room. NHA-A verified another headset was not given to R8 on 02/21/17, and indicated an additional headset was available. NHA-A stated he was going to resolve that concern today (02/22/17), but indicated has not done so yet. On 02/23/17 at 10:45 a.m., Surveyor conducted a telephone interview with FM (Family Member)-P. FM-P stated R7 does not accept change well and never has. FM-P indicated R7 had resided in her previous room for years and without a roommate. R7 stated he did not believe R7 requested the room change and was very upset when the room change occurred. FM-P indicated R7 was upset for a few days, but then did appear to settle in the new room until the roommate was placed. FM-P stated one time when he was speaking with R7 on the phone, both TV's were so loud FM-P could not hear the conversation. FM-P stated R7 was complaining about the roommate's television, so R7 turned her television volume up so she could hear. FM-P stated he was aware R7 has anxiety and does have significant cardiac issues, but due to the anxiety, FM-P does not think these panic attacks R7 is having related to the roommate is helping her health. FM-P indicated he has called NHA-A multiple times and left messages to return his calls, but the NHA does not return the calls. FM-P stated he spoke to R7 every morning and evening, but now R7 calls all the time. FM-P stated R7 calls him now 5-10 times a day and at all hours of the night. FM-P indicated R7 always discusses concerns about the roommate and she is crying on the telephone. 2. On 02/21/17 at 7:30 a.m., Surveyor interviewed R8. R8 stated she had recently changed rooms at the facility and felt she was not given a choice about the move. On 02/21/17 at 9:40 a.m., Surveyor conducted a telephone interview with previous SW (Social Worker)-F regarding the room change, but in the course of the interview, SW-F stated R8 was forced to sign the Admissions Agreement by NHA-A. SW-F indicated NHA-A told her he said R8 has to sign the agreement or R8 would have to leave the facility. SW-F indicated R8 wanted to review the Admissions agreement with her family, who would be coming to the facility the following day and then sign the papers. SW-F stated she thought that was fair, but was told no by NHA-A and was made to sign the agreement. SW-A indicated R8 was sobbing over the encounter. On 02/21/17 at 10:10 a.m., Surveyor interviewed R8 to discuss the admissions process at the facility. R8 stated when she was admitted to the facility on [DATE], she met with NHA-A and there were other staff in the room (but could not recall who). R8 stated NHA-A told me I had to sign the Admissions agreement right then. R8 stated NHA-A told her she had to sign the agreement or would have to leave the facility. R8 indicated she wanted to wait until the following day to review the agreement with her family, but the NHA would not allow that. R8 stated she was upset about being forced to sign the agreement but she did, because she did not have anywhere else to go. On 02/21/17 at 1:35 p.m., Surveyor interviewed NHA-A regarding the Admissions agreement for R8. NHA-A stated R8 did not sign the agreement until weeks after admitted to the facility. NHA-A stated he (NHA) did not speak with R8 about the Admissions agreement when R8 was admitted to the facility, SW-F had. Surveyor requested a copy of R8's Admission agreement. NHA-A provided Surveyor a copy of the Admissions agreement. The Admissions agreement was signed by R8 on 01/13/17, day of admit. There was also a hand written statement that stated I have not read packet or terms and conditions. Surveyor and NHA-A reviewed the agreement and noted R8 signed the Admissions agreement on the day of admission. NHA-A indicated R8 did sign, but R8 did not agree to all the terms on the day of admission. 3. R1's admission face sheet dated 3/17/16 indicated R1 had [DIAGNOSES REDACTED]. R1's weight was listed as 283 pounds and was 64 inches tall. R1 was initially admitted to the facility for short term rehabilitation after the accident. R1 was listed as own decision maker. R1's face sheet indicated the resident was private pay status. R1 had signed the admission agreement on admission to the facility. R1 received therapy services from 3/19/16 to 9/24/16 and again from 12/10/16 to 1/13/17. Review of the resident's MDS(Minimum Data Scale) dated 11/8/16 indicated R1 scored a 15 of 15 on the cognitive screen; had mood indicators of feeling down, depressed or hopeless and feeling bad about self 7-11 days in the past two weeks and trouble sleeping and feeling tired 12-14 days in the past two weeks. Review of R1's MDS dated [DATE] indicated the same data as collected on 11/8/16 with additional assessment that indicated R1 had expressed that it was very important to have family or close friends involved in discussions about care. The facility developed a plan of care for R1 relating to potential for mood distress related to recent automobile accident, medical complications/pain, new admission, and change in lifestyle. An intervention dated 4/3/16 indicated, Provide encouragement/support across all domains of daily life and to follow up with requests and alert nursing/social services to change in mood/behavior. No other interventions were revised when the facility was aware of R1's unhappiness with room change and current room issues. According to the facility's action summary, R1 was moved on 1/5/17 from a single room with own bathroom on the rehabilitation unit to a different unit in the facility with a shared bathroom. Review progress notes in R1's medical record indicated the only entries regarding R1's objection and mood indicators before and after an un consented room change; *12/21/16. Documented by SW-F. Over the past few months, resident has demonstrated the need for 24 hour care to maintain safety. Therapies work to support and encourage resident's goal to return home. The necessity for this level of care has been addressed with resident and family repeatedly, by therapy staff, nursing and writer. Resident has been advised that the wing current room is located is for short term rehab residents and that a move to a different unit would need to take place. Resident stated wanted to speak with daughter. *12/30/16. Documented by SW-F. Writer offered therapy services to resident based on presented sadness, verbalizations of distress and unhappiness. Resident chose to not accept offer for therapeutic counseling. Resident stated did not need any help and that would speak to spouse or daughter if upset. Writer told resident that if changed mind or felt that a counselor may be helpful, to let writer know. Review of CNA daily mood documentation for R1 indicated from 12/21/16-2/21/17, the resident presented with frequent crying on 1/6/17 (day after room change), and again on 2/16/17. The resident of the three times daily documented behavior symptoms for the resident indicated, not applicable or none of the above observed. On 2/21/17 at 6:45 a.m., Surveyor interviewed RN-B. RN-B stated, The NHA is trying to get residents who are long term care all onto the B wing, more independent residents onto D wing and rehab residents on A and E wing. The only other reason residents would be moved is if their payer source changed and were no longer able to pay for a private room so would be moved to a semi private room. (R1) came in for short term rehab but did not progress in therapy so was moved from E to B wing. (R1) keeps to self. I've not heard anything that (R1) is unhappy with room change in report, but may have said more to own family. On 2/21/17 at 7:25 a.m., Surveyor interviewed RN-M. RN-M stated, (R1) moved a couple of weeks ago from the rehab wing to a long term care wing. I believe the NHA does talk with residents before they are moved from a private room to a semi private room. When (R1) first moved, (R1) was not happy but I think it is growing on (R1) now. (R1) now has to share a bathroom with two other residents. Change is hard. The NHA goes in a few weeks ahead of the move and talks with residents. They don't just all of a sudden move residents. I'm not sure why residents are being moved around. On 2/21/17 at 8:00 a.m., DON-C verified to Surveyor that all beds in the facility were dually certified including E wing. DON-C stated, Due to access to the therapy department, residents on that wing who are planning on being long term stay are moved off that wing. We tell residents on admission but I'm not sure if that is in writing. On 2/21/17 at 8:10 a.m., Surveyor interviewed BOM (Business Office Manager)-D. BOM-D stated, (R1) is private pay and is applying for Medical Assistance. The move from one wing to another wing had nothing to do with money. (R1's) last day of Medicare coverage was 6/24/16. (R1) had a room change from E wing to B wing on 1/5/17 but I'm not sure why. On 2/21/17 at 8:15 a.m., Surveyor interviewed SW-F via the telephone. SW-F stated, The day of (R1's) move, the resident's mood was so different. The resident is usually very sensitive but was usually easily redirected, but not on the day of the move. Typically, if the resident was crying, I would talk with the resident and within a half hour, the behavior stopped. The day of the move, (R1) was so very upset. It was a hopeless feeling for me. I knew there was no way I could change it. I know it was not was it was supposed to be. It was a no win situation. All the moves made me very nervous for the residents who didn't want to move. I told them and their families to call the Ombudsman but am not sure if anyone did or not. On 2/21/17 at approximately 8:20 a.m., Surveyor interviewed NHA-A. NHA-A stated, I'm not sure if this is in the admission contract but we tell all residents on admission that are initially admitted for short term stay rehab that if they then require long term care stay, they need to change rooms. All of the beds are dually certified but we really encourage the bed/unit changes. The new regulations state if a resident no longer requires skilled care such as RN services or therapy, we can move residents to other units. I have not had any residents who have not wanted to move. I did have one resident who was short term stay and changed to long term stay who stated would kill self if moved, so we let that resident stay in current room. Usually the residents understand about room changes. We have short term stay residents who stay on A or E wing past their Medicare coverage so they can wait to get the right room fit. If the room change is going to cause a resident a lot of distress, we won't move them. We would have to involve the who family if a resident didn't want to move but weren't distressed. One resident took three months to move until we found a suitable room. Once someone gets into a new room they may say they don't want the move, so we try to work with that resident. On 2/21/17 at 8:30 a.m., Surveyor entered R1's room and noted the room was a semi-private room with a bariatric commode in the room. R1 stated, The (NHA) and the SW(Social Worker) talked with me and I told them I didn't want to change room. Prior to admission, the (NHA) came to the hospital and told me they had a real nice room for me. I wasn't told on admission that I need to change rooms if I needed to stay here long term. I liked my first room really well. I was used to the aides on the unit; I knew them and they knew me. When the discussion about moving came up, I told them I didn't want to move and they didn't say anything. I was told I had to move. They told me since I was no longer needing therapy, I had to move off that unit. I didn't get a tour of rooms, or a choice in a new room. I stated I wanted to see my new room first, but one day, they just moved all my things and took me into the new room to stay. I don't like this room. The toilet is a lot lower and there are bars on either side of the toilet and I don't fit on the toilet. The low toilet causes my knees much pain when I tried to use it so they got me the commode. The others that share the bathroom are in there constantly, so I can't use the bathroom when I need to, so the commode was better for me. My knees are so bad now, and I have accidents if I can't get to the toilet on time, so staff now take me to the commode and I walk back from the commode to avoid accidents. I have told the staff and the new Social Worker that I didn't like this room and they didn't say anything. I don't like this room at all! On 2/21/17 at 9:00 a.m., Surveyor interviewed SW-Q. SW-Q stated, I have been here for three weeks. (R1) never talked with me about the room change. The NHA is taking care of the room changes. All I know is that I am told which residents are going to move to which rooms. On 2/21/17 at 9:10 a.m., Surveyor interviewed CNA-E. CNA-E stated, In the first two weeks after (R1's) room change, the resident stated wasn't happy with the new room. The sit to stand doesn't fit in the bathroom and the bars on the toilet don't allow the resident to fit without cramping. I don't blame the resident for being unhappy. (R1's) original room was very spacious. The resident who now shares the bathroom is constantly in the bathroom making noise and waking (R1). Another resident across the hall from (R1) yells out a lot. E wing was much more quiet. (R1) was not given the choice of rooms. I told the NHA about it and got no response. (NHA) just said, I'll take care of it but never did. (R1) is very reliable and if says the NHA didn't talk to (R1) about her issue, (R1) is probably correct. We (staff) do a daily huddle at 9:30 a.m. We mentioned this issue to the staff involved to include the DON, SW, NHA, Activities people. I've brought this up before and they told me that since (R1) was no considered long term care, (R1) had to go to the long term care unit. (R1) is fairly independent except for need for assist to toilet. (R1) does get very emotional about the room change, not as much now as at first, but I have seen (R1) cry about the room change. On 2/21/17 at 9:40 a.m., Surveyor again interviewed R1. R1 stated, When I first moved to the new room, I was sad and upset about it at a 10 (on a scale of 0-10, 0 being no sadness, 10 being overt sadness). I guess I've gotten used to it so now my sadness is at about a 5. I just don't like this room. On 2/21/17 at 9:45 a.m., Surveyor interviewed SW-F via the telephone. SW-F stated, The NHA just implemented discussions with newly admitted residents regarding the need for room change if change in condition occurs. Someone admitted a year ago would not have been told that. We did not have that discussion with (R1) on admission. With all the room changes going on, and all the residents who were upset by it, I told the family members about resident rights. (R1) would be reliable. (R1) does get emotional though and will dwell on things that aren't significant in the past. The day (R1) moved, I didn't know about it until settled in new room. (R1) was just bawling and I wanted to cry along with the resident. (R1) objected prior to the move and stated didn't want to move; was just pushed into a new room. There was nothing I could do. I wasn't sure why the resident had to move just because was no longer in therapy services when other residents on that wing were okay to stay. The resident's choice was not to move. From the first conversations with (R1) regarding an impending move, the resident stated didn't want to move. If a resident doesn't agree to a room change a room change should not be initiated. The current social worker should be involved with a resident's concerns regarding an undesirable bathroom situation. On the same night of the move, (R1) mentioned the bathroom situation regarding the height of the toilet stating it was too low that it caused knee pain and the bars on the toilet did not accommodate the resident's size. I heard concerns from staff in the huddle meetings about (R1's) concerns about the new room. (R1) did relay concerns about unhappiness with new room and room change. The NHA would have been at those meetings. One of the reasons for the room changes were to accommodate new residents who were coming from a facility near by that was closing but not admitted yet. I had discussions with (NHA-A) about what was going to be best for the residents and regarding resident rights to choose versus just being told had to move. Residents did not have a choice in the move if they objected, they were moved anyway's. (NHA-A) told staff when moving residents who were upset about the move that, residents don't have a choice. On 2/21/17 at 10:00 a.m., Surveyor interviewed DTS (Director of Therapy Services)-I. DTS-I stated, We picked (R1) up again on 12/10/16 for services because (R1) wanted to walk again. The concern is knees are really, really bad. Gets anxious during ambulation and is unsafe during ambulation per the staff. (R1) does have a pivot off toilet and an ambulation program from the commode to the bed or wheelchair due to urge incontinence we didn't want to ambulate resident to the toilet. (R1's) decline was not due to a room change. (R1) wasn't doing well even when on the rehab wing. On 2/21/17 at 10:15 a.m., Surveyor interviewed CNA-H via the telephone. CNA-H stated, (R1) was bawling for a week or so after the room change. (R1) could not use the bathroom in the new room because of the toilet bars on the toilet would not allow for hips to fit. We did try the toilet once after the move. (R1) is large and the toilet was too low to the ground so we went with a commode in the room. (R1's) family members did talk with the NHA about (R1) being so upset when wish not to be moved was declined. We mentioned all of this in the huddle meeting several times and brought it up to the nurses as well. We were told that the room change had to happen due to decline in (R1's) ambulation. (R1) did calm down once the NHA told (R1) that had to stay in that room. It is much more noisy in unit B than it is on unit E. (R1) complained about the resident across the hall yelling and that was afraid of that resident because that resident had screamed at (R1) once. I reported that to my manager and again in the huddle meeting. That was about a month or so ago. I did see (R1) crying on the day of the move. On 2/21/17 at 10:40 a.m., Surveyor interviewed R1's spouse via the telephone. FM (Family Member)-G stated,

Based on staff interviews and record review, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 (resident #1) of 2 sampled residents with pressure ulcers in a total sample of 10 residents. Resident #1 was readmitted to the facility following a left total knee with debridement and hardware removal, wore a leg immobilizer and was at risk for the development of pressure ulcers. Resident #1 developed an unstageable pressure ulcer related to pressure from the leg immobilizer against the resident's skin. The facility did not assess and routinely inspect the skin for potential skin breakdown in relation to a medical device (the immobilizer). Findings include: NPUAP (National Pressure Ulcer Advisory Panel) www.npuap.org Pressure Ulcer Prevention documents Risk Assessment: 10. Conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by the individual's condition. Reassessment should also be undertaken if there is any change in patient condition. Skin Assessment: 3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. 6. Observe the skin for pressure damage caused by medical devices. NPUAP: MDRPU (Medical Device Related Pressure Ulcers): The Hidden Epidemic Across the Lifespan documents MDRPU occur because of: · rigidity & inelasticity of devices · difficulties in adjusting/securing to the body · may be difficult to safely remove/lift · prolonged pressure in the same place · altered microclimate with increased moisture and heat · tight securement · poor positioning or fixation of device · inappropriate size, selection · obscured skin from visualization · lack of awareness of [MEDICAL CONDITION] impact 2010 research indicates patients with a medical device were 2.4 times more likely to develop a pressure ulcer. Practice: thorough skin assessment under devices Q (every) shift if not medically contraindicated; avoid replacing devices on injured skin as feasible; Ensure proper sizing (resize with [MEDICAL CONDITION]). NPUAP: Pressure Ulcer Treatment Quick Reference Guide classification system: Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stage (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. On 7/27/15, surveyor # reviewed the medical record of resident #1. The 6/29/15 facesheet, contained within the medical record, indicated resident #1 was readmitted to the facility 6/27/15 with [DIAGNOSES REDACTED]. The 7/14/15 quarterly MDS (Minimum Data Set) assessment documented resident #1 was moderately cognitively impaired and required extensive assistance with bed mobility and transfers. A hospital discharge summary, dated 6/27/15 documented resident #1 had been living at the nursing home where the resident bumped the left knee, exposed hardware, and required a left knee debridement and hardware removal. Resident #1 had a removable leg immobilizer brace applied to the left leg since discharge from the hospital. A Braden pressure ulcer risk assessment dated [DATE] and 6/27/15, indicated resident #1 was at risk for the development of pressure ulcers. The 5/22/15 CAA (Care Area Assessment) for pressure ulcers documented the following summary (resident #1) lies on back much of time. Calcified area on right flank noted to have been there for many years has a pinpoint opening on it.Daily blood sugar tests often high due to not following diet recommendations. Facility protocol for wheelchair cushions and mattresses for all residents to be preventive for pressure. The re-written skin integrity plan of care for resident #1 dated 2/27/15, indicated resident #1 was at risk for skin breakdown due to diabetes, an unstageable right heel pressure ulcer and left and right buttock abrasions. The care plan did not include the leg immobilizer as a risk factor. The care plan included the following interventions: use assistive devices to reduce friction, keep head of bed at or below 30 degrees, protect elbows and heels, inspect the skin for sign and symptoms of breakdown, specialty mattress and position body with pillows and/or other support devices (foam boots) every 2 hours. The care plan did not include any intervention(s) related to the leg immobilizer. A Skin Grid document dated 11/25/14, indicated the development of a suspected deep tissue injury on resident #1's right heel. A Skin Grid document dated 11/25/14, indicated the development of unstageable pressure ulcer on resident #1's left heel. A Skin Grid document dated 7/5/15, indicated shear/denuded areas on resident #1's right and left buttocks. A Nursing Note dated 7/16/15 documented PTA (Physical Therapy Assistant) reported to nurse resident #1 has open area to left lower posterior leg. Leg brace is rubbing against resident #1's leg . A Skin Grid document for resident #1 dated 7/16/15, indicated the development of an unstageable pressure ulcer, 4 cm (centimeters) in length by 4 cm in width by 0.2 cm in depth, on the left posterior lower calf. The initial identification charting on the Skin Grid, indicated resident #1's pressure ulcer had not been present on admission. physician's orders [REDACTED]. Only to be worn while up at side of beds for meals. Santyl to left lower extremity ulcer every day, and cover with dressing. The June 2015 and July 2015 MAR (Medication Administration Record) and TAR (Treatment Administration Record) did not include an order or documentation that staff had been inspecting resident #1's skin underneath the left leg immobilizer to monitor for skin breakdown. During the survey period from 7/27/15 to 7/29/15, surveyor # was unable to observe cares for resident #1. Resident #1 is a private person and did not want surveyor # in the room during cares. On 7/28/15 at 11:40 a.m., surveyor # interviewed CNA (Certified Nursing Assistant)-M regarding resident #1. CNA-M confirmed resident #1 came back from the hospital on [DATE] with a removable leg immobilizer on the left lower extremity. CNA-M stated (resident #1) wore the leg immobilizer all the time, until (resident) developed the pressure sore. I never took the leg immobilizer off to inspect the skin .I thought the nurses were doing it. On 7/29/15 at 8:30 a.m., surveyor # interviewed CNA-N regarding resident #1's left leg immobilizer. CNA-N verified resident #1 came back from the hospital on [DATE] with a removable left leg immobilizer. CNA-N indicated resident #1 stayed in bed most of the time and wore the immobilizer all the time. CNA-N stated (resident #1's) lower left leg sore came from the immobilizer. I never took the immobilizer off to inspect the skin. Resident #1 had been given bed baths per (resident's)choice, even then, I never removed the immobilizer. On 7/27/15 at 2:45 p.m., surveyor # interviewed LPN (Licensed Practical Nurse)-J regarding resident #1's left leg immobilizer and care plan interventions. LPN-J confirmed the unstageable pressure area developed due to pressure from resident #1's left leg immobilizer. LPN-J confirmed after the development of the unstageable pressure ulcer, the use of the immobilizer was discontinued while the resident was in bed. Surveyor # then questioned LPN-J if skin inspections underneath the immobilizer were being performed. LPN-J stated I took off resident #1's leg immobilizer every 2 days to change the dressing to the resident's knee, but I can't say that I was monitoring resident #1's skin underneath the immobilizer.I would have been alerted to inspect and document on resident #1's skin routinely, if it was on the TAR. LPN-J verified resident #1's June 2015 and July 2015 MAR and TAR did not instruct staff to inspect resident #1's skin underneath the immobilizer every shift. On 7/28/15 at 9:45 a.m., surveyor # interviewed RN (Registered Nurse)-P regarding resident #1's left leg immobilizer and skin inspections. RN-P confirmed resident #1 stayed in bed, and wore the left leg immobilizer at all times until the development of the unstageable pressure ulcer. RN-P stated I checked and changed resident #1's knee dressing every 2 days. I can't remember if I checked the resident's skin underneath the immobilizer. RN-P went on to say I would have inspected and documented the skin assessment every shift, if it was placed in resident #1's TAR. On 7/28/15 at 9:50 a.m., surveyor # interviewed RN-L regarding resident #1's left leg immobilizer. RN-L confirmed resident #1 wore the removable leg immobilizer at all times and stayed in bed per resident #1's choice. Surveyor # then questioned RN-L regarding inspection and documentation of resident #1's skin underneath the immobilizer. RN-L confirmed resident #1's June 2015 and July 2015 MAR/TAR did not include an order or documentation to perform skin inspections underneath the immobilizer every shift. On 7/28/15 at 11:35 a.m., surveyor # interviewed PTA (Physical Therapist Assistant)-O regarding resident #1. PTA-O confirmed resident #1 had an order to wear the left leg immobilizer at all times. PTA-O verified resident #1 refused to get out of bed, and wore the immobilizer for all therapy sessions. PTA-O stated I was doing leg exercises with resident #1 while the resident was in bed on 7/16/15. My hand was positioned underneath resident #1's left lower leg, when I felt something wet. Resident #1 had no pain and could not feel the sore. I told the nurse on duty right away. On 7/28/15 at 11:50 a.m., surveyor # interviewed ADON/WCC (Assistant Director of Nursing/Wound Care Certified)-K regarding resident #1. ADON/WCC-K confirmed the facility utilizes the NPUAP as the standard of practice for pressure ulcer prevention and development. Surveyor # questioned ADON/WCC-K regarding interventions related to the leg immobilizer for resident #1. ADON/WCC-K confirmed after the development of the unstageable pressure ulcer associated with the leg immobilizer, the intervention to discontinue the immobilizer while resident #1 was in bed was added. ADON/WCC-K verified resident #1 wore the left leg immobilizer at all times and developed the unstageable pressure related to the medical device. ADON/WCC-K stated I would have expected nursing staff to inspect resident #1's skin every shift and document in the TAR. ADON/WCC-K verified facility staff did not document resident #1's skin assessment every shift on the June 2015 and July 2015 TAR. ADON/WCC-K confirmed resident #1 immobilizer was removable and stated I'm unaware if the immobilizer would have been medically contraindicated to be removed every shift, because no discussion took place with the physician regarding the removal of the immobilizer, until after the development of the unstageable pressure ulcer. On 7/29/15 at 12:15 p.m., surveyor # interviewed DON (Director of Nursing)-G regarding resident #1. DON-G stated Yesterday I began conducting audits on all residents' that utilize a medical device. Resident's TAR's were updated to include inspection and documentation of residents' skin every shift. DON-G verified staff training had begun for all staff, after the concern had been identified by the surveyor.