Every finding on record at Bethany Home

Based on staff interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 1 Resident (R) (R1) of 3 sampled residents. R1 required an EZ stand mechanical lift with the assistance of 2 staff for transfers. On 9/25/25, R1 slipped from the EZ stand, was lowered to the floor, and suffered a left clavicle fracture when agency Certified Nursing Assistant (CNA)-C transferred R1 alone. In addition, agency Registered Nurse (RN)-D did not transfer R1 to the emergency room (ER) per R1's request because RN-D did not know how to complete the paperwork. The facility identified deficient practices but did not provide education to agency staff who worked since the incident. Findings include:The facility's Abuse Prohibition policy, revised 4/19/21, indicates: .VI. Reporting/Response: .Taking all necessary actions as a result of the investigation, which may include, but are not limited to the following: .c. Training of staff on changes made and demonstration of staff competency after training is implemented. The facility's Safe Resident Handling policy, dated 11/13/24, indicates: .C. The transfer method and equipment needs for each resident are indicated in the resident's care plan, individual service plan, or care card .E. The staff at any time can increase the level of transfer from what is stated in their plan .however, staff cannot reduce the level of device use .B. Training will occur: .2. After transfer-related incidents. On 10/27/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including clavicle fracture, left below-the-knee amputation, type 2 diabetes, and hypertensive heart disease with congestive heart failure (CHF). A Significant Change Minimum Data Set (MDS) assessment completed on 10/2/25 indicated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. R1's medical record indicated R1 was lowered to the floor from a sit-to-stand lift on 9/25/25 at approximately 8:00 PM. R1 was transferred to the ER at approximately 10:30 PM due to shoulder pain and decreased range of motion (ROM). R1 returned to the facility on 9/26/25 at approximately 2:30 AM with a diagnosis of fractured non-displaced left clavicle. On 10/27/25, Surveyor reviewed a facility-reported incident related to R1's transfer and left clavicle fracture. Surveyor also reviewed R1's care plan. Prior to the incident, R1's care plan contained an intervention, dated 9/19/25, that indicated R1 required the assistance of 2 staff and a Portable Assisted Lift (PAL) or EZ stand for all transfers. After the incident was reported to Director of Nursing (DON)-B and it was discovered that agency CNA-C did not follow R1's care plan, the facility began an investigation and suspended CNA-C from resident care. Staff interviews indicated the following:~ CNA-C was told in shift report that R1 was weaker and required the assistance of 2 staff for all transfers.~ CNA-C transferred R1 to the bathroom on 9/25/25 with the assistance of 2 staff. When CNA-C then attempted to transfer R1 to R1's chair, R1 started to slide out of the sit-to-stand lift. R1 was hanging in the lift when CNA-C went to get assistance. R1 was lowered to the floor and staff used a Hoyer lift (full body mechanical lift) to assist R1 back to bed.~ R1 indicated to DON-B that 2 staff assisted R1 to the bathroom, however, only CNA-C returned when R1 was finished. CNA-C stated CNA-C could not find another staff and was going to transfer R1 alone. R1 stated that CNA-C needed a second person. When CNA-C again stated that CNA-C could not find another staff, R1 agreed to the transfer but stated it was not going to end well. During the transfer, R1's leg gave out and R1 started to slide. R1 was hanging in the lift when CNA-C left to get help. R1 wanted to go to the hospital due to poor ROM and pain, however, agency RN-D stated RN-D did not know how to do the paperwork. Approximately 2 hours later, a night shift nurse arrived and sent R1 to the ER for an X-ray. Upon discovering the deficient practices, the facility initiated education. CNA-C was educated verbally via phone and was not allowed to return to the facility.On 9/26/25, RN-D was provided with 1:1 education regarding where to find forms to transfer a resident to the hospital, how to use the after-hours physician group, abuse/neglect, critical thinking skills, resident rights, and when to fill out an incident report. The facility initiated the following 4 pieces of education:1. For All Nursing Staff: Ensuring following a resident's care plan related to transfer status. Staff can always use more staff but not less. Where to find care plans if there are questions and asking a co-worker to assist/work together as a team.2. For All Nursing Staff: Transfer training and if a resident gets weak during a transfer, try lowering them to a chair, bed, toilet, shower chair. If unable to lower them to another surface, then lower the resident to the floor.3. For Licensed Staff Only: If a resident requests to go to the ER, the nurse must contact the provider or after-hours group.4. For Licensed Staff Only: Ruling out abuse or neglect as part of a fall investigation. The unit nurse completes the fall investigation and then must determine whether the care plan was followed. If there was a care plan violation, the nurse should then contact the DON as not following a care plan may be considered abuse.On 10/27/25, Surveyor reviewed the education to ensure facility and agency staff acknowledged receipt of the education. Surveyor reviewed the facility's direct hire staff and noted the education was added to the facility's electronic training system. Over 95% of direct staff had completed the education.On 10/27/25, Surveyor requested proof of education for agency staff. DON-B provided 2 sign-in sheets for the All Staff trainings. Surveyor did not receive any signed acknowledgements for the Licensed Staff Only trainings.On 10/27/25, Surveyor requested a list of agency staff who had worked since 9/26/25 and noted only approximately 7 of 26 agency staff had signed the education regarding following a resident's care plan for transfer status.On 10/27/25 at 11:54 AM and 1:18 PM, Surveyor interviewed DON-B who indicated Licensed Staff Only training was added to the facility's electronic training system but was not provided for agency licensed staff to review and sign. DON-B indicated agency staff do not have access to the facility's electronic training system and verified RN-D was the only agency staff who saw the Licensed Staff Only training. When informed that the All Nursing Staff training signature sheets contained signatures of only a few agency staff, DON-B indicated the facility does not have a process to ensure agency staff see and sign education. DON-B indicated the education is put on a clipboard that direct staff know to check prior to their shift, however, most agency staff do not know to check the clipboard.

Based on staff interview and record review, the facility did not implement policies and procedures to prevent abuse for 1 (Certified Nursing Assistant (CNA)-C)) of 8 staff reviewed for caregiver background checks.The facility did not ensure an out-of-state background check was completed for CNA-C.Findings include: The facility's Abuse Prohibition policy, revised 4/19/21, indicates: Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff .On 10/27/25, Surveyor reviewed background check information for agency CNA-C whose first day of work at the facility was 8/26/25. CNA-C's Background Information Disclosure (BID) form was signed and dated 6/11/25. The form was completed when CNA-C began working for Agency (AG)-F and indicated CNA-C lived outside the state of Wisconsin in the previous 3 years. CNA-C's background check information did not indicate an out-of-state or national search was completed.On 10/27/25 at 11:45 AM, Surveyor interviewed Director of Nursing (DON)-B who provided Surveyor with a national search completed on 10/27/25. DON-B indicated the facility relies on the agency to ensure background checks are done correctly prior to staff working at the facility. DON-B indicated Director of Human Resources (DHR)-E handles all of the background check information.On 10/27/25 at 12:00 PM, Surveyor interviewed DHR-E who indicated DHR-E tries to keep agency staff background checks on site and tries to catch anything that looks incorrect. DHR-E verified an out-of-state background check was not provided or completed for CNA-C. DHR-E confirmed the facility should have complete background check information prior to agency staff starting at the facility.

Based on 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. This practice had potential to affect more than 4 of the 73 residents residing in the facility. The facility allowed 3 staff with gastrointestinal (GI) illness symptoms to return to work earlier than recommended per the facility's policy. Findings include: The facility's Infection Control: Surveillance of Staff Illness policy, revised 9/2024, indicates: .Employees experiencing Norovirus symptoms must remain off work for 48 hours after their last episode of vomiting and/or diarrhea. Employees that are responsible for food handling must remain off work for 48-72 hours after their last episode of vomiting and/or diarrhea .Employee is sick and is at home: .The Infection Preventionist (IP) will be responsible for contacting the employee to determine the date of onset of the illness, the first day well/symptom free, and the date that the employee returns to work. It is the responsibility of the IP to update the campus-wide employee line list. The IP will monitor the list. The facility's Prevention and Control of Viral Gastroenteritis policy, revised 3/14/25, indicates: .A suspected case of Norovirus is defined as having 3 or more loose stools above a person's norm in a 24-hour period or vomiting 2 or more times in 24 hours with no apparent cause .C. Affected staff to remain off work until 48 hours after the last episode of vomiting or diarrhea . From 5/19/25 to 5/20/25, Surveyor reviewed the facility's infection prevention and control policies, staff line lists, and outbreak reports, including a report titled J-wing/B-wing GI Outbreak March 2025. The resident and staff list included an outbreak report line list. Surveyor compared the outbreak report line list to the facility's staff line list and noted the following: ~ Certified Nursing Assistant (CNA)-E's last day worked was 3/11/25. CNA-E had a symptom onset date of 3/12/25 with emesis x 3 and diarrhea. CNA-E returned to work on 3/15/25. The staff line list did not contain a symptom resolution date or time. The J-wing/B-wing GI Outbreak March 2025 line list indicated CNA-E had a symptom resolution date of 3/14/25 which was less than 48 hours before CNA-E returned to work. ~ CNA-F's last day worked was 3/11/25. CNA-F had a symptom onset date of 3/11/25 with emesis x 4 and diarrhea. CNA-F returned to work on 3/14/25. The staff line list did not contain a symptom resolution date. The J-wing/B-wing GI Outbreak March 2025 line list indicated CNA-F had a symptom resolution date of 3/13/25 which was less than 48 hours before CNA-F returned to work. ~ [NAME] (PTR)-G's last day worked was 3/15/25. PTR-G had a symptom onset date 3/17/25 with emesis and diarrhea. PTR-G returned to work on 3/19/25. The staff line list did not contain a symptom resolution date. The J-wing/B-wing GI Outbreak March 2025 line list indicated PTR-G had a symptom resolution date of 3/19/25 which was the same day PTR-G returned to work. On 5/19/25 at 1:43 PM, Surveyor interviewed Infection Preventionist (IP)-D who verified staff symptom resolution dates were not on the staff line list from February 2025 to May 2025. IP-D stated IP-D will add symptom resolution dates to the staff line list in the future. On 5/20/25 at 3:30 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated IP-D discussed implementing symptom resolution dates on the staff line list with DON-B on 5/19/25. DON-B verified 3 staff on the line list with GI illness symptoms returned to work during a GI outbreak prior to being symptom free for 48 hours.

Based on observation, staff interview, and record review, the facility did not consult with a physician when there was a change in condition or a need to alter treatment for 1 resident (R) (R61) of 1 sampled resident. R61 was assessed on 5/12/25 and noted to have a 5 pound weight gain and bilateral pitting edema. The physician ordered compression stockings. R61 did not have compression stockings as of 5/21/25. The physician was not notified of the delay in treatment. Findings include: The facility's Resident Change of Condition policy, dated 12/20/24, indicates: .The licensed nurse will notify the resident's primary care physician or the doctor on call in a timely manner when there has been: .4. A significant change in the resident's physical/emotional/mental condition. 5. A need to significantly alter the resident's medical treatment . On 5/19/25 at 9:44 AM, Surveyor observed R61 in a wheelchair with Tubigrips on both lower extremities. On 5/20/25, Surveyor reviewed R61's medical record. R61 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, hemiplegia, hemiparesis, and hypertension. R61's Minimum Data Set (MDS) assessment, dated 5/1/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R61 had moderate cognitive impairment. R61 had an activated Power of Attorney for Healthcare (POAHC). R61's medical record contained a physician order to monitor weights per facility policy and update as needed (PRN) if R61 had a 3 pound or more weight loss or gain overnight or a 5 pound or more weight loss or gain in 1 week. One time a day every Tuesday morning. On 5/12/25, a nurse notified the physician that R61 had a 5 pound weight gain and bilateral edema. The physician ordered: bilateral knee-high mild (15-20 milligrams per mercury (mmHg)) compression stockings. Measure for appropriate size. Place stockings on in morning and off at hour of sleep for dependent edema. A Registered Dietitian note, dated 5/20/25, indicated R61's weight was 141 pounds on 5/20/25. R61 had a significant weight gain at 30 days of 6% or 8 pounds, at 90 days of 9.3% or 12 pounds, and at 180 days of 11.9% or 15 pounds with edema noted. On 5/21/25 at 9:49 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated R61 had 2+ pitting edema (moderate swelling where pressing on the skin leaves a slight indentation that takes less than 15 seconds to disappear) to both lower extremities and a physician order for bilateral compression stockings. LPN-C indicated the facility ordered the compression stockings from the pharmacy on 5/12/25 and was notified on 5/14/25 that the compression stockings were on back order. LPN-C could not provide communication with the physician regarding the delay in R61's treatment. LPN-C indicated staff initiated Tubigrips to R61's lower extremities on 5/19/25 without a physician's order. LPN-C indicated nursing staff should have updated the physician that the compression stockings were on back order. LPN-C indicated compression stockings were added to the Certified Nursing Assistant (CNA) care card but not R61's care plan. On 5/21/25 at 9:57 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should have notified the physician if compression stockings were unavailable. DON-B indicated staff should not alter the treatment plan without an order from the physician.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R36) of 5 sampled residents suspected of having a mental illness and/or intellectual/developmental disability was screened through the Pre-Admission Screen and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required. The facility did not follow-up appropriately to ensure completion of a PASRR Level II Screen for R36 and did not follow a Qualified Mental Health Professional's (QMHP) request to resubmit for a PASRR Level II Screen if R36 remained in the facility. Findings include: From 5/19/25 to 5/21/25, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, depressive disorder, schizophrenia, auditory hallucinations, and schizoaffective disorder. R36's Minimum Data Set (MDS) assessment, dated 3/27/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R36 had intact cognition. The MDS also indicated R36 was dependent on staff for toileting and required substantial/maximal assistance with dressing, hygiene, and transfers. R36 did not have an activated Power of Attorney for Healthcare (POAHC). On 5/21/25 at 11:27 AM, Surveyor reviewed a PASRR Level II determination document signed by a QMHP representative on 5/7/25. The document indicated R36 was referred to Behavioral Consulting Services (BCS) due to depression, schizophrenia, and schizoaffective disorder. Multiple requests to obtain additional information regarding the date of onset, symptoms, and previous treatment were attempted with no response. The QMHP canceled the PASRR Level II Screen due to an inability to reach the facility and indicated not enough information was obtained to make the PASRR determination. On 5/21/25 at 12:21 PM, Surveyor interviewed Director of Life Enrichment (DLE)-H who indicated DLE-H thought the facility's Social Worker canceled and did not pursue resubmission for another PASRR Level II Screen. DLE-H indicated that was an error on the facility's part. DLE-H stated submission for a new PASRR Level II Screen was completed that day (5/21/25).

Based on staff interview and record review, the facility did not ensure thorough assessments were completed post-fall for 2 residents (R) (R1 and R2) of 3 sampled residents. Staff did not consistently complete vital signs per the facility's policy following R1's fall on 9/5/24. Staff did not consistently complete vital signs per the facility's policy following R2's fall on 7/19/24. Findings include: The facility's Neurological Assessment policy, with a review date of 3/2022, indicates: Vital signs every shift for 24 hours post fall . 1. On 9/30/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. R1's Minimum Data Set (MDS) assessment, dated 7/25/24, indicated R1 was rarely/never understood. R1's medical record indicated R1's Power of Attorney for Healthcare (POAHC) was responsible for R1's healthcare decisions. R1's medical record indicated R1 had an unwitnessed fall on 9/5/24. Surveyor reviewed a neurological review document for R1, dated 9/6/24. At the top of the document the instructions stated, Document vital signs in (named electronic medical record system) every shift for 24 hours post fall. No vital signs were written on the form. A Fall Review for R1, dated 9/5/24, indicated R1's vital signs after the fall were: Blood pressure (BP) 134/64, Pulse (P) 74, Respirations (R) 18, Temperature (T) 97.7 and Oxygen Saturation (O2 Sat) 94%. R1's medical record contained no documented vital signs after 7/21/24. On 9/30/24 at 11:27 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who verified R1's medical record did not contain vital signs after 7/21/24 and only contained one set of vitals signs on the 9/5/24 Fall Review. When asked how staff knew the facility's policy to obtain vital signs every shift for 24 hours post fall, ADON-C indicated fall packets with a checklist were available. On 9/30/24 at 12:03 PM, Surveyor interviewed ADON-C who provided Surveyor with 24 hour report sheets that contained vital signs for R1. ADON-C verified the 24 hour report sheets were not part of R1's medical record. ADON-C indicated R1 fell at approximately 6:30 PM on 9/5/24. Surveyor noted the 24 hour report sheets contained one set of vital signs for the 9/5/24 PM shift that were different from the set of vital signs listed on R1's Fall Review. There were no vital signs documented for the 9/6/24 night (NOC) shift. One set of vital signs was documented for the 9/6/24 AM shift. No vital signs were documented for the 9/6/24 PM shift. On 9/30/24 at 12:45 PM, Surveyor interviewed ADON-C who indicated R1's ER report contained a set of vital signs. ADON-C indicated R1's physician saw R1 on 9/6/24 and R1's vital signs were listed in the physician notes. ADON-C was unsure of the time of the physician's visit. R1's medical record indicated R1 returned to the facility on [DATE] at 11:55 PM. A hospital ER summary, dated 9/5/24, contained one set of vital signs. R1's physician notes, dated 9/6/24, contained the same vital signs documented on the 24 hour report sheet for the 9/6/24 AM shift. On 9/30/24 at 1:18 PM, Surveyor interviewed Medical Doctor (MD)-D who indicated MD-D asked staff to add residents to a rounding list whenever an ER visit occurred. MD-D indicated MD-D asked staff to add R1 to a rounding list on 9/6/24 at 8:10 AM. MD-D indicated MD-C would have seen R1 within a couple of hours of that time. 2. On 9/30/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. R2's MDS assessment, dated 8/22/24, stated R2's Brief Interview for Mental Status (BIMS) score was 6 out of 15 which indicated R2 had severe cognitive impairment. R2's medical record indicated R2's POAHC was responsible for R2's healthcare decisions. R2's medical record indicated R2 had an unwitnessed fall on 7/19/24. Surveyor reviewed a neurological review document for R2, dated 7/19/24. At the top of the document the instructions stated, Document vital signs in (named electronic medical record system) every shift for 24 hours post fall. No vital signs were written on the form. A Fall Review for R2, dated 7/19/24, indicated R2's vital signs after the fall were: BP 146/62, P 71, R 18, T 98.2 and O2 sat 95%. R2's medical record contained the following documented vital signs: ~ 7/19/24 at 5:52 AM (same vital signs as R2's Fall Review listed above) ~ 7/19/24 at 1:45 PM (first shift post fall) R2's medical record contained no further documented vital signs until 7/22/24 at 9:51 AM. On 9/30/24 at 11:27 AM, Surveyor interviewed ADON-C who verified R2's medical record did not contain vital signs for the second and third shifts post-fall on 7/19/24. When asked how staff knew the facility's policy to obtain vital signs every shift for 24 hours post-fall, ADON-C indicated fall packets with a checklist were available. On 9/30/24 at 12:03 PM, Surveyor interviewed ADON-C who provided Surveyor with 24 hour report sheets that contained vital signs for R2. ADON-C verified the 24 hour report sheets were not part of R2's medical record. Surveyor noted the 24 hour report sheets for R2 indicated R2 fell at 4:30 AM on 7/19/24. One set of vital signs was documented for the 7/19/24 AM shift. No vital signs were documented for the 7/19/24 PM shift or the 7/20/24 NOC shift. On 9/30/24 at 12:21 PM, Surveyor interviewed ADON-C who verified R1 and R2's medical records should contain a set of vital signs at the time of the fall plus three more sets each shift post-fall for a full 24 hours. ADON-C verified R1 and R2 had missing vital signs.

Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure all drugs and biologicals were accurately acquired, received, dispensed, and administered for 2 residents (R) (R44 and R48) of 5 residents reviewed for medication administration. R44's medication card labels for diltiazem (a blood pressure (BP) medication), carvedilol (a BP medication) and spironolactone (a BP medication) were not updated to reflect the orders in R44's Medication Administration Record (MAR). During an observation of medication administration on 4/16/24, staff crushed R48's potassium chloride extended release (ER) medication. Findings include: The facility's Oral Medications policy, dated 3/2018, indicates: Procedure: 1) Read the specific instructions that come with the prescription or the medication, e.g. give with food, rush the medication, etc The facility's Crushed Medication policy, updated 7/2023, indicates: Licensed nursing staff and medication technicians to assure that medications shall be crushed in accordance with standards of practice for safety and accuracy in medication administration taking into consideration the resident's preferences. Procedure: 5) Medications that typically should not be crushed include, but are not limited to: .c. Sustained-release or extended-release medications. 1. From 4/15/24 through 4/17/24, Surveyor reviewed R44's medical record. R44 was admitted to the facility with diagnoses including hypertensive chronic kidney disease (chronic high blood pressure causing kidney damage), Parkinson's disease, and bradycardia (slow heart rate). R44's Minimum Data Set (MDS) assessment, dated 2/15/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R44 had intact cognition. On 4/16/24 at 8:25 AM, Surveyor observed Licensed Practical Nurse (LPN)-F administer R44's AM medications from pharmacy cards that contained the following orders: ~Diltiazem 24 hour ER 240 milligrams (mg) hold if systolic blood pressure (SBP) (measures the force the heart exerts on the walls of the arteries each time it beats) <90. ~Spironolactone 25 mg hold if SBP <90 ~Carvedilol 3.125 mg hold if SBP <90. On 4/16/24 at 8:32 AM, Surveyor asked LPN-F if LPN-F obtained R44's BP prior to administering R44's AM medication. LPN-F indicated LPN-F did not obtain R44's BP. When Surveyor asked if R44's BP should have been obtained prior to administering diltiazem, spironolactone and carvedilol, LPN-F indicated LPN-F did not realize the medication cards contained directions to hold the medications if R44's SBP was < 90. LPN-F reviewed the medication cards with Surveyor and confirmed the cards contained BP parameters. LPN-F indicated LPN-F thought R44 was removed from BP monitoring and stated LPN-F would clarify with LPN-F's supervisor (LPN-D). On 4/16/24 at 8:35 AM, Surveyor interviewed LPN-D who indicated R44's BP parameters were initiated in October 2023, however, R44's provider was updated in January 2024 and changed the order to weekly BP/update provider with any issues. LPN-D stated the order was faxed to pharmacy to discontinue R44's BP parameters. LPN-D indicated the pharmacy did not update R44's diltiazem, spironolactone, and carvedilol medication cards. Surveyor requested a copy of the fax which was not provided. On 4/16/24 at 9:23 AM, Surveyor interviewed Consultant Pharmacist (CP)-G via phone regarding BP parameters for R44's diltiazem, spironolactone, and carvedilol. CP-G indicated if a medication card contains BP parameters, CP-G expects staff to check a resident's BP prior to administration of the medication. CP-G confirmed R44's diltiazem, spironolactone, and carvedilol medication cards contained BP parameters. CP-G verified the pharmacy did not remove R44's BP parameters because the pharmacy did not receive an order to discontinue the BP parameters. CP-G indicated the pharmacy's medication cards reflect the most current order, therefore, directions on the cards should be followed. CP-G stated if the order on a card is not current, the facility should contact the pharmacy and clarify the order. CP-G stated if R44's BP parameters were discontinued in January, the facility should have updated the pharmacy. CP-G confirmed the pharmacy did not receive a fax from the facility to discontinue R44's BP parameters. On 4/16/24 at 9:37 AM, Surveyor reviewed R44's medical record and noted a progress note, dated 1/12/24, that indicated: ~Order Note: Fax sent with request to decrease BP monitoring. Provider response: Thanks for update BPs are variable, but overall acceptably controlled, as are heart rates (HR). No reported symptoms related to BP/HR or meds. Check BP/HR once weekly per unit routine and update PRN (as needed) concerns. On 4/16/24 at 9:44 AM, Surveyor reviewed R44's physician orders and noted the following: ~Carvedilol oral tablet, give 3.125 mg by mouth in the morning for hypertension and give 6.25 mg by mouth at bedtime for hypertension ~Diltiazem HCl ER oral capsule 24 hour, give 240 mg by mouth in the morning for hypertension ~Spironolactone oral tablet, give 25 mg by mouth in the morning for hypertension 2. From 4/15/24 through 4/17/24, Surveyor reviewed R48's medical record. R48 was admitted to the facility with diagnoses including Parkinsonism, hypokalemia (low potassium), and dementia. R48's MDS assessment, dated 3/17/24, contained a BIMS score of 14 out of 15 which indicated R48 had intact cognition. On 4/16/24 at 8:12 AM, Surveyor observed LPN-F prepare R48's AM medications which included potassium chloride ER 20 milliequivalents (mEq). LPN-F crushed the potassium chloride ER with R48's other medications, except fluoxetine (an antidepressant medication). On 4/16/24 at 8:14 AM, Surveyor asked LPN-F to clarify which medications were crushed prior to administration. LPN-F reviewed R48's MAR and confirmed R48's potassium chloride ER was crushed, but should not have been crushed. On 4/16/24 at 10:33 AM, Surveyor reviewed R48's physician orders and noted the following: ~Potassium chloride ER oral tablet, give 20 mEq by mouth in the morning for low potassium prevention. May be broken in half and each half swallowed separately, or dissolve in 4 ounces (oz) of water. -May crush medications unless contraindicated On 4/16/24 at 1:11 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated if a medication card does not coinicide with the order in a resident's medical record, staff should clarify the order with pharmacy. DON-B also indicated since R48's BP parameters were discontinued in January, staff should have already clarified the discrepancy with pharmacy. On 4/17/24 at 8:27 AM, Surveyor interviewed DON-B regarding the facility's policy on ER medications, including potassium chloride ER. DON-B indicated if the directions state don't crush, staff should not crush the medication.

Based on observation, staff interview, and record review, the facility did not ensure the necessary treatment and services were provided to prevent weight loss for 1 resident (R) (R17) of 5 sampled residents. R17 had a significant weight loss of 22 pounds between 10/11/23 and 4/22/24. During observations on 4/15/24 and 4/16/24, the facility did not ensure R17 received one-to-one (1:1) assistance with meals per R17's plan of care. Findings include: The facility's Resident Nutrition policy, with an effective date of 1/2017, indicates: If a resident is identified as being at risk for weight loss, has weight loss, or has an existing skin ulcer, a care plan will be implemented listing the interventions aimed at minimizing the risk. Options may include: .physical assistance with eating including cueing, partial or full assistance. Between 4/15/24 and 4/17/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and dementia. R17's Minimum Data Set (MDS) assessment, dated 1/29/24, contained a Brief Interview for Mental Status (BIMS) score of 1 out 15 which indicated R17 had severe cognitive impairment. Swallowing guidelines, completed on 12/21/22, indicated R17 required a 1:1 staff next to R17 to assist with mealtime. A quarterly nutrition assessment, completed on 10/9/23, indicated R17 had an 18 pound (lb) weight loss and required supervision at meals. A speech therapy recommendation form, completed on 1/24/24, indicated R17's liquids should be in a cup with a lid and straw. The recommendation form also indicated R17 required 1:1 assistance with feeding, loading utensils, and initiating hand-to-mouth motions. A speech therapy treatment note, completed on 2/7/24, indicated R17 was easily distracted by external distractions in the dining room and was unable to identify food items. R17's care plan, revised on 2/9/24, indicated R17 was at risk for aspiration related to not consistently wearing dentures. The care plan also indicated R17 required assist/cues, had weight loss, and was at risk for further weight loss related to severe dementia. The care plan contained interventions to assist R17 with loading utensils and initiating hand-to-mouth motions with non-dominant hand and indicated R17 did best with finger foods and a sandwich cut in quarters. An intervention, revised on 1/31/24, indicated: Swallow Guidelines: 1:1 Certified Nursing Assistant (CNA) or nursing next to R17 to assist. Small bites/sips. R17's mealtime intake is required to be monitored and recorded. A nurse must be notified if R17 consumes less than 50% of meal. R17's medical record indicated R17 had a 22 lb weight loss from 10/11/23 to 4/10/24 which was a significant weight loss of 10% over six months. R17's medical record contained the following weights: ~10/11/2023 - 220.0 lbs ~12/12/2023 - 214.0 lbs ~2/13/2024 - 208.0 lbs ~4/10/2024 - 198.0 lbs On 4/15/24 at 11:28 AM, Surveyor observed the lunch meal on R17's unit. Surveyor observed R17 at a dining table near the nurses' station with 2 other residents. Surveyor did not observe a 1:1 staff seated with R17 and noted R17 was unassisted during the meal. On 4/16/24 at 10:57 AM, Surveyor interviewed CNA-C who stated part of CNA-C's duties included providing mealtime assistance to residents. CNA-C indicated R17 required observation, encouragement, and assistance during meals. On 4/16/24 at 11:24 AM, Surveyor observed staff serve lunch to R17. R17's eating utensils were within reach, however, R17 was seated alone at the table without staff assistance or supervision for the duration of the meal. Surveyor observed 3 staff members seated at a nearby table feeding 4 residents at that table. The 3 staff members had their backs to R17. On 4/16/24 at 11:34 AM, Surveyor observed CNA-C stand up from the nearby table, walk to R17's table, and provide R17 with verbal cues and encouragement to eat. R17 took R17's first bite of lunch with a butter knife. CNA-C then walked away from R17's table and sat down at the nearby table to assist another resident. On 4/16/24 at 11:41 AM, Surveyor observed R17 attempt to take a second bite of food with a butter knife. R17 put a small amount of food in R17's mouth, however, most of the food fell off the butter knife. R17 then picked up a spoon and moved food around R17's plate. On 4/16/24 at 11:44 AM, Surveyor observed R17 attempt to take a third bite of food with a spoon. Approximately half of the mashed potatoes fell off the spoon when R17 attempted to feed R17's self. Surveyor noted R17 was unsupervised as staff at a nearby table assisted other residents and had their backs to R17. On 4/16/24 at 11:49 AM, Surveyor observed R17 remove the lid and straw from R17's cup. Surveyor observed R17 drink water directly from the cup without staff supervision. On 4/16/24 at 12:12 PM, Surveyor observed a staff sit next to R17 and ask if R17 wanted R17's food reheated. R17 declined. Staff asked if R17 was hungry and R17 indicated R17 was finished eating. When staff encouraged R17 to take another bite of food, R17 took a fourth bite. Surveyor noted R17 consumed less than 20% of the meal. On 4/17/24, Surveyor reviewed R17's meal documentation for the 4/16/24 lunch meal. The documentation indicated R17 ate 51-75% of the meal. On 4/16/24 at 10:57 AM, Surveyor interviewed Director of Nursing (DON)-B who verified if R17's care plan indicated 1:1 meal supervision and R17 should have received 1:1 assistance.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R216) of 1 sampled resident received the necessary care and treatment for respiratory therapy. R216 received respiratory therapy via oxygen concentrator and nasal cannula. R216's plan of care did not contain orders for staff to clean/change R216's equipment in accordance with the facility's policy. Findings include: The facility's Oxygen Therapy policy, dated 12/2017, indicates: Enter the following on resident's Plan of Service (POS) and Treatment Administration Record (TAR) .4) (ex) Oxygen (O2) at 1-3 liters per minute (LPM) via nasal cannula to keep O2 saturations >89%. Change O2 tubing and clean concentrator filter every 7 days. Change humidified oxygen container when empty, date container when initiated. 5) Add problem, goal, and interventions to care plan. On 4/15/24, Surveyor reviewed R216's medical record. R216 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of unspecified part of right bronchus or lung, secondary malignancy of the bone, liver and brain, and acute and chronic respiratory failure with hypoxia. R216's Minimum Data Set (MDS) assessment, dated 4/8/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R216 had intact cognition. R216's medical record indicated R216 was responsible for R216's healthcare decisions. On 4/15/24, Surveyor observed R216 who was receiving 5 LPM of O2 via nasal cannula. R216's oxygen tubing did not contain a label that indicated when the tubing was initiated or last changed. In addition, R216's medical record and care plan did not contain orders or a schedule to clean or change the equipment. On 4/17/24 at 10:49 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R216 received oxygen therapy and reviewed R216's care plan and physician orders with Surveyor. DON-B confirmed R216's care plan and TAR did not contain a cleaning or replacement schedule but should instruct staff to clean R216's oxygen tubing/filter every 7 days. On 4/17/24 at 11:17 AM, Surveyor interviewed R216 who indicated R216's oxygen tubing/filter were not changed or cleaned since R216 was admitted on [DATE].

Based on staff interview and record review, the facility did not ensure adequate monitoring of a high-risk medication for 1 resident (R) (R4) of 6 sampled residents. R4 was prescribed digoxin (used to treat atrial fibrillation (abnormal heart rhythm)). Staff indicated R4 was administered digoxin without an apical pulse taken one minute prior to administration. In addition, R4's digoxin level was not checked as indicated in R4's plan of care. Findings include: The [NAME] Drug Guide copyright 2024 indicates: Monitor apical pulse for 1 full minute before administering digoxin. Hold dose and notify health care professional if pulse rate is <60 beats per minute (bpm) in an adult, <70 bpm in a child, or <90 bpm in an infant. Notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse. The National Institutes for Health (NIH) website, dated 1/19/23, indicates: Digoxin: Important considerations during administration include: If bradycardia is present, re-evaluate and withhold treatment as necessary; Digoxin levels should be checked one week after starting the medication and regularly afterward. On 4/17/24 at 10:52 AM, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), essential hypertension (high blood pressure), and paroxysmal atrial fibrillation. R4's Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 had intact cognition. A Hospital Discharge Summary indicated R4 presented to the hospital on 2/26/24 with shortness of breath and a large pericardial effusion (buildup of extra fluid in the space around the heart). On 2/28/24, R4 underwent left-sided ultrasound-guided thoracentesis (removal of fluid) during which 550 mls (milliliters) of fluid were removed. A pericardial window procedure (a procedure that allows fluid to drain) was also performed and R4 was started on digoxin. R4's hospital digoxin laboratory level indicated in process at the time R4 was discharged on [DATE]. R4's discharge medication orders indicated R4 should start taking digoxin 125 mcg (micrograms) by mouth every morning. for atrial fibrillation and cardiac failure. R4's care plan indicated R4 took digoxin related to atrial fibrillation. The care plan contained instructions to check R4's apical pulse for one minute prior to administration, hold according to the physician-ordered parameter (i.e. <60 bpm), check R4's digoxin level as ordered, and report abnormal levels to R4's physician (date initiated: 3/15/24). On 4/17/24 at 11:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D related to digoxin and asked if R4's pulse was monitored prior to administration. LPN-D stated, We should. LPN-D reviewed R4's Hospital Discharge Summary and stated, If it is not ordered on the discharge summary, then we are not. LPN-D confirmed R4 did not have an order to check R4's digoxin level and verified R4's most recent lab draw was on 3/4/24 prior to discharge from the hospital. On 4/17/24 at 12:33 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility does not have a policy related to high-risk medication monitoring. DON-B confirmed DON-B expects staff to obtain a pulse prior to administering digoxin. On 4/17/24 at 3:35 PM, Surveyor interviewed Medical Doctor (MD)-E who indicated MD-E expects staff to alert MD-E if R4's pulse is low.

Based on observation, interview, and record review, the facility did not follow proper sanitation in accordance with professional standards for food service safety. This had the potential to affect all 67 residents. The facility did not consistently check temperatures of facility warewashing machines and failed to [MEDICATION(S)] when temperatures were below minimum wash and rinse temperatures specified for proper sanitization of dishes. Additionally, on 2/23/22, the facility identified an outbreak of Gastrointestinal Illness with the first case that began on 2/19/22. Facility failure to ensure systems were in place to ensure wash and rinse temperatures met the identified standard for properly sanitizing dishes and utensils created a finding of Immediate Jeopardy (IJ) that began on 2/19/2022. RFOD (Regional Field Operations Director) notified Nursing Home Administrator (NHA-A) of the immediate jeopardy on 3/2/22 at 12:35 PM. The immediate jeopardy was removed on 3/2/22, however the deficient practice continues at a scope/severity of F (Potential for harm/widespread) as the facility continues to implement its action plan. Findings include: On 2/28/22, during the initial kitchen tour, the facility indicated they follow the Wisconsin State Food Code as their kitchen's operational standards of practice. Wisconsin State Food Code defines a highly susceptible population as: persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining FOOD at a facility that provides services such as custodial care as, .hospital or nursing home. Wisconsin State Food Code Code states: ~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. ~At 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (2) For a stationary rack, dual temperature machine, 150 degrees F; (3) For a single tank, conveyor, dual temperature machine, (160 degrees F); ~At 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 degrees F, or less than: (2) For all other machines, 180 degrees F. 4-703.11 Hot Water and Chemical (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under 4-501.15, 4-501.112, and 4-501.113 and achieving a utensil surface temperature 160 degrees F as measured by an irreversible registering temperature indicator. The United States Food and Drug Administration (FDA) Food code at 4-703.11 further explains the reason why it is important for mechanical dishwashers to reach proper temperatures: If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Pressures below the specified limit will result in incomplete coverage of the heat-conveying sanitizing rinse across utensil surfaces. On 2/23/22, the facility identified a gastrointestinal (GI) outbreak (an illness characterized by nausea, vomiting, and/or diarrhea (runny stool)) within the facility on Unit E. Once a facility identifies an outbreak of GI Illness, the facility initiates increased measures for mitigating the spread of illness. Related mitigation measures include: not serving the food to residents from the unit kitchenettes and sending all unit dishes back to the main kitchen for the affected units. On 2/23/22, the facility reported the outbreak on Unit E to public health. County public health guidance included submitting three stool samples to the state lab for testing for Norovirus (another highly contagious gastrointestinal illness), which came back negative. On 2/28/22, after Unit F had a case, the facility sent in two stool samples to the local hospital after to determine what gastrointestinal illness was present in the facility. These two stool samples came back positive for Rotavirus. Centers for Disease Control (CDC) indicates the following information about Rotavirus: Rotavirus disease is characterized by vomiting and watery diarrhea for three to eight days. Fever and abdominal pain also are common. Additional symptoms include loss of appetite and dehydration. Symptoms of dehydration include: decreased urination; dry mouth and throat; feeling dizzy when standing up; crying with few or no tears and unusual sleepiness or fussiness. The incubation period for rotavirus disease is approximately two days. The primary mode of transmission is the fecal (stool or poop)-oral route, usually through direct contact between people. Because the virus is stable in the environment, transmission also can occur through ingestion of contaminated water or food and contact with contaminated surfaces or objects. In the United States and other countries with a temperate climate, the disease has a winter and spring seasonal pattern, with annual epidemics occurring from January through June. Transmission of rotavirus can happen if one: -puts your unwashed hands that are contaminated with stool into your mouth -touch contaminated objects or surfaces and then put your fingers in your mouth -eat contaminated food People who are infected with rotavirus shed the virus in their stool. This is how the virus gets into the environment and can infect other people. People shed rotavirus the most, and are more likely to infect others, both when they have symptoms and during the first three days after they recover. People with rotavirus can also infect others before they have symptoms. The American Journal for Infection Control article titled SHEA (Society for Healthcare Epidemiology of America)/APIC (Association for Professionals in Infection Control and Epidemiology) Guideline: Infection Prevention and Control in the Long Term Care Facility, July 2008 indicates: Other infections: [CONDITION(S)] gastroenteritis (caused by rotavirus, enteroviruses, or noroviruses), . are well-known causes of diarrhea outbreaks in Long Term Care Facilities. The elderly are at increased risk of infectious gastroenteritis due to age-related decrease in gastric acid. In a population with a high prevalence of incontinence, the risk of cross infection is substantial. Person-to-person spread, particularly due to shared bathroom, dining, and rehabilitation facilities, plays a role in [CONDITION(S)] gastroenteritis . Foodborne disease outbreaks also are very common in this setting, . underscoring the importance of proper food preparation and storage. On 3/1/22, Surveyor reviewed the facilities line list (a tracking tool used in infection control practices to track resident names, locations, symptom onset date, what the symptoms were, and when symptoms resolved. Facilities keep logs for both residents and staff.). The following is a summary of the line list as well as when units went on outbreak status and timing of kitchen practices as of 3/2/22. 2/19/22 - 1 Case: Unit E (This case was traced back to a visitor of a resident). 2/22/22 - 1 Case: Unit E 2/23/22 - 5 Cases: Unit E 2/23/22 - Unit E meets criteria for outbreak status: Unit E goes on restrictions, Unit E's dishes are moved to main dishwasher. 2/26/22 - 3 Cases: Unit E 2/27/22 -1 Case: Unit G (this case was also traced back to a visitor of a resident). 2/27/22 - Unit G goes on Restrictions; Unit G's dishes are moved to main dishwasher. 2/27/22 - 2 Cases: Unit E 2/28/22 - 3 Cases Unit G 3/1/22 - 2 Cases on Unit F - Unit F goes on restrictions. Unit E Total in outbreak - 12/36 Residents (1st case 2/19/22) Unit G Total in outbreak - 4/18 Residents on 2nd floor (1st case 2/27/22) Unit F Total in outbreak - 2/14 Residents (1st case 3/2/22) On 3/2/22 at 10:29 AM, Infection Preventionist (IP-I) indicated this dietary employee last worked on 2/23/22 in the main kitchen dishwashing area. This was confirmed in interview on 3/2/22 at 11:00 AM with DM-C. At this time IP-I also indicated that a Resident (R58) had gone to the hospital on 2/28/22 due to coffee ground emesis (vomiting) and fever. On 3/2/22, Surveyor reviewed R58's EHR and hospital return note. R58 was placed on isolation on 2/26/22 due to an episode of diarrhea. R58 returned from the hospital on 3/2/22 and R58's discharge summary noted: 1. Diarrhea / vomiting; Had no episodes of vomiting or diarrhea while admitted . Stool studies done and was positive for rotavirus. 2. AKI (Acute Kidney Injury): on admission creatinine was 1.35 likely related to dehydration from vomiting / diarrhea. He was started on IVF (Intravenous Fluids - a method used to increase hydration) and his AKI resolved. 3. CAP (Community Acquired Pneumonia): Right lower lung pneumonia seen on CT (Computed Tomography) scan and procalcitonin was positive (a level that can indicate an infection). Was started on [MEDICATION(S)] and [MEDICATION(S)] (Antibiotics that can fight infection). Completed the full course of [MEDICATION(S)]. Will be discharged on [MEDICATION(S)]. 4. [CONDITION(S)] (low iron) with positive occult stool (likely has bleeding somewhere in the GI tract); Stool check for occult blood and was positive. General surgery consult was not able to be done during visit. Referral for outpatient general surgery consult. Will continue to hold aspirin and will continue on [MEDICATION(S)]. 5. [CONDITION(S)] (low potassium): Potassium 4.1 on admit and trended down to 3.0. He was given oral potassium supplement. Will need recheck in 3 days. On 2/28/22 at 8:38 AM, the initial kitchen tour began with Assistant Dietary Manager (ADM)-D. During this tour, Surveyor reviewed temperature logs for the coolers and noted a few temperatures missing for the month of February, though all other temperatures taken for the kitchen coolers were within range. At this time, Surveyor requested all temperature logs for both kitchen and unit refrigerator and dishwasher monitoring. On 3/1/22 at 8:51 AM, Dietary Manager (DM-C) provided Surveyor with copies of February 2022 temperature logs that included the unit dishwasher temperature logs. DM-C indicated the facility does not have a policy or procedure for dishwasher temperature logs. The expectation is that the staff complete temperatures 2 times per day. DM-C indicated that blank areas on the logs are where staff did not complete the temperature or missed doing it. DM-C then explained the dishwashing process in the facility. There is a dishwasher in the kitchen (main dishwasher) which, in non-outbreak status, washes the pots and pans. Furthermore, each of the facility's units (3 at the time of this survey) has an undercounter dishwasher (Unit E, Unit F, Unit G). These 3 dishwashers do all of the dishes the residents use for each meal (plates, silverware, cups, trays, etc.). Facility food service process in non-outbreak status is that the main kitchen sends bulk food to each unit kitchenette. Kitchen staff then serve the meals from the kitchenettes, do the dishes in the undercounter dishwashers, and put the clean dishes away in each kitchenette. However, when a unit goes on outbreak status, the meals are served from the kitchen and all unit dishes come back to be done using the main dishwasher. This is an extra mitigation measure to decrease the spread as it eliminates the number of staff moving between the units and the facility kitchen. On 3/1/22 during this same interview, DM-C indicated that the facility does not regularly check the internal temperature or surface temperature with an irreversible thermometer when doing dishes in the unit dishwashers. DM-C indicated, one of the kitchen staff may do this on own, but it would not be documented and it would not be consistent. DM-C indicated staff use the gauges on the front of the machine to log the temperatures. On 3/1/22 at 2:33 PM, Surveyor was interviewing DM-C and requested a copy of the February 2022 main dishwasher temperature log since it was not provided earlier in the day. Surveyor briefly reviewed the log at this time and noted several low temperatures. Surveyor pointed out several missed temperatures and low temperatures. DM-C indicated the logs state on the bottom that any temperatures outside the range, staff should contact a manager who would then contact maintenance or the contracted company that maintains the dishwashers. DM-C indicated DM-C would look through email as DM-C was just returning from vacation to see if there were any reports of any low wash or rinse temperatures in any of the dishwashers. On 3/1/22 at 3:00 PM, Surveyor reviewed more closely the dishwasher temperature logs and noted some of the missing days and low temps had coincided with the facilities current GI outbreak. The facilities log is titled, Dish Machine Log, and indicates on the bottom: Report rinse temps below 180F and wash temps below 160F (150F on undercounter machines). Please also report temps above 194. Dish logs for the Main Kitchen for February 2022 show the following: MAIN KITCHEN February 2022 Temperature Log -8/56 opportunities for temperatures were missing -8/48 wash temperatures that were taken were low -18/48 rinse temperatures that were taken were low (NOTE: If there is no comment about a temperature, that means the in-range temperature was listed on the log). 2/1 - PM Low rinse: 167 2/2 - AM low rinse: 170; PM Low wash: 161 and low rinse 163 2/3 - PM low rinse: 172 2/4 - AM low rinse: 160 2/5 - AM low rinse: 157; PM low rinse: 171 2/6 - AM low rinse: 162 / PM low wash: 158 and low rinse: 172 2/7 - AM MISSING / PM: low rinse 155 and low wash: 159 2/8 - AM Missing / PM low rinse 161 2/9 - PM Missing 2/10 - AM Missing / PM low rinse: 150 2/16 - AM Missing / PM low wash: 159 and low rinse: 172 2/17 - PM Missing 2/19 - NO TEMPS AT ALL (FIRST GI CASE Unit E) 2/20 - AM low wash: 150 2/21 - AM low wash: 152 and low rinse: 153 / PM low wash: 159 and low rinse 159 2/22 - PM low rinse: 167 2/23 - PM low rinse: 152 (Unit E goes on restrictions, unit dishes start to come back to main kitchen). *Dishwasher who began symptoms on 2/24 was last working in main kitchen dishwasher area on this date. 2/24 - PM Missing 2/25 - PM low wash: 156 and low rinse 155 2/26 - (3 more cases on Unit E) 2/27 - Unit G goes on restrictions 2/28 - PM Missing 3/1 - 2 Cases on Unit F 3/2 - Unit F on restrictions, unit F dishes start coming back to main kitchen) UNIT E February 2022 Dishwasher Temperature Log -26/46 opportunities for temperatures were missing -2/20 wash temperatures that were taken were low -1/20 rinse temperatures that were taken were high 2/1 - 2/4 MISSING ALL 2/5 - PM Missing 2/7 - PM Missing 2/8 - PM Missing 2/10 - PM Missing 2/12 - 2/14 - MISSING ALL 2/15 - PM Missing 2/16 - PM Missing 2/17 - PM low wash: 148 and high rinse: 197 2/18 - PM low wash: 145 2/19 - PM Missing (First case on Unit E) 2/20 - PM Missing 2/21 - PM Missing 2/22 - PM Missing 2/23 - PM Missing (5 additional cases on Unit E) 2/24 - 2/28 - Dishwasher not being used due to Unit E on restrictions and all dishes going back to the kitchen. Unit F February 2022 Dishwasher Temperature Log -29/56 opportunities for temperatures were missing -5/27 rinse temperatures that were taken were low 2/1 - 2/4 MISSING ALL 2/5 - Missing PM 2/8 - Missing PM 2/10 - Missing PM 2/12 - 2/14 - Missing ALL 2/15 - Missing PM 2/16 - Missing PM 2/17 - PM - low rinse: 155 2/18 - Missing AM 2/19 - 2/24 Missing PM 2/24 - AM low rinse: 156 2/25 - AM low rinse: 155 2/26 - PM low rinse: 155 2/27 - PM low rinse: 149 3/2 - Dishwasher not being used to to Unit F on restrictions and all dishes going back to the kitchen Unit G February 2022 Dishwasher Temperature Log -27/54 opportunities for temperatures were missing -2/27 rinse temperatures that were taken were low 2/1 - 2/4 MISSING ALL 2/5 - PM Missing 2/7 - PM Missing 2/8 - PM Missing 2/10 - PM Missing 2/11 - PM low wash: 155 2/12 - 2/14 MISSING ALL 2/15 - PM Missing 2/16 - PM Missing 2/18 - AM Missing 2/19 - 2/24 - PM Missing 2/25 - AM low rinse: 158 2/27 - 1st case - unit on restrictions 2/28 - NOT USING (due to outbreak) On 3/2/22 at 11:30 AM, Surveyor interviewed Service Technician (ST-J) who works for the facility's contracted company to repair and maintain the dishwashers. ST-J indicated that prior to Covid-19, ST-J would come to the facility every 4-6 weeks to check the dishwashers. Since the restrictions were implemented due to Covid, ST-J indicates ST-J comes as needed. ST-J indicated ST-J was just there on Monday 2/28/22 due to ADM-D contacting ST-J for the main kitchen dishwasher not maintaining temperature. ST-J indicated the dishwasher was taking longer than normal for the wash temperature to recover. ST-J explained one rack would go through and it would start out hot, but then it would lose temperature. If staff were doing multiple racks in a row, the wash cycle wouldn't reach the proper temperature. If racks were spaced out, the wash temperature met the required temperature, it was just taking a long time to recover the hot water for the next rack. ST-J indicated after this repair, the dishwasher was reaching temp as quickly as it should. ST-J also provided Surveyor with dates and work orders when the other dishwashers in the facility were last serviced: Unit E Dishwasher- Last serviced in September of 2021. Unit F Dishwasher - Last serviced on 9/20/21 Unit G Dishwasher - Last serviced on 9/20/21 During this interview, ST-J also indicated that the undercounter dishwasher temperatures should be checked after the machine is running for 10-15 seconds (the entire wash cycle is approximately 90 seconds). DM-C indicated the temperature on the digital gauge on the front of the dishwasher will generally fluctuate a bit. In this same interview, DM-C was unsure what temperature the staff were actually using to put on the dishwasher temperature logs (either the initial temperature as soon as it shows up or waiting the 10-15 seconds). On 3/2/22 during the 11:30 AM interview, ST-J also indicated that in ST-J's training, ST-J would use the dishwasher gauges to test the temperature. At this time, the facility provided Surveyor with the manufacturer books for both the main kitchen dishwasher and the undercounter dishwashers. On 3/2/22 at 2:00 PM, Surveyor reviewed the manuals provided and noted that the facility uses model CMA - 180UC as their undercounter dishwashers on Unit E, Unit F, and Unit G. Surveyor noted a 1 page instruction on proper operation of the undercounter dishwashers. This document indicated: 1. Turn on power and machine will be automatically filled to correct level. 2. Start machine by pushing start button. CAUTION: Do not start until wash temperature reads 150 On 3/2/22 at 2:30 PM, Surveyor asked DM-C if this one page instruction was posted near the unit dishwasher machines for staff to follow. DM-C was not aware of this instruction page. On 3/2/22 at 1:08 PM, Surveyor called DW-H and inquired about the low temperature on the dishwasher on 2/28/22 and the subsequent call to ST-J for repair. DW-H indicated that DW-H did note about 8:30 or so that the dishwasher was not holding temperature. DW-H indicated DW-H does pay attention frequently to the temperatures and watches the gauges. DW-H reported this to ADM-D and ST-J arrived later in the morning to look at the dishwasher. DW-H indicated DW-H continued to do dishes using this dishwasher, though DW-H did them more slowly. DW-H used the irreversible temperature gauge to check internal surface temperatures and then watched the gauges on the machine. DW-H indicated it was taking longer for the dishwasher to get back up to the proper start temperature and DW-H watched the gauge that indicated the dishwasher was at temp. DW-H indicated the dishwasher would click and DW-H verified this with the irreversible thermometer. DW-H indicated DW-H did dishes in the dishwasher (though DW-H was behind because DW-H had to wait longer between loads). On 3/2/22 at 12:42 PM, Surveyor inquired about follow up or who is looking at logs to make sure they are filled out completely. DM-C indicated that as the day staff leave, they are supposed to check the logs to ensure they were filled out for their shift and the closing managers at the end of the day are supposed to ensure the logs are filled out as well. DM-C indicated this has been a longstanding practice and staff would be reeducated on this. On 3/1/22 at 4:20 PM, Surveyor interviewed NHA-A who indicated that NHA-A had gone over the logs with DM-C and had noted that many of the low not-reported temperatures were from newer staff and education had already begun for their staff. On 3/2/22 at 7:55 AM, NHA-A indicated the facility began education last night (3/1/22) on the importance of checking temperatures, how to temp the dishwashers, and reporting of temperatures outside the range. Facility failure to ensure systems were in place to ensure wash and rinse temperatures met the identified standard for properly sanitizing dishes and utensils created a finding of immediate jeopardy. The Immediate Jeopardy was removed on 3/2/22 when the facility implemented the following: * Dish machine temp log was updated on 3/1/2022 to specify who to report any temperature issues to. Log was also updated to include space for manager/maintenance to document action of temperature issue. * Temperatures were accurate for 2/26, 2/27, 2/28, 3/1 and forward on main dish machine in kitchen. * Staff that documented out of range temps and did not inform food service manager or maintenance, will be educated prior to working their next shift. * All Food and Beverage staff immediately trained on the dish machine temperature policy and procedure regarding all dish machines (main kitchen and unit dishwashers). Contents of training (how to read temp gauges, when to read temp gauges and what to do if out of range,) will be verified via return demonstration by each staff member prior to working their next shift. * On 3/2/2022, facility reviewed policy and procedure on dishwasher temperatures with Medical Director - including training on how to read gauges, when to read gauges, and what to do if out of range. Policy and procedure will be reviewed at QAPI meeting on 3/2/2022. * Food and Beverage managers will conduct audits twice daily for 2 weeks, daily for 8 weeks and then weekly for 3 months to ensure components are in place. Results of the audits will be reviewed at the QAPI meeting for further recommendations. Facility assessment will be updated related to the dish machine requirements and functionality.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R67) of 1 resident reviewed for a reportable investigation was reported to the State Agency (SA) as required. Additionally, the facility did not ensure 1 supplemental resident (R318) of 1 reviewed for investigations not reported to the SA was properly reported. R67 sustained a fall on 2/7/22 when Certified Nursing Assistant (CNA)-L did not follow R67's plan of care which resulted in a fracture. R318's wedding ring was reported missing to the facility on [DATE] and the facility did not report to the SA. Findings include: The facility's policy entitled, Abuse Prohibition Identification, Reporting & Response, Protection, Investigation, with a revised date of December 2019 states, To ensure that all residents are free from verbal, physical, sexual and mental abuse, corporal punishment, involuntary seclusion, misappropriation of funds or client's property, exploitation, and neglect. E. Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. G. Neglect: The failure of the facility, its employees or service providers to provide goods, and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Facility Reporting Requirements according to DQA: Per CMS direction, all nursing homes must immediately report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property to the facility administrator and to the Division of Quality Assurance (DQA). 1. On 2/28/22, Surveyor reviewed R67's medical record. Documentation included: ~Nursing note dated 2/7/22 4:29 PM Approximately 1600 CNA was toileting resident with PAL lift. (a portable mechanical lift used to assist residents with standing and transferring) .Resident started to slide out of sling so CNA lowered resident to floor. Resident bumped head on wall .c/o (complained of) pain to left side of neck and left shoulder. Surveyor requested further information from Nursing Home Administrator (NHA)-B regarding R67's fall on 2/7/22. NHA-B provided Surveyor with a full investigation that was completed for R67's fall. The documentation stated CNA-L answered the bathroom call light for R67 who needed assistance off the toilet. CNA-L stood R67 up off of the toilet using the PAL lift to clean R67. R67 started slipping down in the sling and stated R67 needed to sit back down on the toilet but R67's legs gave out and R67 slipped completely out of the sling and onto the floor. R67 hit R67's head on the wall and landed hard on the left shoulder. It was noted that CNA-L did not follow R67's plan of care and transferred R67 alone. R67's plan of care stated R67 was a 2 person assisted transfer. R67 was sent to the Emergency Department (ED) where R67 was diagnosed with a left clavicle (collarbone) fracture. On 3/2/22 at 12:36 PM, Surveyor interviewed CNA-L via phone regarding R67's fall on 2/7/22. CNA-L verified CNA-L transferred R67 alone. CNA-L stated CNA-L thought R67 was a one person assisted transfer. CNA-L stated that was on me for not checking the plan of care before initiating the transfer. On 3/2/22 at 12:21 PM, Surveyor interviewed NHA-B regarding not reporting the incident to the SA. NHA-B stated NHA-B should have reported the incident but initially they (facility administration) felt they did not have to report to the SA as it was felt the CNA did not intentionally bring harm to R67. 2. On 3/2/22, Surveyor reviewed the facility's investigations not reported to the SA. Upon review of the files, Surveyor noted missing item form for R318. On 1/28/22, R318's family reported to the facility that R318's wedding ring was missing. On 1/31/22, missing ring was reported to the Waupaca Police Department. Facility policy titled, Inventory Process for Personal Property Admission & Discharge, with effective date of 9/2020 stated the following: a. Social services will take inventory of personal items that resident has brought with them. Such as jewelry, wallet, money, cell phone, electronics, glasses, hearing aids. b. Social service will gather clothing and will bring to Laundry with a copy of the personal property form. Social worker will fill in resident name and room number and leave with the clothing for Laundry. c. Laundry will take inventory on the clothing and fill out the personal property form and will place in folder or binder . On 3/2/22 at 11:12 AM, Surveyor interviewed Life Enrichment Coordinator (LEC)-K who initiated the investigation of the missing ring on 01/28/22. LEC-K explained the process of searching the facility for the missing ring and not finding ring. Surveyor requested supporting documentation of the investigation and was not provided any further information other than the missing item form and a blank personal property inventory sheet. On 3/2/22 at 11:58 AM, Surveyor interviewed NHA-B who explained it was not reported to the SA since the facility couldn't prove it was ever there.

Based on interview and record review, the facility did not ensure 2 of 20 Residents (R) (R66, R57) had a preadmission screen and resident review (PASRR) Level 2 screening completed when the county 30 day exemption expired. Additionally, R66 had changes to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57 did not have a PASRR Level 2 screening completed when the county 30 day exemption expired. R66 did not have a PASRR Level 2 screening completed when the county 30 day exemption expired or when changes to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. R57 was admitted to the facility on [DATE] with related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57 was prescribed [MEDICATION(S)] for anxiety and depression. On [DATE] at 2:28 PM, Surveyor reviewed R57's Electronic Health Record (EHR) which showed a PASRR Level 1 screen was completed upon admission on [DATE]. The PASRR Level 1 screen was marked as 30 day exemption for hospital stay. Surveyor did not find a Level 2 screening in R57's chart since the 30 day exemption expired on [DATE]. On [DATE] at 8:54 AM, Surveyor interviewed Life Enrichment Coordinator (LEC-K) who indicated that the Level 2 screen after the 30 day exemption expired for R57 was not completed. LEC-K had just completed it and sent the screening to the state mental health agency for review. LEC-K indicated that LEC-K's process for remembering to submit for the Level 2 if the resident's 30 day exemption expires before discharge was to write it on LEC-K's calendar. LEC-K did state that LEC-K is not great at this and these do get missed. LEC-K further indicated that in late 2021, LEC-K was made aware that Level 2 screenings needed to be updated with medication changes or if any question in section A was checked yes, the PASSR needed to be submitted to the state's mental health agency for review. LEC-K indicated that LEC-K had misread and misunderstood the form and was not aware that these needed to be submitted for updates with changes in medications or diagnoses. After LEC-K learned this, LEC-K indicated the facility began the process of reviewing the residents during medication reviews. A checklist for PASRR was added to the medication review sheet to aid in LEC-K being made aware of any changes and determining if a new PASRR needed to be submitted for review. LEC-K additionally stated LEC-K has been randomly selecting a few people per month to review, but is still behind. LEC-K indicated LEC-K had watched a training online regarding PASRR but this training was not helpful and LEC-K was still unclear about when PASRR needed to be updated for residents . 2. R66 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Surveyor reviewed R66's medical record that included PASRR Level 1 signed on admission [DATE] marked to have a 30 day exemption. Surveyor did not find a PASRR level 2 in medical record. On [DATE], Surveyor reviewed R66's current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R66 is prescribed and taking [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] for the anxiety and psychotic disorder. On [DATE], Surveyor interview with LEC-K explained submission of PASRR level 2 on [DATE] and a copy of completed PASRR level 2 was signed and dated [DATE].

Based on staff and outside agency interviews and record review, the facility did not ensure a Resident (R) was safely discharged under the care of a home health agency as required by physician discharge orders and that the agency information was clearly documented on discharge paperwork provided at the time of discharge for 1 (R1) of 1 residents reviewed for safe discharge. The facility discharged R1 without R1 being accepted by a home health agency. Discharge paperwork provided to R1's activated Power of Attorney (POA)-F documented three different home health agencies as responsible for R1's post-discharge home health needs. Findings include: On 9/16/21, Surveyor reviewed R1's closed medical record which documented R1 discharged from the facility on 8/6/21. Director of Nursing (DON)-B and Social Worker (SW)-G noted on 8/9/21 that POA-F complained home health was not set up upon R1's discharge. SW-G documented SW-G assured (POA-F) that (POA-F) must have called the wrong number because writer had set that (home health) up last week. SW-G documented calling home health agency A (name withheld for privacy) who verified having a referral for R1. Discharge note for R1 documented home health agency A would be responsible for physical therapy, occupational therapy, nursing, wound care, and medication management upon R1's discharge. Primary Care Provider (PCP) documented in discharge note for recapitulation of stay that R1 would be served by home health agency B (name withheld for privacy) upon discharge. Nursing discharge summary form documented R1 would be served by home health agency C (name withheld for privacy). On 9/16/21 at 11:59 AM, Surveyor interviewed SW-C because SW-G was not available for interview during investigation. SW-C indicated having an awareness of R1's discharge and related details. SW-C explained the facility had a practice of providing a form with a summary of services set up for home. A blank form was provided to Surveyor as SW-C further elaborated that the facility does not keep a copy of the form provided to discharged residents because the practice is to write a discharge note with informational contents of form included. SW-C verified R1 was sent home with home health agency A's services set up per R1's discharge note entered by SW-G. On 9/16/21 at 12:36 PM. Surveyor interviewed Director of Nursing (DON)-B regarding discharge procedure. DON-B indicated discharged residents go home with forms from PCP, Nursing, and SW. DON-B was not able to indicate how POA-F should have known which of the three different home health agencies listed on various discharge paperwork was lined up to provide care to R1 at home. On 9/16/21 at 1:37 PM, Nursing Home Administrator (NHA)-A expressed the opinion that the home health agency lined up for R1 clearly communicated to POA-F verbally and in writing by SW-G. NHA-A explained the facility experienced frequent set-backs in lining up home health for residents during the COVID-19 pandemic due to home health agency staffing issues. On 9/17/21 at 9:53 AM, Surveyor interviewed home health agency A's Care Coordinator (CC)-E identified as responsible for most of facility discharges to home health by agency A. CC-E explained the process to obtain home health coverage began when the facility made a referral to home health A's intake. Intake then distributed the referral to the branch office associated with the discharge location's area for coverage. CC-E indicated R1's referral was made on 8/5/21 (day before R1's discharge). CC-E explained CC-E could access limited information about R1 because it was assigned to a different branch office based on projected care location. CC-E indicated R1's referral was rejected on 8/16/21 with an entry of R1 being determined as out of the service area. CC-E revealed an expectation that a resident be accepted by home health prior to discharge when home health is ordered because home health agency A has a goal to physically meet with a resident in home within 24 to 48 hours of discharge. If home health A is not able to meet a resident in that timeframe, the agency's practice is to communicate this information to the facility to see if a resident is safe home for the delay period or if the resident needs to remain at the facility longer for a safe discharge. CC-E expected a facility to have a home health acceptance for a resident before discharge if a physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/16/21 at 2:12 PM, Surveyor interviewed home health agency A's Intake Coordinator (IC)-D via telephone. IC-D indicated R1 was referred to home health agency A on 8/5/21. IC-D revealed documentation that attempts to contact POA-F were not made until 8/11/21 and 8/12/21 and POA-F's number on file was not functioning. IC-D indicated POA-F's phone contact information would have been obtained from referral paperwork provided by the facility at the time of referral. IC-D indicated R1 was not admitted for service by home health agency A because according to note entered 8/16/21, it was determined R1 was out of the service area which IC-D explained it was a place the branch handling the referral physically did not travel to.

Based on observations, record review and staff interviews, the facility did not ensure each resident received necessary treatment to prevent and heal pressure injuries for 5 Residents (R) (R15, R64, R19, R14, and R5) of 18 sampled residents. R15 was admitted to the facility without a pressure injury (PI) and was identified to be at risk for development of pressure injuries. The facility identified that R15 developed avoidable bilateral (affecting both sides) heel Stage 2 PIs on 2/23/2021 that deteriorated. In addition, R15's left heel pressure injury was not cleansed during wound care per treatment orders. The facility failed to provide Licensed Practical Nurses (LPN) with on-going supervision by a Registered Nurse (RN) while completing weekly wound care assessments for R64, R19, R14, and R5 who had facility acquired PIs. (See F726 for additional information) R15 is being cited at severity level 3 (harm). Findings Include: The Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Wound Cleansing: Wound cleansing is the process of using fluids to remove surface contaminants (debris), remnants of previous dressings and microorganisms from the wound and the peri-wound surface. Cleansing does not 'sterilize' a wound; instead, it 'washes' a wound. If fibrinous material and detritus/debris cannot be removed gently with fluids, then an evaluation for the appropriateness of debridement (i.e., removal of devitalized tissue) is required. Research on cleansing of pressure injuries is sparse. Most clinical articles regarding cleansing speak to general cleansing principles for any type of wound bed preparation. Cleansing is an important first step in preparing the pressure injury wound bed for healing by removing surface debris and dressing remnants, which facilitates better wound visualization for assessment. 1. R15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's most recent quarterly MDS (Minimum Data Set) assessment dated [DATE], documented R15 required extensive assistance from 2 staff for bed mobility, transfers, and dressing. R15's MDS further documented R15 was at risk for developing PIs. On 4/6/2021 at 8:59 AM, Surveyor reviewed R15's medical record. R15's medical record included the following documentation: ~ On 2/23/2021 at 4:45 AM, a fax was sent to R15's Primary Care Physician indicating R15 had bilateral open areas to heels. ~ On 2/23/2021 a Wound Assessment Report was completed by Registered Nurse (RN)-D. The assessment documented a Stage 2 PI measuring 6.0 centimeters (cm) x 8.8 cm on the left heel and a Stage 2 PI measuring 6.0 cm x 7.8 cm on the right heel. Plan: added heelz up (cushion used to free float heels off the mattress) for use in bed. On 4/6/2021 at 1:00 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C. LPN-C indicated LPN-C had completed an online wound care certification course but had not taken the final exam at this time. LPN-C indicated when a resident has a wound RN-D will complete the initial wound assessment. Following completion of the initial assessment LPN-C will complete the weekly assessments, document the weekly assessments and contact the physician as needed. On 4/8/2021, Surveyor reviewed R15's Wound Assessment Notes. R15's Wound Assessment Notes documented the following assessment completed by RN-D: ~ 2/23/21 at 5:34 PM, Pressure Ulcer/Right Heel .right heel with clear fluid filled blister .6.0 cm x 7.8 cm .Wound identified due to drainage on sheets-long line of drainage on sheet like resident was rubbing heels/moving legs. Plan: added heelzup (a cushion used to free float heels) for use in bed. Cleanse wound with wound cleaner, skin prep to wound edges and cover with foam padded [MEDICATION(S)] (a type of wound dressing), change every 2 days and prn (as needed.) ~ On 2/23/21 at 5:37 PM, Pressure Ulcer/Left heel .Left heel with stage 2 pressure injury 6.0 cm x 8.8 cm- leaking blister of calloused skin to left heel, some of callous pealing off. Small amount of bloody drainage in dressing, otherwise serous fluid (body fluid resembling serum). Wound treatment- cleanse with wound cleanser, apply skin prep to wound edges, cover with foam padded [MEDICATION(S)] every 2 days and prn to contain drainage. On 4/8/2021, Surveyor reviewed R15's Wound Assessment Notes. R15's Wound Assessment Notes documented the following assessments completed by LPN-C: ~ on 2/26/2021 at 4:30 AM, Left heel with stage 2 pressure injury today measures 5.3 cm x 7.1 cm x <0.1 cm, moderate amount of bloody drainage on dressing, otherwise serous fluid leaking from blister. New Plan: cleanse area, dry, skin prep to surrounding skin, place aqua cell AG foam secured with retention tape. then secure with kerlix. check dressing every shift for breakthrought drainage. Change every 3 days and PRN with breakthrough drainage. ~ 2/26/2021 at 4:35 AM, Right heel wound now measuring 6.9cm x 7.8cm. New Plan: cleanse area, dry, skin prep to surrounding skin, place aqua cell AG foam secured with retention tape. then secure with kerlix, measure wounds to right and left heel weekly. ~ 3/4/2021 at 2:21 PM, Left heel with stage 2 pressure injury .Today measures 5.8 cm x 4.7 cm x <0.1 cm. Scant amount of drainage in dressing. Continue with Plan. ~ 3/4/2021 at 2:25 PM. Right heel , wound now measures 7.3 cm x 10.4 cm x <0.1 cm. Continue Plan. ~ 3/11/2021 at 1:22 PM, Left heel stage 2 pressure injury measures 5.9 cm x 4.0 cm x <0.1 cm. eschar has decreased to 50 %. ~ 3/11/2021 at 1:26 PM, Right heel with stage 2 pressure injury,. Today measures 6.0 cm x 9.3 cm x <0.1 cm. ~ 3/20/2021 at 4:00 AM, late entry 3/17/2021. Left heel pressure injury . Today measures 5.5 cm x 4.9 cm x <0.1cm. Scant amount of drainage in dressing. ~ 3/20/2021 at 4:04 AM, right heel pressure injury now measuring 6.3 cm x 9.4 cm x <0.1 cm. ~ 3/26/2021 at 3:45 AM, left heel with stage 2 pressure injury today measures 5.0 cm x 7.2 cm x <0.1cm, scant amount of drainage in dressing. dressing changed today, resident did had slight moaning with the application of new dressing, only scant amount of drainage in the dressing, small particles of skin dislodged with removal of the foam. 3/26/2021 pressure ulcer right heel .current measurements to right heel 5.5 cm x 7.5 cm x <0.1 cm. slight discomfort with dressing removal and application of new. ~ 4/1/2021 at 12:25 PM, left heel with stage 2 pressure injury, eschar has decreased to 30% Today measures 4.0 cm x 5.4 cm x <0.1 cm, scant amount of drainage in the dressing. ~ 4/1/2021 at 12:26 PM, current measurements to right heel 6.9 cm x 7.2 cm x <0.1 cm. On 4/8/2021, Surveyor reviewed a fax dated 3/28/21 sent to R15's Primary Care Provider by LPN-E . Fax documented the following: Wound care was done this morning. On left heel the eschar is starting to come off and green purulent (drainage is thick and milky, often indicates an infection) coming out .Left message with wound nurse to look at it tomorrow .please advise. On 4/8/2021 at 8:50 AM, Surveyor observed Licensed Practical Nurse (LPN)-C perform wound care on R15's left heel. After removing the dressing, Surveyor observed R15 to have an unstagable pressure injury due to the presence of unstable eschar (devitalized tissue) observed in the wound base. LPN-C indicated the eschar was soft upon palpation and measured 3.9 cm x 2.6 cm. The periwound skin from 9 to 3 o'clock was observed to be pink and nonblanchable. A moderate amount of serosanguineous (clear liquid swirled with blood) drainage was observed. Before applying the new/clean dressing LPN-C failed to cleanse the wound. When Surveyor asked LPN-C why LPN-C did not clean the wound, LPN-C indicated LPN-C did not want to add moisture to the wound as the eschar present in the wound bed should remain dry. On 4/8/2021, Surveyor reviewed R15's Treatment Administration Records (TAR) dated 2/25/21 - 4/8/21. R15's TAR documented the following: ~ Bilateral heels: cleanse, dry, skin prep to surrounding intact skin, cover wound bed with [MEDICATION(S)] AG foam, secure with retention tape, double secure with wrapping foot with kerlix (a type of wound dressing.) On 4/8/2021 at 9:07 AM, Surveyor observed R15's Primary Care Physician (PCP) assess the wound on R15's right heel. Surveyor asked RN-D why the physician had not assessed the wound on R15's left heel despite a decline in the wound and the need for a change in treatment. RN-D indicated that because the wound had a clean dressing in place the PCP was not asked assess the left heel wound. On 4/8/2021 at 11:35 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated DON-B was not aware if a root cause analysis was completed to determine the cause of the PIs on R15's bilateral heels. On 4/8/2021 at 11:47 AM, Surveyor interviewed RN-D regarding the 3/28/21 documentation/fax indicating purulent drainage was noted during the left heel dressing change. RN-D indicated RN-D had not seen R15's bilateral heel wounds since 2/23/2021 and was unaware of the 3/28/21 documentation of purulent drainage. Surveyor then asked RN-D if R15's physician had assessed/seen the wounds on R15's heels prior to today's date (4/8/21). RN-D indicated physicians are not regularly asked to observe or assess wounds. RN-D indicated the bilateral heel PIs discovered on 2/23/2021 were avoidable. RN-D indicated due to fall risk R15 wore gripper socks at all times. RN-D further indicated prior to the training provided on 3/23/2021 the staff were not routinely removing R15's gripper socks to complete skin checks ensuring R15's skin remained intact. 2. Surveyor reviewed the medical record for R64. R64 most recently readmitted to the facility 6/17/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Further review of the medical record indicated R64 acquired a stage 2 pressure injury to the buttocks and coccyx areas while residing at the facility. Surveyor reviewed R64's weekly skin reports entitled Wound Assessment Report, Pressure Ulcer, Coccyx. Surveyor noted LPN-C had completed and signed 26 of 28 wound assessments for R64 dated between 9/17/20 and 4/1/21. 3. On 4/5/21-4/8/21, the Surveyor reviewed R19's medical record. R19's medical record documented R19 developed a facility acquired stage 2 pressure injury to left buttock which developed on 2/25/21. R19's medical record documented weekly skin reports entitled Wound Assessment. R19's wound assessments were completed and signed by LPN-C and LPN-C did not consult with a RN for 6 out of 6 wound assessments completed on R19 from 2/25/21- current. 4. On 4/5/21-4/8/21, the Surveyor reviewed R14's medical record. R14's medical record documented R14 developed a facility acquired stage 2 pressure injury to sacral/coccyx area while residing at the facility. R14's stage 2 facility acquired pressure injury had an initial assessment dated [DATE]. R14's medical record documented weekly skin reports entitled Wound Assessment. R14's wound assessments were completed and signed by LPN-C and LPN-C did not consult with a RN for 7 out of 7 wound assessments completed on R14 from 1/22/21- current. 5. On 4/5/21-4/8/21, the Surveyor reviewed R5's medical record. R5's medical record documented R5 developed a stage 2 facility acquired pressure injury to left coccyx on 12/14/20. R5's medical record documented weekly skin reports entitled, Wound Assessment. R5's wound assessments were completed and signed by LPN-C and LPN-C did not consult with a RN for the most recent 11 wound assessments completed on R5 from 1/1/21- current. (See F726 for additional information)

Based on observation, record review and staff interview, the facility did not identify issues to which quality assessment and assurance activities are necessary, or develop and implement appropriate plans of action to correct identified quality deficiencies. This was evidenced by the number of facility acquired pressure injuries, which affected 5 Residents (R) ( R15, R64, R19, R14, and R5) who were at risk for PIs and who developed facility-acquired PIs. The facility's Quality Assurance & Performance Improvement Plan (QAPI), dated 7/9/15 and reviewed yearly with the latest review date of 3/25/21, includes, in part: Purpose Statement: The purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and engage with our clients, caregiver, and other partners that we may realize our vision to embrace the further and develop creative solutions. I. QAPI Goals A. using the vision, mission, purpose, and guiding principles to develop the goals by stating what you want to accomplish, how you will measure your progress, how you will determine an achievable goal, how the goal determined to be relevant to the care you deliver, and how you will choose a timeline to attain the goal. During the recertification survey, from 4/5/21 to 4/8/21, the following deficiencies were cited: F697 D (scope/severity) Pain related to wound and pressure injury care, F686 G Treatment to prevent /heal pressure ulcers, and F726 E Competent Nurse Staffing related to wound/ pressure injury treatment. The facility's Quality Assurance Committee was aware of concerns related to facility pressure injury care and did not develop and implement appropriate plans to correct identified issues related to resident care and pressure injury treatment. Findings include: On 4/07/21 at 2:39 PM Surveyor was provided with facility QAPI Policy and meeting attendance record. Required members including NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, and RN (Registered Nurse)-D attended all of the required quarterly 2020 meetings; the most recent meeting took place on 1/27/21. During this recertification survey Surveyors identified seven facility acquired pressure injuries, affecting five residents, through observation and record review. The facility's updated matrix identified 10 facility acquired pressure injuries. On 4/08/21 at 09:19 AM NHA-A explained skin and resident needs were discussed at every QAPI meeting and a concern was identified over a year ago. NHA-A explained RN-D had been seeing residents with LPN (Licensed Practical Nurse)-C to examine wounds and was aware LPN-C had been performing wound examinations and treatments without RN-D but believed LPN-C consulted RN-D with questions. NHA-A was aware LPN (Licensed Practical Nurse)-C was not wound certified but had performing wound rounds without direct RN supervision. At 11:03 AM NHA-A provided Survey QAPI Action Plan SKIN. Section 1- Action Step Increased pressure injuries noted. Review and audits initiated. Continued issues with skin breakdown 5/2020. Responsible person- (DON-B) with no target date or outcome identified. Section 9: Wound nurse left employment Responsible Person (LPN-C) -to finish wound course by February 10th (RN-D) - mentor (LPN-C) in rounds, (RN-D) - increase personal knowledge on wounds to improve skill. Target date: 10/2020 Outcome: (LPN-C) taking wound care course and (RN-D) is working with (LPN-C) on wound rounds. 12/2020- meeting with (DON-B, LPN-C and RN-D) to review current wounds and plans 1/21- notes identify (LPN-C) completing most wound rounds, requesting RN input as needed. Reviewed at QAPI Section 10: Increased heel breakdown, even with use of heel devices date 1/31/21 1/2021 - (LPN-C) completing most of wound rounds, requesting RN input as needed. Reviewed at QAPI Section 10: Increased heel breakdown, even with use of heel devices, Responsible Person: No new heel breakdown Target date: 1/31/21 Outcome: 1/2021 - reviewed heel inspection form and nurse meeting again to reinforce. At 11:50 AM RN-D explained the pressure injuries on R15 had not been examined or treated by an RN and the wounds were avoidable. RN-D was aware LPN-C did not have a wound care certification and had been performing wound care without direct RN supervision. RN-D was aware of the number of increased facility acquired pressure injuries.

Based on staff interview and record review, the facility did not ensure their infection control program included a system of surveillance designed to identify infections and prevent the spread of infections such as COVID-19. This had the potential to affect all 78 residents in the facility. The facility did not have a process in place to ensure visitors entering the facility were properly screened by staff members. Surveyors entered the building and had to seek out staff members who were working the unit to screen the Surveyors when they entered the building. Education on visitor requirements was sent to resident representatives by email with no way to verify if resident representative received the education. Staff did not cleanse the injection site for a resident receiving an insulin injection prior to the injection. Findings include: 2. Limit access to facility The facility provided the Surveyor with the following visitor policy with a most recent revision date of 4/6/21, entitled COVID-19 documented; 1. Post sign on all entry doors about visitor procedure 3. Allow family visits for end of life issues & compassionate care visits at all time. See general visitation policy for general visits. 4. Screen visitors with questionnaire (see attached questionnaire/screening) - refuse entrance if meet restricted criteria. Take temperature of visitor - must be under 99.5 degrees. If available, screen with rapid covid-test prior. If has proof of receiving full COVID-19 vaccination may defer rapid COVID-19 test. On 4/5/21 at 6:00 PM, the Surveyors entered the unlocked facility which was the start of the facility's off-hour recertification inspection. Upon entering the building the Surveyors could not locate a staff member to assist with the screening process. The Surveyor entered the 1st floor unit to find a staff member. There were no staff members located at the 1st floor nurses station as 1st floor only has three residents residing on the unit. The Surveyor continued down the hallway to the J-wing nurses station where staff were present. The Surveyor requested staff assistance with the screening process. Staff accompanied the Surveyor to the lobby entrance to complete the required screening. On 4/5/2021 at 8:19 PM, the Surveyor interviewed Director of Nursing (DON)-B. The Surveyor informed DON-B the survey team had entered the facility at 6:00 PM unknown to the staff as the doors were unlocked. DON-B indicated the doors to the facility are not locked at that time of day. Surveyor asked DON-B how staff would be alerted a visitor had entered the facility as there was not a staff member monitoring the entrance to the facility to ensure a COVID-19 screening had been completed. DON-B indicated the Surveyor had a valid point. On 4/6/21, at 9:53 AM, the Surveyor interviewed Family Member (FM)-I who stated FM-I was in the building to visit a resident on 4/4/21. FM-I entered through the canopy entrance and filled out the screening questionnaire and left the questionnaire on the desk. FM-I stated no staff were present when FM-I completed a self-screening into the building. On 4/5/21 at 8:17 PM, DON-B informed the Surveyor FM-I was not in the building on 4/4/21, because FM-I did not sign in on the visitor log which is required of visitors in addition to the screening questionnaire. DON-B stated FM-I and all family members have been educated on the visitor policy requirements through email. On 4/6/21 10:31 AM, the Surveyor interviewed RA (Restorative Aide)-J who informed the Surveyor on 4/4/21, RA-J worked the front desk screening visitors from 9:00 AM - 1:00 PM at the canopy entrance. RA-J stated a staff member was not assigned to screen visitors at the facility's other unlocked entrance. RA-J confirmed FM-I was in the building and approached RA-J to ask how long FM-I could stay in the building. RA-J informed the Surveyor RA-J did not screen FM-I because RA-J did not see FM-I enter the building. RA-J was unaware of who assisted with screening of FM-I or through which door FM-I entered into the facility. RA-J stated FM-I could have entered the building through the other set of unlocked doors or may have entered the building before 9:00 AM. On 4/6/21 at 8:15 AM, MD (Maintenance Director)-H informed the Surveyor the facility has made a change to when the facility doors are locked and unlocked. The facility has two outside entrance doors which were previously locked at 9:00 PM. A change was made starting 4/6/21, and the doors will now be locked at 4:00 PM instead of 9:00 PM. On 4/6/21 at 12:26 PM, NHA-A provided the Surveyor with a check in questionnaire filled out by FM-I on 4/4/21 NHA-A stated FM-I must have filled out the screening questionnaire and left the questionnaire on the desk. NHA-A stated no staff member signed the staff signature section so it was assumed FM-I check self into the building. NHA-A stated staff need to be present when visitors are screened into the building, so staff are able to determine if screening questionnaire is answered appropriately to determine if visitor is appropriate to visit. NHA-A stated resident representatives received an email providing education about visitor screening and guidelines. NHA-A stated resident representatives were asked to share the information with other family member. NHA-A stated the facility did not have a way to monitor who received the education or to verify if the resident representative received the education sent by email from the facility. NHA-A stated the facility is currently in the process of changing the unlocking and locking of the doors. NHA-A stated the doors will now be locked at 4:00 PM, instead of 9:00 PM, and visitors will enter and be screened by staff at the J-wing entrance which has a door bell in place to alert staff visitors are at the facility. On 4/7/21 at 12:49 PM, Surveyor re-entered the facility through the unlocked canopy-covered entrance. Surveyor noted the following upon entering the facility: -No staff were available within direct sight of the COVID-19 screening check-in table to assist with symptom and exposure monitoring sheets or temperature checks -No clean pens were available for visitors to use, all available pens were within the dirty pens cup Surveyor independently completed sign-in process and had to find staff at the corner office/check-in desk area to ensure sign-off on symptom and exposure monitoring sheet. 2. Bethany Home Inc. Facility Policy related to Insulin Pens Checklist indicates the following: Procedure: VI. A. Cleanse the skin with alcohol pad. On 4/06/21 at 8:00 AM Surveyor observed LPN (Licensed Practical Nurse)-E give an insulin injection in the upper right arm to a resident. LPN-E did not clean the area before administering the injection. LPN-E explained to Surveyor that LPN-E does not clean the skin before administering injections and stated, Each person does it different. At 2:30 PM DON (Director of Nursing)-B explained to Surveyor the facility expectation is for nurses to clean the injection site before an injection is given.

Based on observation and staff interview, the facility did not ensure all medications were stored in accordance with currently acceptable standards of practice. 3 of 5 facility medication carts were unlocked while not in direct supervision of a licensed nurse. Nursing staff left medications carts unlocked and unsupervised. Findings include: Bethany Home Inc Policies and Procedures Manual Administering Medications Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 10. During administration of medication, the mediation cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. On 4/05/21 at 6:07 PM, Surveyor observed medication cart B floor 1 and floor 1 treatment cart unlocked in the resident dining area without the presence of a nurse. Surveyor stood by the medication and treatment carts for six minutes until RN (Registered Nurse)-L returned to the area. RN-L reported the carts were not locked because RN-L left to take a phone call. RN-L explained the call was from a provider that did not like to wait, and acknowledged the carts should have been locked before RN-L left. Observation of the treatment cart showed medicated creams of Clotrimoxole (anti-fungal), [MEDICATION(S)] (moisturizing cream) and a skin repair cream labeled for individual residents' use were left unsecured on top of the cart. The second drawer of the unlocked treatment cart had an open container of uncapped soiled straight edge razors. The container had hair, dirt, and one loose unidentified orange pill in it with the used razors. RN-L was not aware of how many razors were in the container and estimated 30 razors remained in the container. At 7:13 PM Surveyor observed RN-M enter a resident room to administer medication and left the medication cart unlocked in the hall. The front of the medication cart faced into the hall; RN-M's back was to the cart leaving the cart out of direct supervision of RN-M while RN-M administered the medication. RN-M acknowledged the cart should have been locked. At 7:46 PM Surveyor observed LPN (Licensed Practical Nurse)-N enter a resident room to administer medication. The medication cart faced the resident room, but allowed sufficient space for a person to pass between the cart and the resident room. The cart was not in directed supervision of LPN-N while LPN-N administered medications to a resident. At 8:14 PM NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B confirmed the open container of used razors with Surveyor and indicated they did not know why it was located in the treatment cart. NHA-A and DON-B approximated 30 razors remained in the container along with dirt and an orange pill. DON-B instructed RN-L to dispose of the razors into sharps container. NHA-A and DON-B further explained they expected the medication and treatment carts to be locked at all times when not in use or direct supervision of the nurse.

Based on record review, observation and interview, the facility did not ensure nursing staff received sufficient wound care training to properly assess, care and treat pressure injuries (PIs). This failure to assess, care and treat pressure injuries was observed to directly affect 5 Resident (R) (R15, R64, R19, R14, R5) who were at risk for PIs and who developed facility-acquired PIs. The facility failed to provide Licensed Practical Nurses (LPN) with on-going supervision by a Registered Nurse (RN) while completing weekly wound care assessments. Findings Include: 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 . Wound Care Education Institute Skin and Wound Management Course, copyright 2018, section 1, titled Principles of Practice states: C. WCC/Certified Wound Practitioner 2. Ethics d. Engage only in services for which you have the necessary knowledge, skills, and experience. 1. Just because someone is certified in wound care does not automatically give them special privileges. IE Sharps debridement, consulting skills, advanced assessment. 2. All practitioners as well as those who have received certification in wound care may only practice wound care that is within the Scope of Practice for their respective license. 3. Professional Sate Licensure scope of practice (Government Licensure Board) governs over and above the scope of wound care certification. 1. R15 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's most recent quarterly MDS (Minimum Data Set) assessment dated [DATE], documented R15 required extensive assistance from 2 staff for bed mobility, transfers, and dressing. Further review of R15's medical record indicated on 2/23/2021 R15 had acquired pressure injuries to R15's bilateral (affecting both sides) heels. Surveyor reviewed R15's Wound Assessment Reports. LPN-C completed and signed the weekly assessments from 2/25/21 through 4/1/2021. On 2/25/2021 and 3/3/2021 the Wound Assessment Reports document the wounds had deteriorated bilaterally. Surveyor was unable to locate documentation a RN assessment was completed on 2/25/2021 and 3/3/2021. On 4/6/2021 at 1:00 PM, Surveyor interviewed LPN-C. LPN-C indicated LPN-C had completed an online wound care certification course but had not taken the final exam at this time. LPN-C indicated when a resident has a wound RN-D will complete the initial wound assessment. Following completion of the initial assessment LPN-C will complete the weekly assessments, document the weekly assessments and contact the physician as needed. On 4/7/2021 at 10:47 AM, Surveyor interviewed RN-D. RN-D indicated RN-D is a wound certified nurse. RN-D indicated LPN-C recently completed the online wound certification course but is not wound certified as LPN-C has not taken the final exam. RN-D further indicated LPN-C does complete most of the weekly wound assessments, the weekly documentation and will update the physician as needed. On 4/8/2021 at 11:47 AM, Surveyor interviewed RN-D regarding the 3/28/21 documentation indicating purulent drainage was noted during the left heel dressing change. RN-D indicated RN-D had not seen R15's bilateral heel wounds since 2/23/21 and was unaware of the 3/28/21 documentation of purulent drainage (thick and milky, often indicates and infection). Surveyor then asked RN-D if R15's physician had assessed/seen the wounds on R15's heels. RN-D indicated physicians are not regularly asked to observe or assess wounds. On 4/8/2021 at 9:07 AM, Surveyor observed R15's Primary Care Physician (PCP) assess the wound on R15's right heel. Surveyor asked RN-D why the physician had not assessed the wound on R15's right heel despite a decline in the wound and the need for a change in treatment. RN-D indicated that because the wound had a clean dressing in place the PCP was not asked assess the left heel wound. At 12:39 PM, RN-D provided Surveyor with the following additional information. RN-D had assisted LPN-C with weekly wound assessments until January 2021 and LPN-C completed the online certification course in March . On 4/8/2021, Surveyor was provided dates of participation by Director of Nursing (DON)-B. LPN-C participated in the online wound certification course from 10/1/2020 until 3/22/2021. 2. Surveyor reviewed the medical record for R64. R64 most recently readmitted to the facility 6/17/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Further review of the medical record indicated R64 acquired a stage 2 pressure injury to the buttocks and coccyx areas while residing at the facility. Surveyor reviewed R64's weekly skin reports entitled Wound Assessment Report, Pressure Ulcer, Coccyx. Surveyor noted LPN-C had completed and signed 26 of 28 wound assessments for R64 dated between 9/17/20 and 4/1/21. 3. On 4/5/21-4/8/21, the Surveyor reviewed R19's medical record. R19's medical record documented R19 developed a facility acquired stage 2 pressure injury to left buttock which developed on 2/25/21. R19's medical record documented weekly skin reports entitled Wound Assessment. R19's wound assessments were completed and signed by LPN-C and LPN-C did not consult with a RN for 6 out of 6 wound assessments completed on R19 from 2/25/21- current. 4. On 4/5/21-4/8/21, the Surveyor reviewed R14's medical record. R14's medical record documented R14 developed a facility acquired stage 2 pressure injury to sacral/coccyx area while residing at the facility. R14's stage 2 facility acquired pressure injury had an initial assessment dated [DATE]. R14's medical record documented weekly skin reports entitled Wound Assessment. R14's wound assessments were completed and signed by LPN-C and LPN-C did not consult with a RN for 7 out of 7 wound assessments completed on R14 from 1/22/21- current. 5. On 4/5/21-4/8/21, the Surveyor reviewed R5's medical record. R5's medical record documented R5 developed a stage 2 facility acquired pressure injury to left coccyx on 12/14/20. R5's medical record documented weekly skin reports entitled, Wound Assessment. R5's wound assessments were completed and signed by LPN-C and LPN-C did not consult with a RN for the most recent 11 wound assessments completed on R5 from 1/1/21- current.

Based on staff interview and record review, the facility did not ensure the development of comprehensive person-centered care plans with measurable goals, time frames, and interventions for 2 Residents (R) (R5 and R14) of 18 sampled residents R14's medical record did not contained [CONDITION(S)]-focused, individualized care plan which included information on the critical aspects of care for patients who received [CONDITION(S)], including information on how to respond to common acute and chronic complications for patients who received [CONDITION(S)]. R5 did not contain individualized plan of care with measurable goals, objectives, time frames and interventions to manage R5's [CONDITION(S)]. Findings Include: 1. Per CFR 483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Patients who receive hemodialysis are at high risk for acute and chronic complications and require a high level of monitoring that would be identified in the care plan. On 4/5/21-4/8/21, the Surveyor reviewed R14's medical record. R14 original admission to the facility was 8/6/20. R14 was readmitted to the facility on [DATE], from an acute care hospital. R14's had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Surveyor could not locate a comprehensive and person-centered plan of care with a [CONDITION(S)] focus for R14 that included measurable goals, objectives, time frames, and interventions. R14 received [CONDITION(S)] treatment outside of the facility three times weekly at an off-site facility, for [CONDITION(S)]. On 4/8/21 1:55 P.M., the Surveyor requested R14's [CONDITION(S)] care plan from Director of Nursing (DON)-B. DON-B stated R14 did not have a care plan addressing R14's measurable goals, objectives, time frames, and interventions. DON-B stated there is a communication sheet that goes back and forth to [CONDITION(S)] with R14, but not all staff are able to see the communication sheet. 2. The Surveyor reviewed R5's medical record from 4/5/21-4/8/21. R5 was admitted to the facility on [DATE]. R5's most recent nurse practitioner visit note dated 3/5/21, indicated R5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment portion indicated R5 is noted with 1-2+ pitting [CONDITION(S)] bilaterally. Nursing reports some ongoing [CONDITION(S)], improved from prior. R5's medication list included [MEDICATION(S)] (a diuretic medication used to treat blood pressure and fluid retention) 25 mg to be given by mouth daily. General The Surveyor could not locate a comprehensive and person-centered plan of care with a [CONDITION(S)]/fluid retention focus for R5 that included measurable goals, objectives, time frames, and interventions. On 4/8/21 at 1:55 P.M., the Surveyor interviewed DON-B who confirmed R5's care plan does not address diuretic medication use and interventions to alert staff on how to manage R5's diuretic medication and fluid retention/[CONDITION(S)].

Based on observation, record review and staff interview, the facility did not ensure the resident environment remained as free of accident hazards as possible for 9 Residents (R) (R2, R8, R7, R5, R9, R10, R11, R12 and R13) of 10 sampled residents. R2's plan of care indicated R2 was at risk for wandering. R2's medical record indicated R2 eloped from the facility on 10/26/19. R2's plan of care contained an intervention for a wanderguard (a device that sounds an audible alarm to alert staff when a resident passes a sensor) on R2's wheelchair with the placement to be checked daily. That intervention was not consistently implemented. In addition, R2 fell down a second floor stairwell on 1/20/20 after getting through an alarmed stairwell door. During observations on 1/28/20, the Surveyor noted two of the first and second floor stairwell egress doors did not function properly when activated by a wanderguard. R8's plan of care indicated R8 was at risk for wandering and wore a wanderguard on the right ankle. R8's medical record indicated R8 attempted to exit the second floor doors multiple times and was found on the floor in the first floor restorative room after leaving the second floor via elevator. R8's plan of care contained interventions to check the function and placement of R8's wanderguard. Those interventions were not consistently implemented. R7's plan of care indicated R7 was at risk for wandering and wore a wanderguard on the left wrist. R7's medical record indicated R7 was found in the second floor stairwell on two occasions. R7's plan of care contained interventions to check the function and placement of R7's wanderguard. Those interventions were not consistently implemented. R5's plan of care indicated R5 was at risk for wandering and had a wanderguard on R5's wheelchair. R5's plan of care contained interventions to check the function and placement of R5's wanderguard. Those interventions were not consistently implemented. R9's plan of care indicated R9 was at risk for wandering and had a wanderguard on R9's wheelchair. R9's plan of care contained interventions to check the function and placement of R9's wanderguard. Those interventions were not consistently implemented. R10's plan of care indicated R10 was at risk for wandering and had a wanderguard on R10's wheelchair. R10's plan of care contained interventions to check the function and placement of R10's wanderguard. Those interventions were not consistently implemented. R11's plan of care indicated R11 was at risk for wandering and wore a wanderguard on the the right ankle. R11's plan of care contained an intervention to check the placement of R11's wanderguard every shift. That intervention was not consistently implemented. R12's plan of care indicated R12 was at risk for wandering and had a wanderguard on R12's wheelchair. R12's plan of care contained an intervention to check the placement of R12's wanderguard every shift. That intervention was not consistently implemented. R13's plan of care indicated R13 was at risk for wandering and wore a wanderguard on the left wrist. R13's plan of care contained interventions to check the function and placement of R13's wanderguard. Those interventions were not consistently implemented. The facility's failure to ensure wanderguards were worn and checked as ordered as well as the failure to ensure egress doors functioned properly with regard to alerting staff of resident egress created a finding of IJ (Immediate Jeopardy) that began on 1/20/20. NHA (Nursing Home Administrator)-A was notified of the IJ on 1/28/20 at 4:00 PM. The IJ was removed on 1/28/20; however, the deficient practice continues at a scope/severity level [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: On 1/28/2020, the Surveyor reviewed a complaint filed with the State Agency. The complaint stated, (R2) lives on the second floor, the locked unit. (R2) was moved (to the second floor) because (R2) has eloped on numerous occasions. This week (R2) fell down the stairs from the second floor to the first floor down the stairwell. (R2) was found at the bottom of the stairs sitting on the ground with (R2's) wheelchair next to (R2). This is a locked door but the system is broken and (R2) got out . The Surveyor reviewed R2's medical record. R2 was admitted to the facility with [DIAGNOSES REDACTED]. R2's most recent Annual MDS (Minimum Data Set), dated 11/21/19, indicated R2 was severely cognitively impaired. R2's plan of care stated R2 had a wanderguard on R2's wheelchair due to increased confusion and exit seeking. R2's plan of care contained interventions to check the placement of R2's wanderguard every shift and check the function weekly. R2's TAR (treatment administration record) indicated the placement of R2's wanderguard was not checked during one or more shifts on 1/11/20, 1/12/20, 1/14/20, 1/22/20, 1/25/20, 1/26/20, 1/27/20 and 1/28/20. The Surveyor reviewed a wandering incident, dated 10/26/19, that indicated R2 was found outside the facility. R2 had a wanderguard on the left ankle; however, the wanderguard did not activate the door alarm. R2's wanderguard was tested and subsequently moved from the ankle to the back of R2's wheelchair. R2 was transferred to the third floor following the elopement and then to the second floor dementia unit on 10/28/19. The Surveyor reviewed a fall report, dated 1/20/20, that indicated R2 opened an egress door on the second floor and was found at the bottom of the stairwell sitting upright on the first step. R2's wheelchair was toppled over on the landing above. R2 sustained a minor abrasion to the left back and a bruise on the top of the left hand. R2 was able to move all extremities and was in no apparent discomfort; however, R2 was sent to the ER (emergency room ) for evaluation. The investigation indicated R2 stated R2 wanted to go home. R2's attempt to leave the facility was determined to be the root cause of the fall. Following the fall, mesh stop sign banners were applied across the door frames of all egress doors on the second floor. During an interview with the Surveyor on 1/28/20 at 9:15 AM, CNA (Certified Nursing Assistant)-G stated R2 exited the stairwell doors a few times prior to the incident on 1/20/20. CNA-G stated, I had to run down the hallway .the alarm was sounding .sometimes (R2) has (R2's) (wheelchair) through the doors .(R2) is fast. CNA-G also stated R2 attempted to access the second floor elevator. On 1/28/20 at 9:33 AM, the Surveyor observed R2 asleep in bed. R2's wheelchair, which was next to R2's bed, did not contain a wanderguard. On 1/28/20 at 9:35 AM, the Surveyor and CNA-F entered R2's room. CNA-F verified R2's wheelchair did not contain a wanderguard. The Surveyor and CNA-F checked R2's wrists and ankles. CNA-F verified R2 was not wearing a wanderguard either. CNA-F verified if R2 was not equipped with a wanderguard, R2 could leave the second floor via the elevator and exit multiple doors on the first floor without alarm notification. R2 could also exit three second floor egress doors and access the stairwells without activating the door alarms. The Surveyor noted the three egress doors on the second floor also contained motion sensor alarms in or near the door frames. During an interview with the Surveyor on 1/28/20 at 10:15 AM, CNA-F stated the three stairwell exit doors were changed (September 2019) after the facility's last recertification survey (March 2019). CNA-F stated stairwell exit doors used to lock when residents with wanderguards approached. The stairwell doors were unable to be opened unless they were disengaged with a keypad code. CNA-F stated the doors were replaced with magnetically locked fifteen second egress doors. CNA-F stated R2, R7 and R8 could push down the door handle, hold the handle for fifteen seconds, disengage the magnetic lock and enter the stairwell. CNA-F stated, Those doors aren't safe. CNA-F also verified the second floor elevators were not equipped with the wanderguard system. CNA-F stated residents with wanderguards were able to access the elevator at will. CNA-F stated CNA-F notified the maintenance department when CNA-F noted the egress stairwell exit door near R2's room didn't engage for fifteen seconds before opening when the door alarm was activated. CNA-F stated, (R2) can figure out (how to open) the door. During an interview with the Surveyor on 1/28/20 at 11:45 AM, MA (Maintenance Assistant)-H stated, (After R2's fall), I checked all three (stairwell) doors (on the second floor). They worked the way they're supposed to. MA-H stated MA-H didn't receive notification prior to 1/20/20 that the second floor egress doors weren't functioning properly. MA-H stated motion sensors were added to the egress door frames prior to 1/20/20 per staffs' request. MA-H stated, (Staff) wanted more sound to be able to hear the alarms. MA-H also stated velcro mesh STOP banners were added to the egress doors following R2's fall. During an interview with the Surveyor on 1/28/20 at 12:00 PM, AS (Anonymous Staff)-I stated the maintenance department was notified multiple times the egress door near R2's room didn't function properly. AS-I stated, There's supposed to be a fifteen second delay before the door opens. AS-I stated laser alarms were added to the doors when it was discovered the doors didn't consistently function properly. AS-I stated AS-I observed R5 push one of the doors open approximately two months prior. AS-I stated, I stopped (R5). (R5) didn't get all the way through .The (laser) sensors were added the first time (R7) got in the stairway .(R8) also .they were all in the stairwell prior to (R2). AS-I stated it was difficult to keep residents away from the doors, especially R2. AS-I stated, (R2) is always exit seeking. (R2) would try to push out the door (to the stairwell) by the nurses' station. AS-I indicated [REDACTED]. Prior to (R2's) decline, I believe (R2) was wandering. Once the decline started (approximately six to eight weeks ago), I believe (R2) is exit seeking and looking to get out .looking for (R2's) husband. AS-I stated, I complained about that door so many times .it was a safety concern. During an interview with the Surveyor on 1/28/20 at 1:30 PM, RN (Registered Nurse)-J stated RN-J sent R2 to the hospital after R2 was found at the bottom of the stairwell on 1/20/20. RN-J stated R2 had no visible injuries and became combative with staff during a full body assessment. RN-J stated, (R2) did not want to go to the hospital. (R2) wanted to go home. On 1/28/20 at 1:45 PM, the Surveyor and CNA-F tested the second floor egress door across from R8's room. When R8 approached the door, the alarm activated. When the Surveyor tested the door, the Surveyor and CNA-F noted the fifteen second locking mechanism did not engage. The Surveyor was immediately able to open the door and access the stairwell. During an interview with the Surveyor on 1/28/20 at 1:50 PM, MA-K and MA-N indicated they hadn't received any recent maintenance requests about the second floor egress doors. MA-K stated, I had them all working. (MA-H) told us they were good. We tested the doors (the morning after R2's fall in the stairwell). MA-N stated a representative from the door manufacturer checked the doors on 1/21/20 following R2's fall. On 1/28/20 at 2:02 PM, the Surveyor, MA-K and MA-N tested the first floor stairwell exit door. The Surveyor, MA-K and MA-N noted the door alarmed appropriately; however, the fifteen second looking mechanism did not engage. The Surveyor noted MA-K was able to immediately open the door and access the stairwell. When tested a second time at approximately 2:03 PM, the Surveyor, MA-K and MA-N noted the locking mechanism again did not engage. During an interview with the Surveyor on 1/28/20 at 2:10 PM, NHA-A verified the facility was required to change the doors following a Life Safety Code survey in (MONTH) of 2019. NHA-A stated the facility was informed the doors were required to have magnetic locks and a fifteen second egress mechanism. During an interview with the Surveyor on 1/28/20 at 2:40 PM, MA-H stated MA-H retested the first floor stairwell exit door and the magnetic lock again failed to engage. MA-H stated, That's not right. We busted right through. We're calling (MD (Maintenance Director)-O) and (a named security services company that services door alarms) immediately to get them here. During an interview with the Surveyor on 1/29/20 at 9:32 AM, ADON (Assistant Director of Nursing)-M stated all wanderguards that were previously on wheelchairs were now on residents' wrists. ADON-M stated R2's wanderguard may have been removed from R2's wheelchair when the chair was washed on the 1/27/20 PM shift. When asked if staff expressed concerns regarding safety on the second floor, ADON-M stated, A few CNAs expressed their concerns. ADON-M stated the concerns weren't specific to residents who exited the doors, but rather what could happen if they did. 2. On 1/29/20, the Surveyor reviewed R8's medical record. R8 resided on the second floor dementia unit. R8's plan of care indicated R8 was at risk for wandering due to Alzheimer's dementia. R8's plan of care stated, I have a history of wandering and continue to wander in my current living situation, often trying to get into the stairwell or elevator. A progress note, dated 10/05/19, stated R8's wanderguard was necessary as R8 wandered and explored the unit and was known to open stairwell doors and access the elevator. A progress note, dated 12/12/19, stated R8 was found in the restorative room on the first floor on 12/11/19 with no apparent injuries. A progress note, dated 12/24/19, stated staff intervened and provided redirection when R8 attempted to exit into the stairwell. R8's plan of care contained an intervention for a wanderguard on the right ankle. R8's TAR contained interventions to check the placement of R8's wanderguard every shift and check the function weekly. The Surveyor noted the function of R8's wanderguard was not checked on 1/06/20 and 1/27/20. The placement of R8's wanderguard was not checked during one or more shifts on 1/08/20, 1/12/20, 1/13/20, 1/14/20, 1/15/20, 1/16/20, 1/21/20, 1/22/20, 1/25/20, 1/26/20, 1/27/20 and 1/28/20. 3. On 1/29/20, the Surveyor reviewed R7's medical record. R7 resided on the second floor dementia unit. R7's plan of care stated R7 was at risk for wandering due to Alzheimer's dementia with delusions, confusion, poor safety awareness and impulsivity. R7's plan of care contained an intervention for a wanderguard to the left wrist. R7's TAR contained interventions to check the placement of R7's wanderguard every shift and check the function weekly. The Surveyor noted the function of R7's wanderguard was not checked on 1/23/20. The placement of R7's wanderguard was not checked during one or more shifts on 1/08/20, 1/09/20, 1/11/20, 1/13/20, 1/14/20, 1/16/20, 1/21/20, 1/22/20, 1/25/20, 1/26/20, 1/27/20 and 1/28/20. A progress note, dated 9/28/19, stated R7 exited a second floor stairwell door and was discovered ascending the stairs. A progress note, dated 10/17/19, stated R7 was found in the third floor stairwell with the door alarm sounding. During an interview with the Surveyor on 1/28/20 at 3:50 PM, MT (Med Tech)-L stated MT-L found R7 in the stairwell heading up a flight of stairs approximately four to five months prior. MT-L stated, I'm not sure if the fifteen second egress (on the alarmed door) worked or not. I just know (R7) got out and was on the third step heading upstairs .I called maintenance right away. I just wish we could make it safer . 4. On 1/29/20, the Surveyor reviewed R5's medical record. R5 resided on the second floor dementia unit. R5's plan of care indicated R5 was at risk for wandering due to [MEDICAL CONDITION], dementia, cognitive decline and confusion. R5's plan of care contained an intervention for a wanderguard on R5's wheelchair. R5's TAR contained interventions to check the placement of R5's wanderguard every shift and check the function weekly. The Surveyor noted the function of R5's wanderguard was not checked on 1/17/20 and 1/24/20. The placement of R5's wanderguard was not checked during one or more shifts on 1/03/20, 1/05/20, 1/12/20, 1/13/20, 1/14/20, 1/15/20, 1/16/20, 1/21/20, 1/22/20, 1/25/20, 1/26/20, 1/27/20 and 1/28/20. 5. On 1/29/20, the Surveyor reviewed R9's medical record. R9 resided on the second floor dementia unit. R9's plan of care indicated R9 was at risk for wandering due to Alzheimer's dementia. R9's plan of care contained an intervention for a wanderguard on R9's wheelchair. R9's TAR contained interventions to check the placement of R9's wanderguard every shift and check the function weekly. The Surveyor noted the function of R9's wanderguard was not checked on 1/08/20 and 1/15/20. The placement of R9's wanderguard was not checked during one or more shifts on 1/06/20, 1/10/20, 1/11/20, 1/13/20, 1/15/20, 1/16/20, 1/21/20, 1/22/20, 1/25/20, 1/26/20, 1/27/20 and 1/28/20. 6. On 1/29/20, the Surveyor reviewed R10's medical record. R10 resided on the second floor dementia unit. R10's plan of care indicated R10 was at risk for wandering due to dementia, cognitive decline and confusion. R10's plan of care contained an intervention for a wanderguard on R10's wheelchair. R10's TAR contained interventions to check the placement of R10's wanderguard every shift and check the function weekly. The Surveyor noted the function of R10's wanderguard was not checked on 1/23/20. The placement of R10's wanderguard was not checked during one or more shifts on 1/08/20, 1/09/20, 1/12/20, 1/13/20, 1/14/20, 1/25/20, 1/26/20 and 1/27/20. 7. On 1/29/20, the Surveyor reviewed R11's medical record. R11 resided on the second floor dementia unit. R11's plan of care indicated R11 was at risk for wandering due to dementia. R11's plan of care contained an intervention for a wanderguard on R11's right ankle. R11's TAR contained interventions to check the placement of R11's wanderguard every shift and check the function weekly. The Surveyor noted the placement of R11's wanderguard was not checked during one or more shifts on 1/08/20, 1/11/20, 1/12/20, 1/13/20, 1/14/20, 1/16/20, 1/22/20, 1/25/20, 1/26/20, 1/27/20 and 1/28/20. 8. On 1/29/20, the Surveyor reviewed R12's medical record. R12 resided on the second floor dementia unit. R12's plan of care indicated R12 was at risk for wandering due to Alzheimer's dementia and confusion. R12's plan of care contained an intervention for a wanderguard on R12's wheelchair. R12's TAR contained interventions to check the placement of R12's wanderguard every shift and check the function weekly. The Surveyor noted the placement of R12's wanderguard was not checked during one or more shifts on 1/05/20, 1/06/20, 1/07/20, 1/08/20, 1/09/20, 1/11/20, 1/12/20, 1/13/20, 1/14/20, 1/16/20, 1/21/20, 1/22/20, 1/25/20, 1/26/20, 1/27/20 and 1/28/20. 9. On 1/29/20, the Surveyor reviewed R13's medical record. R13 resided on the second floor dementia unit. R13's plan of care indicated R13 was at risk for wandering due to dementia, confusion and memory impairment. R13's plan of care contained an intervention for a wanderguard on R13's left wrist. R13's TAR contained interventions to check the placement of R13's wanderguard every shift and check the function weekly. The Surveyor noted the function of R13's wanderguard was not checked on 1/10/20, 1/17/20 and 1/24/20. The placement of R13's wanderguard was not checked during one or more shifts on 1/08/20, 1/11/20, 1/12/20, 1/13/20, 1/14/20, 1/15/20, 1/16/20, 1/21/20, 1/22/20, 1/25/20, 1/26/20, 1/27/20 and 1/28/20. During an interview with the Surveyor on 1/29/20 at 1:00 PM, DON (Director of Nursing)-B verified R2, R8, R7, R5, R9, R10, R11 R12 and R13's wanderguards were not consistently checked for placement and functionality as evidenced by documentation or lack thereof on the residents' TARs. The facility's failure to ensure R2's wanderguard was in place, failure to implement wanderguard placement checks for multiple residents, and the intermittent functionality of the egress door alarms created a finding of Immediate Jeopardy. The facility removed the Immediate Jeopardy on 1/28/20 when it completed the following: ~A wanderguard was immediately placed on R2's wheelchair and checked for functionality. ~Other residents with wanderguards were checked for placement and functionality. ~(A named security services company) was immediately contacted regarding the egress doors. A company representative arrived at the facility at approximately 4:00 PM and adjusted the magnetic locks on the doors. ~Secondary alarms were placed on all stairwell doors to alert staff of breach of doors into stairwells. ~All residents with wanderguards were placed on fifteen minute checks until provided assurance the delayed egress system was functioning properly. ~All nurses educated on the wandering risk policy and retrained prior to their next shift with specific focus to ensure wanderguards are checked for placement every shift and functionality every week. ~All staff reeducated prior to their next shift on the importance of responding to alarms to ensure the safety of residents. ~Administrative staff will conduct daily, weekly and monthly audits to ensure placement and functionality of residents' wanderguards as well as functionality of the facility's egress doors.

Based on record review, staff and family interviews, the facility did not ensure 1 Resident (R) (R1) of 3 sampled residents received care in accordance with professional standards of practice. R1 presented with two episodes of vomiting, change in demeanor, and decreased appetite on 4/20/19. R1's symptoms continued until 4/23/19. The facility did not complete thorough monitoring or an assessment of R1 during that time and did not keep the physician and POA (Power of Attorney) updated until R1's POA came to the facility on [DATE] and insisted R1 be transferred to the hospital for an evaluation. R1 was transferred to a local hospital, was diagnosed with [REDACTED]. Findings include: R1's physician orders [REDACTED]. R1's MDS (Minimum Data Set) assessment with a ARD (Assessment Reference Date) of 10/16/18, included documentation that R1 had a BIMS (Brief Interview for Mental Status) completed by staff assessment because resident is rarely/never understood (which demonstrated impaired cognition). R1's medical record did not include documentation to include any nurses notes, comprehensive assessment, vital signs, or blood sugar checks from 4/20/19 until 4/23/19. On 4/24/19 at 9:40 AM, the Surveyor interviewed CNA (Certified Nursing Assistant)-B who normally cares for R1 and worked at the facility on 4/20/19-4/21/19. CNA-B stated that on 4/20/19, R1 was not R1's usual self. CNA-B informed the Surveyor R1's facial expressions and overall facial demeanor were different than usual; R1 hands were shaking when holding drinking glasses at meals and R1 was not eating per usual. CNA-B could tell something was wrong with R1. CNA-B reviewed intake charting with the Surveyor and stated R1's meal intake was charted in error for 4/20/19; R1's breakfast should have indicated R1 ate 25% of R1's meal instead of 100% which was incorrectly charted in R1's medical record. CNA-B stated R1 vomited at breakfast on 4/20/19, which was immediately reported to RN (Registered Nurse)-D. CNA-B stated the vomit was a moderate amount with a phlegm consistency. CNA-B was instructed by RN-D to continue to monitor R1. CNA-B stated R1 ate 100% of lunch on 4/20/19. When R1 was finished with lunch and still at the table, R1 vomited again. CNA-B described the vomit as a moderate amount of vomit with a phlegm consistency. CNA-B reported the vomiting along with the other symptoms R1 was presenting to RN-D and RN-D instructed CNA-B to continue to monitor R1. CNA-B stated R1 presented with symptoms on 4/20/19 and continued to decline until R1 was sent to the hospital on [DATE]. CNA-B stated the symptoms were reported daily to nursing staff on 4/20/19 and 4/21/19. CNA-B stated she did not work at the facility on 4/22/19. On 4/24/19, at 10:53 AM, the Surveyor interviewed CNA-C who was working on 4/20/19 and 4/21/19. CNA-C works on the other side of the unit on which R1 resides but provides care for R1 daily by assisting with transfers and activities of daily living. CNA-C stated R1 was not per usual baseline on 4/20/19 and 4/21/19; CNA-C could tell something was not right with R1. CNA-C confirmed R1 had vomited at both breakfast and lunch on 4/20/19. CNA-C stated she had informed RN-D immediately of R1 vomiting so that CNA-B, who was assisting R1 could stay with R1 and assist. CNA-C was not sure what RN-D did with R1 after being informed of R1's condition because CNA-C does not provide direct care to R1. On 4/24/19 at 10:20 AM, the Surveyor interviewed RN (Registered Nurse)-D who informed the Surveyor RN-D was working on the unit on 4/20/19. RN-D stated it was reported to RN-D that R1 was not eating per usual. RN-D did not recall being told about the other symptoms to include R1 vomiting two separate occasions. RN-D stated no further monitoring of R1 occurred, an assessment was not performed and vitals to include a blood sugar were not obtained for R1 on 4/20/19. On 4/26/19 at 9:22 AM., the Surveyor interviewed LPN (Licensed Practical Nurse)-E who worked on the unit where R1 resides on 4/21/19. LPN-E contacted ST (Speech Therapy) on 4/23/19, regarding R1 because it was reported to LPN-E on 4/21/19 and 4/23/19 that R1 had a decrease in appetite and was having difficulty with eating. LPN-E described the difficulty eating as increase in coughing while eating. LPN-E was not aware of R1 vomiting. On 4/25/19 at 10:00 AM., the Surveyor interviewed ST-F who was informed verbally on 4/23/19 of coughing concerns when eating related to R1 over the weekend. On 4/23/19, ST-F completed a screening assessment on R1. ST-F had planned to write orders related to dysphasia (difficulty swallowing) concerns, but R1 was discharged to the hospital, and orders were never completed. On 4/25/19 at 7:08 PM., the Surveyor interviewed CNA-G who worked with R1 on the PM shift on 4/21/19. CNA-G was informed in report on 4/21/19 that R1 had vomited at meals over the weekend. CNA-G stated on 4/21/19, R1 was more talkative than normal on CNA-G's shift. On 4/25/19 at 7:29 PM., the Surveyor interviewed RN-H who worked with R1 on the PM shift on 4/21/19 and 4/22/19. RN-H informed the Surveyor that R1 did not have much of an appetite on 4/21/19 and 4/22/19. RN-H stated that R1 normally has a good appetite, but at supper meals on 4/21/19 and 4/22/19, R1 appeared to only eat a bite or two. On 4/23/19, a fax was sent to the physician from the facility stating, Hallucinating? 'little people' 'talking into computer mouse' very sleepy, does not recognize daughter, coughing up phlegm on food Saturday. Picking at air with fingers, not able to follow simple directions can not answer simple questions. POA concerned gallbladder versus aspiration versus disease process. Previous [MEDICATION NAME] did manage hallucinations in past. Speech Therapy is going to see patient today at lunch swallowing issues The fax documented vital signs such as temperature 96.8 degrees F, pulse 80 beats per minute, and respirations of 18 per minute, blood pressure 138/86, oxygen saturation of 86% of room air, and blood glucose reading of high. On 4/26/19 at 9:10 AM., the Surveyor interviewed RN (Registered Nurse)-J who is the charge nurse on R1's unit and sent the fax to the physician on 4/23/19. RN-J stated the information in the fax was reported to RN-J by R1's PO[NAME] RN-J did not work on 4/20/19 or 4/21/19 and was not aware of R1 throwing up. RN-J stated no concerns related to change of condition were reported to RN-J regarding R1. On 4/23/19 at 12:45 PM., R1's PCP (Primary Care Physician) ordered STAT (urgent) medical laboratory work as a result of the fax sent by RN-[NAME] On 4/23/19 at 3:32 PM., R1's PCP noted R1 had a significant blood glucose elevation, acute kidney injury, and increased white blood cell count. PCP discussed with R1's POA and it was agreed upon to transfer R1 to the hospital emergency room . R1 was noted to have a blood sugar level greater than 800 (less than 140 is considered normal) in the emergency room . An IV (intravenous line) was placed in R1's internal jugular (side of the neck) and R1 was sent to ICU for medial management of DKA (Diabetic Ketoacidosis.) On 04/25/19, the Surveyor interviewed DON (Director of Nursing)-A who was not informed of any information regarding R1 health status until the Surveyor entered the building on 4/25/19. DON-A informed the Surveyor that DON-A reviewed the information regarding R1 and determined a physician was not contacted regarding R1 until 4/23/19 when the POA arrived on the unit and spoke with the charge nurse regarding the condition of R1. DON-A stated R1 was not on the nursing report board from 4/20/19-4/23/19. DON-A stated an assessment was not completed on R1 when R1 had episodes of vomiting and reports were made to RN-D regarding R1's change of condition. DON-A stated an assessment to include vitals should have been completed on R1, along with contact with R1's physician and POA when R1 vomited at breakfast and lunch on 4/20/18, and it after it was reported that R1 had a change in demeanor and decreased appetite.

Based on observation, record review, staff and family interviews, the facility did not ensure that a resident that entered the facility without a pressure ulcer did not develop a pressure ulcer, appropriately assess for pressure ulcer prevention, and/or ensure appropriate pressure ulcer prevention interventions were in place for 6 (residents #1, #2, #3, #4, #5, and #6) of 6 sampled residents. In this citation, resident #1 is considered actual harm isolated (G level); residents #2, #3, #4, #5 and #6 are considered less than actual harm, isolated (severity level 2/potential for harm). 1. Resident #1 was admitted to the facility with a right femur fracture. The facility implemented a plan of care not to reposition the resident when the resident is in bed an claimed that not repositioning the resident was the family's request. The family denies making a request not to reposition the resident. The facility did not have documentation that the risks versus benefits of not repositioning the resident were reviewed with the family member. In addition, the facility did not appropriately complete the Pressure Ulcer Risk Assessment and did not make changes to the document after recognizing the resident's risk assessment was incorrect. The resident's Pressure Ulcer risk results were higher than originally scored. In addition, the facility had completed a sleep study that indicated resident #1 spent 9 - 15 hours in bed without repositioning and the use of an air mattress was not implemented, according to the plan of care. DON (Director of Nursing)-A indicated she requested that an air mattress be placed on resident #1's bed, however this never occurred, according to DON-A. The facility failed to properly assess and implement interventions to prevent pressure ulcers. Resident #1 subsequently developed an unstageable pressure ulcer and a stage III pressure ulcer to the left buttocks. Although resident #1's pressure ulcers were first assessed to be bruises, the facility only provided education to the nurse who documented the inaccurate assessment and did not re-educate all the nurses in the facility on the assessment of pressure ulcers. 2. Resident #2 was admitted to the facility without a pressure ulcer. Resident #2 experienced a decline in condition and the facility did not re-assess the resident's risk factors for the potential to develop a pressure ulcer. The facility did not develop and implement a plan of care for pressure ulcer prevention. Resident #2 developed a purple area to the coccyx and DON (Director of Nursing)-A indicated the purple area was a suspected DTI (deep tissue injury) caused by a surgical procedure that was completed 4 days prior to the development of the purple area. The resident's medical record did not include documentation that an investigation to the causal factor was completed. Documentation indicated resident #2's purple area developed into a stage III pressure ulcer. Although the facility developed and implemented an intervention in the plan of care to reposition resident #2 every two hours and to encourage the resident to lie down between meals, staff did not consistently ask the resident to lie down after meals and staff considered the resident being taken to the bathroom as being repositioned. The facility completed a Braden scale (a tool that is used to identify risk factors for pressure sore development) after resident #2 developed the pressure ulcer. The facility identified the resident not to be at risk for pressure ulcer development. Weekly measurements of the pressure ulcer were not completed. The facility initially identified resident #2's pressure ulcer as a stage III by a Certified Wound Nurse, this was not classified correctly. According to the National Pressure Ulcer Advisory Panel, an ulcer that is covered by 100% of slough is classified as unstageable, as the depth of the wound bed cannot be determined. Resident #2's pressure ulcer treatment was observed and handwashing was not completed per accepted standard of practice. 3. Resident #3 developed a stage II pressure ulcer to the left heel that had healed. The facility implemented a plan of care that indicated to use heel booties in bed. This intervention was not consistently implemented. The plan of care did not address offloading pressure to the resident's heels when the resident was seated in the recliner. Resident #3 was observed to be seated in the recliner with the left heel resting on the foot rest of the recliner. 4. Resident #4, #5 and #6 did not have appropriate pressure ulcer prevention interventions in place, nor did resident #4 have a current Braden assessment completed. Findings include: The facility's Wound Prevention and Management policy and procedure, dated 08/2012, indicated Bethany Home strives to ensure that a resident who is admitted without a pressure ulcer does not develop a pressure ulcer unless clinically unavoidable. 1. According to the undated facesheet, resident #1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 had a previous admission from 8/1/15 to 8/31/15, only weeks before the current admission. Resident #1's Admission MDS (Minimum Data Set) assessment completed on 10/4/15, with an ARD (Assessment Reference Date) of 9/28/15, documented the resident required extensive assistance with three staff physical assistance for bed mobility and transfers. The Nursing Admission Readmission Assessment completed by RN (Registered Nurse)-B dated 9/21/15 at 5:16 p.m., documented the following: ~ Uses 2A (two assist) maxi (lift) for toileting, transfers, and no ambulation. DT (Due to) poor mobility, will be repositioned Q2 (every two hours), PR (Pressure Relieving) cushion in wc (wheelchair) and blue booties when in bed. Here short term and the goal is for (resident #1) to return to Garden Parks once strong enough to do so. Continues to have a small amount of dribbling .Liners for dribbling .Barrier cream as needed. Resident #1's Pain Assessment for Dementia Patients completed by RN-B on 9/21/15 at 1:51 p.m., documented the resident was able to communicate pain verbally and can describe where the pain is located. The assessment documented the resident did not have other behaviors that would indicate the resident was having pain. The findings of the pain assessment were summarized as follows: (Resident #1) states does not have pain, but does in fact have pain to right hip. (Resident #1) will refuse cares and repositioning. Will anticipate pain needs and medicate Q4 (every 4) hours. Resident #1's Pressure Ulcer Risk Assessment completed by RN-B on 9/21/15 at 1:52 p.m., included the following: ~ mobility - very limited, potential for friction or shearing. Potential problem, current activity - walks occasionally. ~ degree of moisture - rarely/never incontinent. ~ nutritional status - usually eats ok. ~ response to pain - adequate response. The results of this assessment indicated the resident scored 19 and was at no risk for pressure ulcer development. This assessment was not consistent with the Nursing Admission Readmission Assessment of no ambulation and the resident's Pain Assessment for Dementia Patients which indicated issues with pain response. A correction to resident #1's Pressure Ulcer Risk Assessment was not completed until 10/2/15, at which time the resident scored 14 and at that time was considered to be a moderate risk for pressure ulcer development. Resident #1 had two unstageable pressure ulcers at that time with no additional change in status or physical decline. On 10/21/15 at 1:00 p.m., surveyor # interviewed WCC (Wound Care Coordinator)/RN-C regarding resident #1. WCC/RN-C stated she felt the 9/21/15 Pressure Ulcer Risk Assessment was accurate, even when presented with the disputing evidence that she, herself commented on the same date. Resident #1's skin condition was documented to have no pressure ulcers or areas of concern to the buttock area. Resident #1's Plan of Care: ~ The IPCTP (Interdisciplinary Plan of Care for Temporary Problems) dated 9/21/15, indicated resident #1 had the following interventions in place: pressure relieving cushion in wheelchair, every two hour repositioning, booties when in bed, per family- allow to sleep through the night. The IPCTP dated 10/1/15, was updated to include three bruises noted to L (left) buttock near coccyx. ~ The IPCTP dated 10/1/15, was updated again, which stated two pressure ulcers to left buttocks with interventions to include: continue with air mattress, and pressure relieving cushions in wheelchair and recliner, reposition every 1 hour and every two hours at night, foam padded [MEDICATION NAME] to right side as well for protection. On 10/2/15, a Roho cushion was ordered. Resident #1 had a Sleep Assessment form completed from 9/21/15 to 9/25/15 and documented resident #1 slept 7.5 hours during the night shift and an average of 9.5 to 15 hours per day were spent in bed, without repositioning. The assessment indicated resident #1 was being left in bed, without assistance to change position for extended periods of time. A Fax Transmittal Sheet dated 10/1/15, documented resident #1 had two unstageable pressure ulcers to the left buttocks; one measuring 3.0 cm (centimeters) by 0.7 cm that was flat and the second pressure ulcer measured 2.1 cm x 0.6 cm that was flat. The areas are purple in color and firm, no drainage was noted and the skin remained intact. On 10/21/15 at 7:30 a.m., surveyor # interviewed POA (Power of Attorney)-D regarding concerns. POA-D stated resident #1 was admitted to the facility for a few weeks in August 2015, following a UTI (Urinary Tract Infection). POA-D indicated the resident was more independent and could reposition self in bed at that time. POA-D indicated she requested staff not wake the resident at night to prevent triggering behaviors. POA-D stated at this current admission she did not request the staff leave the resident in bed without repositioning. POA-D stated she spoke to RN/Manager-E on approximately 9/30/15, but only reviewed medications. POA-D stated she did not review or request anything related to the resident's repositioning schedule. POA-D stated she believed the staff were repositioning the resident while in bed. POA-D also stated she observed an air mattress on resident #1's bed in the previous room occupied by resident #1 at the facility. When resident #1 was moved to her current room on 9/26/15, the air mattress was not moved to the new room. POA-A stated she reported the air mattress not being moved to the room on 9/29/15 to DON-A. On 10/21/15 at 8:29 a.m., surveyor # interviewed DON-A regarding what education was provided relating to appropriate pressure ulcer assessment. DON-A confirmed she only educated one nurse regarding the appropriate pressure ulcer assessment and how to categorize wounds and/or pressure ulcers, rather than all nursing staff. DON-A confirmed she should have educated all the nurses. On 10/21/15 at 9:30 a.m., during an interview with surveyor # , RN-B stated she added the intervention to allow the resident to sleep at night to the IPCTP because she overheard POA-D tell RN/Manager-E that she did not want resident #1 to be disturbed at night. On 10/21/15 at 3:30 p.m., surveyor # interviewed RN/Manager-E regarding POA-D request that resident #1 not be repositioned at night. RN/Manager-E stated she believed she had a conversation with RN-B, POA-D, and herself upon admission (9/21/15) at which time the resident's medications and not waking the resident at night were discussed. Resident #1's medical record did not include documentation that supported RN/Manager-E's conversation with POA-D that included a review of the risks associated with not repositioning the resident were explained to POA-D. On 10/23/15 at 8:50 a.m., surveyor # interviewed the nurse educator, RN-G regarding resident #1. RN-G stated resident #1 was assessed to be at a risk according to the Braden and the resident should have had an air mattress on the bed if the resident was not going to be repositioned at night and also relating to the number of hours the resident spent in bed. On 10/23/15 at 11:00 a.m., surveyor # interviewed DON-A regarding resident #1's air mattress. DON-A stated she told RN-B that resident #1 needed an air mattress and it was never actually placed on the resident's bed. Resident #1's medical record did not include documentation that the resident had received an air mattress on admission. DON-A confirmed that POA-D reported the concern that the air mattress was not on the resident's bed in current room and as a result she questioned staff regarding the air mattress. DON-A stated she did not complete an investigation or provide any education related to resident #1's pressure ulcer development. LIFT SLING, SOAKER PADS: On 10/21/15 at 1:45 p.m., surveyor # interviewed DON-A and WCC RN-C regarding the following entries on resident #1's IPCTP: ~ 10/1/15 - NO soaker pads on cushions. ~ 10/2/15 - Maxi (with) 2A - DO NOT leave sling under (resident #1) after transfers. (Decreases) effect of pressure reduction cushion. DON-A indicated the entry dated 10/2/15, was entered made by herself and it was a reminder for staff not to leave the sling under the resident. DON-A denied POA-D reporting the concern of resident #1 having a sling under the resident. WCC/RN-C indicated stated entered the comment on 10/1/15 after POA-D reported the concern to her. On 10/23/15 at 11:00 a.m., surveyor # interviewed DON-A regarding resident #1. DON-A commented at this time that POA-D did, in fact, report to her that a lift sling was left under the resident, and as a result the IPCTP was changed on 10/2/15. DON-A confirmed she did complete an audit of other residents who utilize the full lift, to monitor if the slings or soaker pads were used in their wheelchairs or on pressure reduction surfaces. DON-A indicated additional staff education was not provided regarding the same. 2. On 10/21/15 at 1:30 p.m., surveyor # observed resident #5 and resident #6 sitting in wheelchairs with soaker pads over their pressure reducing wheelchair cushions. On 10/21/15 at 1:43 p.m., surveyor # observed resident #4 sitting up in a wheelchair in a common area with the left sling left under the resident. During an interview with the surveyor, resident #1 stated the staff leave the left sling under them while sitting in the wheelchair on a daily basis, to get me back to bed. On 10/21/15 at 3:33 p.m., surveyor # interviewed WCC/RN-C regarding the observation of resident #5, resident #6 and resident #4. WCC/RN-C confirmed that residents #5 and #6 had soaker pads on top of their wheelchair cushions. When asked regarding facility's policy regarding the use of soaker pads placed on top of pressure reducing wheelchair cushions, WCC/RN-C stated the facility did not have a policy that discussed that specifically. WCC/RN-C confirmed that it was not good practice to leave lift slings under residents because it can cause skin breakdown and pressure ulcers. BRADEN ASSESSMENT CONCERN: The facility's policy and procedure, noted in the beginning of this document, states the following: Braden assessment shall be completed on all residents during their quarterly review. Resident #4's Braden Assessment was completed 4/10/15 and the resident's score indicated the resident was at minimal risk for the development of pressure ulcers. On 10/21/15 at 3:21 p.m., surveyor # interviewed RN-B regarding resident #4's Braden assessment dated [DATE]. RN-B stated resident #4's Braden assessment dated [DATE] was the most current assessment for the resident. RN-B then stated residents are to have a Braden assessment completed quarterly. 3. On 10/21/15, surveyor # reviewed resident #2's medical record. According to the MDS assessment with an ARD of 05/07/15, resident #2 had [DIAGNOSES REDACTED]. The MDS indicated resident #2 had moderately impaired cognitive skills for daily decision making, required extensive assistance of one staff for bed mobility and limited assistance of one staff for ambulation in the room and hall. The MDS also indicated resident #2 was at risk for pressure ulcer development, but did not have any pressure ulcers. The Departmental Notes dated 05/01/15, indicated the resident was started on [MEDICATION NAME] (an antibiotic) for pneumonia and required oxygen therapy to maintain oxygen saturations above 90% (percent). Resident #2 was seen by a physician on 05/30/15. According to the physician's note, resident #2 seems to be a little more mentally slow. Answers to questions are somewhat slow and ponderous. Weight is at 130 pounds which is down almost 20 pounds over the last month. According to the ADL (Activities of Daily Living) Assistance and Support records. Resident #2 was independent to requiring minimal assistance of one for bed mobility and ambulation in the hall in April 2015. The ADL Assistance and Support records for May 2015, indicated during the month of May resident #2 only ambulated in the hall with staff assistance 8 times. June and July resident #2's ADL Assistance record indicated resident #2 continued not to ambulate with or without staff assistance. The Departmental Notes documented the following regarding resident #2: ~ 06/18/15- seen by a cardiologist (heart doctor) and was diagnosed with [REDACTED]. ~ 06/21/15- required assist of 2 and a mechanical lift. Presents with increased generalized weakness. ~ 06/27/15- lethargic. Had to have cues for eating supper and taking medications and treatments. ~ 07/15/15- left the facility at 5:45 a.m. for the hospital to have the pacemaker generator replaced. The notes indicated the resident returned to the facility just before supper. The Ambulation Flow Sheet indicated for the month of April 2015, resident #2 ambulated independently with a wheeled walker or with assist of one staff. The May Ambulation Flow Sheet indicated resident #2 continued to ambulate with one staff assistance but was starting to refuse ambulation indicating the resident wasn't feeling well or was too weak. Starting on 06/17/15, the Ambulation Flow Sheet indicated resident #2 no longer ambulated through the month of July indicating the resident was too weak. The ambulation program was discontinued on 07/30/15. Surveyor # reviewed resident #2's written Care Plans which were reviewed and revised on 05/21/15. The medical record did not include a care plan from the dates of 05/21/15 to 07/23/15 relating to pressure ulcer prevention. Resident #2's Departmental Notes indicated the following: ~ 07/16/15- found on the floor on their buttocks next to the bed. No injury to buttocks. ~ 07/18/15- small bruised like/fragile area noted to resident's coccyx. When writer asked resident how (resident) fell the other day, the resident stated (resident) fell on (resident's) butt. (written by Certified Wound Care Nurse). ~ 07/19/15- slightly bruised area to coccyx. ~ 07/23/15- pressure ulcer/coccyx resident noted with a stage 3 pressure ulcer to coccyx. Area measures 2.0 cm (centimeter) by 1.3 cm by 0.1 cm with 100% yellow slough Initiated every 2 hour repositioning and to lay down in bed after meals. Resident in agreement. The facility added to the Daily Care Guide on 07/23/15: ~ pressure reduction cushion in wheelchair and recliner ~ continue air mattress ~ every 2 hour repositioning ~ lay down after meals The facility completed an MDS assessment with an ARD of 08/05/15. The assessment indicated resident #2 was alert and oriented, required extensive assistance of 2 staff for bed mobility. Ambulation in the hall required extensive assist of one staff, but the activity only had occurred once or twice during the reference period. The MDS also indicated resident #2 had an unstageable pressure ulcer. The facility completed a Pressure Ulcer Risk Assessment, dated 08/29/15 which indicated resident #2 wasn't at risk for pressure ulcer development. The Daily Care Guide, dated 09/29/15 had an updated problem which indicated, I like to be in my recliner during the day more often. My family is encouraging this. Interventions added were, heel booties on when in bed, lay down in bed after meals, reposition every 2 hours, pressure reduction cushion in wheelchair and recliner. The Departmental Notes indicated pressure ulcer measurements were completed weekly until 10/07/15. There was no documented assessment of the pressure ulcer after 10/07/15. On 10/21/15, surveyor # observed resident #2. Resident #2 was observed seated in the wheelchair throughout the morning and afternoon hours with additional observations as noted: ~ 10:05 a.m.- assisted into the bathroom and immediately returned to the wheelchair. ~ 10:20 a.m.- transferred to bed for a dressing change to the coccyx pressure ulcer. The open area to coccyx was observed to be approximately 1.5 cm by 0.3 cm and the wound bed was covered with 100% yellow slough. The periwound was purple in color and measured approximately 0.5 cm. No evidence of pain with the dressing change. Resident #2 was assisted back into the wheelchair after the completion of the dressing change. On 10/21/15 at 1:45 p.m., surveyor # interviewed RN-F regarding resident #2's decline in status. RN-F indicated prior to summer, the resident was independent. RN-F verified resident #2 had declined in status little by little over the summer. RN-F stated the resident required more staff assistance with all ADL's to include eating. RN-F indicated when resident #2 developed the pressure ulcer, that was when the resident was placed on an every 2 hour repositioning schedule. RN-F stated prior to the development of the pressure sore, the resident utilized some type of pressure reducing cushion in the wheelchair and recliner. On 10/21/15 at 2:15 p.m., surveyor # interviewed CNA (Certified Nursing Assistant)-I regarding resident #2. CNA-I verified she was very familiar with resident #2. CNA-I indicated resident #2 started a decline in condition approximately 6 months prior. CNA-I stated resident #2 was independent and then required one staff assist and progressed to 2 staff assistance. CNA-I indicated resident #2 has intermittent confusion but is able to verbalize her needs and requests to use the bathroom. CNA-I stated the resident is able to make small movements and shift changes, but would be unable to make complete repositioning changes. CNA-I indicated when resident #2 developed the pressure ulcer, the facility implemented an every 2 hour repositioning schedule. CNA-I indicated resident #2 prefers to stay up in the wheelchair during the day. CNA-I stated pressure reducing mattress and cushions were standard devices for all residents. On 10/21/15 at 2:30 p.m. and 2:50 p.m., surveyor # interviewed WCC/RN-C regarding resident #2. WCC/RN-C stated resident #2's pressure ulcer had not been measured since 10/07/15 because she completes the measurements and she was ill the previous week. WCC/RN-C indicated if she wasn't at work the nurses are to complete the measurements and assessments. WCC/RN-C stated she would be completing the assessment with measurements tomorrow (10/22/15). WCC/RN-C stated there wasn't a standard of practice for how often a pressure ulcer should be measured. WCC/RN-C stated the facility uses the National Pressure Ulcer Advisory Panel as their standard of practice. WCC/RN-C stated the wound care certification class does not teach how often a pressure ulcer needs to be measured. Surveyor # and WCC/RN-C reviewed resident #2's medical record. WCC/RN-C verified she was the first staff to document on the resident's pressure ulcer on 07/23/15. WCC/RN-C stated she typically is not the first staff to document on concerns, unless a CNA came to her and told of the skin concern. WCC/RN-C stated she could not recall how the pressure ulcer was first discovered in July. WCC/RN-C indicated the cause of the pressure ulcer was from pressure. Surveyor # asked how the pressure ulcer developed and WCC/RN-C replied from pressure. WCC/RN-C verified resident #2 was placed on an every 2 hour repositioning schedule when the pressure ulcer developed, and was not on a repositioning schedule prior. WCC/RN-C stated the intervention to lay down after meals was also added after the development of the pressure ulcer. Surveyor # and WCC/RN-C reviewed the CNA charting. WCC/RN-C verified resident #2 was mostly independent with ADL's and starting in May started with a slow decline in condition requiring staff assistance. WCC/RN-C indicated when resident #2 required more assistance with ADL's, the resident would have been at higher risk for pressure ulcer development and staff should have implemented a plan of care to prevent pressure ulcer development. WCC/RN-C stated staff had told her that the resident only made minimal movement independently and not complete repositioning. Surveyor # observed resident #2 sitting up in the wheelchair from 8:00 a.m. to 4:00 p.m., with the exception when the resident was taken to the bathroom and placed in bed to have the dressing changed to the coccyx. On 10/22/15 at 8:55 a.m., surveyor # interviewed CNA-I regarding resident #2. CNA-I stated the resident does stay up in the wheelchair during the morning and staff usually ask after lunch if the resident would like to lie down. Surveyor # reminded CNA-I the resident was up in the wheelchair all day on 10/21/15. CNA-I verified the resident did remain sitting up in the wheelchair, but stated she attended an activity in the afternoon. CNA-I indicated when the resident is toileted that was considered repositioning as pressure is relieved during transfer. On 10/22/15 at 10:00 a.m., surveyor # observed resident #2 sitting up in the wheelchair in the resident's room. Resident #2 stated staff do not ask (resident) if (resident) would like to lay down after meals. Resident #2 stated if staff asked, (resident) would like to lay down at times. Resident #2 indicated it would depend on how they felt and if wanted to attend an activity. Resident #2 stated doesn't want to bother staff so doesn't ask them to lay down. Resident #2 indicated staff changed the wheelchair cushion this morning and didn't know why. On 10/22/15 at 10:10 a.m., surveyor # interviewed RN-E regarding resident #2 stating the wheelchair cushion was changed. RN-E stated she didn't know anything about a cushion change for resident #2. RN-E indicated if the cushion was changed, WCC/RN-C would have changed the cushion. On 10/22/15 at 12:20 p.m., surveyor # interviewed WCC/RN-C. WCC/RN-C verified she had changed resident #2's cushion this morning. WCC/RN-C indicated she changed the cushion because the cushion was very dirty and she placed a clean cushion that was the same type. WCC/RN-C indicated the specialty cushion was applied to resident #2's wheelchair on 07/23/15. WCC/RN-C stated multiple different kinds of cushions were tried prior, but the resident complained of discomfort. WCC/RN-C indicated the resident hasn't complained of any comfort concerns since the current cushion was placed on 07/23/15. WCC/RN-C stated the facility does not track what type of mattresses or cushions are placed and when they are placed. WCC/RN-C indicated the air mattress the resident was using could have been on since admission to the facility. WCC/RN-C and surveyor # reviewed the Pressure Ulcer Risk assessment that was completed on 08/29/15. WCC/RN-C verified the assessment indicated the resident was not at risk for pressure ulcer development even though the resident had acquired a pressure ulcer. WCC/RN-C indicated the assessment is only a tool that is used and nurse should use their judgement as well. WCC/RN-C verified a plan of care for pressure ulcer prevention was not developed and implemented until resident #2 developed a stage III pressure ulcer. WCC/RN-C indicated she was unaware if any staff had identified the resident's change in condition and increase risk factors prior to the development of the pressure ulcer. WCC/RN-C verified she could not locate documentation in the medical record that indicated when staff identified resident #2's decline in condition, which should have triggered a Pressure Ulcer Risk Assessment to be completed. WCC/RN-C stated the bruise on the resident's coccyx that was discovered on 07/18/15, was caused by the resident's fall on her buttocks that occurred on 07/16/15. WCC/RN-C indicated it was possible the resident sustained [REDACTED]. On 10/22/15 at 1:30 p.m., surveyor # observed WCC/RN-C complete a dressing change on resident #2's pressure sore located on the coccyx. Resident #2 was lying on their right side in bed. WCC/RN-C washed her hands and applied gloves. WCC/RN-C removed the soiled dressing which was noted to have yellow drainage on the dressing. WCC/RN-C proceeded to cleanse the pressure sore with soap and water and rinse and dried the area. WCC/RN-C removed the gloves and without washing or sanitizing her hands, applied clean gloves. WCC/RN-C proceeded to measure the pressure sore. The measurements were 1.5 cm by 0.5 cm with 100% firm yellow slough on the wound bed. WCC/RN-C covered the pressure sore with the prescribed dressing. WCC/RN-C proceeded to remove her gloves and wash her hands. On 10/22/15 at 1:35 p.m., surveyor # interviewed WCC/RN-C regarding handwashing and wound care. WCC/RN-C verified the above observation that she had not changed her gloves and washed/sanitized her hands after removing the soiled dressing and before cleansing of the wound. WCC/RN-C also verified she hand not washed/sanitized her hands between glove changes. WCC/RN-C stated she was not required to wash/sanitize her hands as she had not contaminated her hands. On 10/22/15 at 4:00 p.m., during the exit conference, DON-A and NHA (Nursing Home Administrator)-J were made aware of the above concerns. DON-A stated the pressure ulcer had developed from a suspected deep tissue injury from which the resident had sustained during the surgical procedure that was completed on 07/15/15. 4. On 10/21/15, surveyor # reviewed resident #3's medical record. According to the [DIAGNOSES REDACTED].#3 had [DIAGNOSES REDACTED]. Resident #3's Departmental Notes indicated the following: ~ 09/16/15- Pressure ulcer/left heel . resident has a stage 2 pressure ulcer to left heel. Area is blistered and skin intact. Measures 1.8 cm by 3.5 cm. The resident continues on an air mattress, heel booties in bed, pressure reducing cushion in wheelchair and every 2 hour repositioning . ~ 10/08/15- Pressure ulcer to left heel is resolved. The facility developed a plan of care I require assist with my mobility needs and I am at risk for skin breakdown related to weakness and debilitation secondary to [MEDICAL CONDITION], diverticulitis, [MEDICAL CONDITIONS] arthritis, normal pressure [DIAGNOSES REDACTED] and cervical lumbosacral spondylosis. I also have a history of [MEDICAL CONDITION] and psoriasis. I currently have a stage 2 pressure ulcer to my heel, dated 09/15/15 (care plan dated prior to first entry of pressure ulcer in the medical record). The interventions included the following: ~ Every 2 hour repositioning. ~ Air mattress. ~ Heel booties when in bed. ~ Pressure reduction cushion in the wheelchair. (There were no interventions addressed on the plan of care for when the resident was seated in the recliner). On 10/21/