Every finding on record at Brown CTY Comm Treatment CTR-Bayshore Village

Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated to initiate a PASRR Level II Screen for 1 resident (R) (R6) of 17 sampled residents.Since R6's PASRR Level 1 Screen on 2/14/02, R6 was prescribed antipsychotic medication and had a significant change in status. The facility did not update R6's PASRR Level I Screen and submit for Level II reevaluation.Findings include:From 3/2/26 to 3/4/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, unspecified dementia, insomnia, and anxiety disorder. R6's Minimum Data Set (MDS) assessment, dated 1/12/26, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R6 had moderate cognitive impairment. R6 had a Guardian who was responsible for R6's healthcare decisions.R6's PASRR Level I Screen, dated 2/14/02, indicated R6 had a major mental illness and was prescribed a major tranquillizer and/or an antipsychotic medication. The Level I Screen also indicated R6 had cognitive deficits due to dementia. Based on the information provided on the Level I Screen, the facility submitted for a PASRR Level II Screen which was completed on 3/5/02.R6's medical record indicated R6 was prescribed the following medications with contributing diagnoses that were not reflected on R6's PASRR Level I or Level II Screens:~ Haloperidol (an antipsychotic medication) 10 millgrams (mg) twice daily for schizophrenia (starting on 12/18/15)~ Risperidone (an antipsychotic medication) 0.5 mg three times daily for schizophrenia (starting on 12/18/15)Psychiatry notes from Advanced Practice Nurse Prescriber (APNP)-G, dated 12/30/25, 1/28/26, and 2/25/26, indicated R6 had hallucinations.R6's medical record did not contain an updated PASRR Level I or PASRR Level II Screen that indicated R6 received haloperidol and risperidone and/or had symptoms of mental illness, including hallucinations.On 3/4/26 at 9:49 AM, Surveyor interviewed Certified Social Worker (CSW)-F regarding R6's PASRR Level I and Level II Screens. CSW-F indicated the facility did not complete any PASRR screenings for R6 since 2002 because R6 did not have a change in payor source, a need for specialized services, or a new mental health diagnosis. Surveyor reviewed R6's PASRR Level I with CSW-F and indicated there were no antipsychotic medications listed on the PASRR and the PASRR indicated R6 did not have hallucinations. Surveyor and CSW-F also reviewed R6's progress notes which indicated R6 had hallucinations. CSW-F verified R6's PASRR Level I Screen should be updated and submitted for PASRR Level II reevaluation.

Based on observation, staff interview, and record review, the facility did not ensure 15-minute checks were consistently completed for 1 resident (R) (R54) of 2 sampled residents.R54 was at risk for elopement. R54's care plan contained an intervention for staff to complete 15-minute checks at all times (dated 2/10/26). Between 2/10/26 and 3/3/26, R54's 15-minute checks were not consistently completed.Findings include: The facility's Elopement/Absent Without Leave (AWOL) policy, revised 12/2024, indicates: It is the policy of the facility to provide specific strategies for healthcare personnel in the event a consumer attempts to leave the facility .without notifying appropriate healthcare personnel of his/her intentions to do so. The specific strategies will also apply if a consumer's whereabouts are unknown .Elopement: The act of a consumer leaving the immediate building or facility grounds without permission. The consumer does not have prior-authorization to leave but does .Wandering: A consumer who strays beyond the view or control of staff without the intent of leaving .Observed Departure: An event in which the consumer intends to leave, but remains within the line of sight by healthcare personnel .It is the responsibility of all healthcare personnel to immediately report any consumer whose whereabouts cannot be determined or who is knowingly attempting elopement. Elopement can be a planned or impulsive act. Risk factors for elopement include confusion .history of elopement, problem solving skills .history of wandering .Healthcare personnel are to make all attempts to keep the eloping consumer within a line of sight, if the elopement attempt is observed .From 3/3/26 to 3/4/26, Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE] and had diagnoses including dementia with psychotic disturbance, delusional disorder, wandering, and anxiety. R54's Minimum Data Set (MDS) assessment, dated 12/17/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R54 had moderately impaired cognition. R54 had an activated Power of Attorney (POA).A care plan, revised 2/10/25, indicated R54 was at risk for elopement and wandering. R54 had a WanderGuard due to impaired cognition and exit-seeking behavior. The care plan also indicated R54 was at moderate risk for falls due to the use of assistive devices, a decrease in muscle coordination, and a history of multiple falls in the facility.An elopement risk decision tree assessment, dated 9/30/25, indicated R54 was at risk for elopement, (Of note: The last paragraph of the assessment indicated: If Yes to any of the above, consider implementing elopement prevention measures such as 15-minute checks or a WanderGuard). R54's nursing progress notes indicated the following:~ On 3/2/26, R54 wandered to the Blue Ridge unit multiple times on the PM shift (which is separated from R54's unit by double glass doors).~ On 3/1/26, R54 was awake all shift, paced the hall, and attempted to exit the unit. R54 exited to the Meadowview unit and was redirected by staff.~ On 2/18/26, R54 wandered off the unit and was redirected by staff. R54 continued to attempt to leave and was redirected several times.~ On 2/6/26, R54 had increased exit-seeking behaviors. R54 exited the unit, sat in the town hall, and was redirected by staff. ~ A psych note, dated 1/7/26, indicated nursing staff reported exit seeking behavior for R54.Surveyor reviewed R54's 15-minute check sheets and noted the following:~ On 2/16/26 from 3:00 PM to 8:45 PM, twenty-three 15-minute checks were not documented.~ On 2/19/26 from 3:00 PM to 5:45 PM, eleven 15-minute checks were not documented. From 11:00 PM to 11:45 PM, three 15-minute checks were not documented. ~ On 2/27/26 from 7:00 PM to 10:45 PM, fifteen 15-minute checks were not documented.~ On 3/2/26 from 7:15 PM to 10:45 PM, fourteen 15-minute checks were not documented.On 3/3/26 at 10:42 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who confirmed that R54 wandered and exit sought. CNA-H stated R54 did not have a WanderGuard.On 3/3/26 at 1:25 PM and 1:32 PM and on 3/4/26 at 11:19 AM, Surveyor interviewed Registered Nurse (RN)-C who indicated R54 used to reside on another unit and thinks R54 still lives there. RN-C verified R54 is on 15-minute checks and staff complete 15-minute check sheets every shift. RN-C and Surveyor reviewed a 15-minute check sheet, dated 3/2/26, that indicated 15-minute checks were not completed from 7:15 PM to 10:45 PM. RN-C verified CNAs are responsible for completing and documenting 15-minute checks. RN-C stated agency staff get busy, forget, and don't document. RN-C indicated R54 was on 15-minute checks after 8:00 PM prior to 2/12/26; however, the checks were upgraded due to R54's increased wandering. RN-C stated RN-C reports missing safety checks to RN-C's supervisor.On 3/4/26 from 9:00 AM to 12:00 PM, Surveyor observed R54 and noted a 15-minute check was completed at 9:14 AM. At 9:32 AM, staff had not checked on R54 who was in another resident's room. The resident asked Surveyor to get a nurse to remove R54 from the room. Surveyor informed Life Enrichment Supervisor (LES)-I who assisted R54 to R54's room.On 3/4/26 at 1:00 PM and 3:06 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility audits 15-minute check sheets to ensure they are completed each shift. DON-B verified several sheets were not completed. DON-B indicated R54 previously had a WanderGuard; however, R54 could remove the WanderGuard and did not leave the premises. DON-B indicated a WanderGuard was unnecessary for R54 and was for residents who had a pattern of leaving the unit. DON-B confirmed CNAs are responsible for completing and documenting 15-minute checks. DON-B was not aware that R54's safety checks were not consistently documented. Surveyor referred to a progress note, dated 3/2/26 at approximately 9:50 PM, that indicated R54 wandered to another unit that was separated by glass doors. When Surveyor indicated 15-minute checks were not documented on 3/2/26 from 7:15 PM to 10:45 PM, DON-B stated R54 can go to the neighborhood next door because it is the same unit and staff work both units together. DON-B indicated the nurse who charted on R54 on 3/2/26 was watching R54 which is why it was documented in a progress note. DON-B verified the 15-minute check sheets didn't indicate the same. On 3/4/26 at 3:10 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated R54's unit and the Blue Ridge unit are considered different units. LPN-D stated CNAs are designated to each unit and a float CNA goes between the units.On 3/4/26 at 3:10 PM, Surveyor interviewed CNA-J who was assigned to the Blue Ridge unit. CNA-J indicated R54's unit and the Blue Ridge unit are considered a household and staff work as a team; however, CNA-J's duties are on the side on which CNA-J is assigned. CNA-J stated each unit has one CNA and there is a float (who goes between the units) for the AM and PM shifts. CNA-J works on CNA-J's assigned unit unless alerted via walkie talkie that help is needed on the other unit. CNA-J stated residents usually stay on their units but occasionally wander and are redirected. CNA-J indicated 15-minute check documentation includes codes for the resident's activity and location and should be completed as soon as possible. CNA-J verified residents occasionally wander though the automatic push doors and are redirected back to their unit. On 3/4/26 at 3:14 PM, Surveyor interviewed CNA-E who ensures 15-minute checks are completed by taking the clipboard and documenting after CNA-E makes contact with R54. CNA-E indicated if there are missing entries on the 15-minute check sheets, it could mean the checks were not done. CNA-E verified R54 can exit through the unit's automatic push doors independently and go to the town square which is on the way to the main exit.On 3/5/26, Surveyor requested the facility's wandering, supervision, and/or monitoring policy via email. Surveyor received an email from Nursing Home Administrator (NHA)-A that indicated the facility does not have a policy related to wandering, supervision, or monitoring,

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 61 residents residing in the facility. The facility did not cool pre-cooked leftover food with an approved cooling method. Findings include: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at section ,d+[DATE].14 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S ,d+[DATE].14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial kitchen tour with Dietary Manager (DM)-C on [DATE] that began at 8:28 AM, Surveyor noted the freezer contained pre-cooked leftover food items labeled with use-by dates. DM-C verified the facility kept leftovers. Surveyor observed the following leftover foods in the freezer: ~Lasagna with a use-by date of [DATE] ~Meatloaf with a use-by date of [DATE] ~Veggie lasagna with a use-by date of [DATE] ~Hot dogs with a use-by date of [DATE] ~Pizza casserole with a use-by date of [DATE] ~Chopped fish with a use-by date of [DATE] ~Two containers of bacon with use-by dates of [DATE] ~Pureed ham with gravy with a use-by date of [DATE] ~Ground ham with a use-by date of [DATE] ~Ribs with a use-by date of ,d+[DATE] ~Macaroni and cheese with a use-by date of [DATE] ~Pork ribs with a use-by date of [DATE] ~Minestrone soup with a use-by date of [DATE] ~Tuna noodle casserole with a use-by date of [DATE] ~Tuna noodle casserole with a use-by date of [DATE] ~Clam chowder with a use-by date of [DATE] ~Corn chowder with a use-by date of [DATE] ~Sausage gravy with a use-by date of [DATE] ~Pork ribs with a use-by date of [DATE] ~Taco meat with a use-by date of [DATE] ~Philly steak with a use-by date of [DATE] ~Lemon pepper chicken with a use-by date of [DATE] ~Cheeseburger casserole with a use-by date of [DATE] ~Loaded baked potato soup with a use-by date of [DATE] ~Roast chicken with a use-by date of [DATE] ~Two containers of loaded baked potato soup with use-by dates of [DATE] Surveyor reviewed the kitchen's food cooling logs. Surveyor noted there were no cooling log for October and November (2024) and noted the food observed in the freezer was not listed on the cooling logs provided. Surveyor interviewed DM-C who indicated DM-C would speak with [NAME] (CK)-D because DM-C was new and unsure of the process. Following the interview with DM-C, Surveyor interviewed CK-D who indicated the food in the freezer was leftovers and labeled with use-by dates which were three months after the cooked dates. When Surveyor asked about the expired items, CK-D indicated the dates were most likely mistakes, but because the items were not documented on the cooling log there was no way to ensure that. CK-D indicated the food in the freezer was not cooled using the facility's blast chiller and was not documented on the logs with an appropriate cooling method because that has never been the process. CK-D indicated the blast chiller was only used to cool roasts and pork loins. CK-D indicated food was left to cool and then labeled and stored in the freezer for future use.

Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 7 Residents (R) (R16, R8, R1, R2, R14, R20 and R53) of 20 sampled residents. R16's Quarterly MDS assessment, dated 8/1/23, did not contain a Brief Interview for Mental Status (BIMS) assessment (used to determine level of cognition). A progress note, dated 8/8/23, indicated R16 had mild cognitive impairment. In addition, the MDS inaccurately indicated R16 had a physical restraint. R8's Quarterly MDS assessment, dated 7/7/23, did not contain a BIMS assessment. R1's Quarterly MDS assessment, dated 6/13/23, contained a BIMS score of 4 out of 15 which indicated R1 had severely impaired cognition; however, R1 is able to communicate. R2's Annual MDS assessment dated [DATE], contained a BIMS assessment that indicated R2 is rarely/never understood; however, R2 is able to communicate. R14's Quarterly MDS assessment, dated 6/16/23, indicated R14's side rail was a physical restraint. R14's medical record indicated the side rail was for therapeutic use and contained an assessment for independent use, and consent. R20 was enrolled in Hospice services. R20's Quarterly MDS assessments, dated 6/14/23 and 3/16/23, indicated R20 was not enrolled in Hospice services. R53's Quarterly MDS assessment, dated 7/26/23, did not contain a BIMS assessment to determine R53's level of cognition. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual (a guide for completing MDS assessments (a screening and assessment tool which forms the foundation of a comprehensive assessment and is used to guide care planning and monitoring for residents) reads: Section C: Cognitive Patterns, Intent: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in many care planning decisions .Most residents are able to attempt the Brief Interview for Mental Status (BIMS). A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance . - Without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis. - Structured interviews will efficiently provide insight into the resident's current condition that will enhance good care . Coding Tips: * Attempt to conduct the interview with ALL residents . * Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted but was not done. Section P: Restraints and Alarms, Intent: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices, or an alarm was used, at any time during the day or night, during the 7-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories. - Bed rails used with residents who are immobile - If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. For residents who have no voluntary movement, the staff need to determine if there is an appropriate use of bed rails. The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last revised 8/2021, included the following: 1. Upon admission, with significant changes in the resident's status, and annually, the interdisciplinary team (IDT) will complete a comprehensive assessment in accordance with timeframes per regulatory requirements. In addition, a quarterly review assessment is completed. A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently then once every 3 months. a. The facility must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care . The facility's Restraints Policy, last reviewed 6/2018, included the following: The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that: prohibits the use of physical restraints for discipline or convenience; prohibits the use of physical restrains to unnecessarily inhibit a resident's freedom of movement or activity; and limits physical restraint use to circumstances in which the resident had medical symptoms that may warrant the use of restraints .4. A physical restraint assessment must be completed a minimum of quarterly for the duration of restraint use and as otherwise indicated with significant change in condition or resolve of the medical symptoms that required the use of the restraint . 1. R16 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure, anxiety, and depression. R16's Quarterly MDS assessment, dated 8/1/23, indicated R16's BIMS was not assessed. A progress note, dated 8/8/23, indicated R16 had a BIMs score of 7 out of 15 which indicated R16 had severely impaired cognition. On 8/28/23 at 10:18 AM, Surveyor interviewed R16 who was able to communicate and answer Surveyor's questions appropriately. Surveyor observed R16 sitting upright in bed with a tray table and personal items within reach. Surveyor also noted half rails on each side of R16's bed. From 8/28/23 through 8/30/23, Surveyor reviewed R16's medical record and noted the following: ~A Quarterly MDS assessment, dated 8/1/23, indicated R16's BIMS was not assessed. ~Quarterly MDS assessments, dated 5/4/23 and 11/8/22, indicated R16 was rarely/never understood. Staff assessments indicated R16 had moderately impaired cognition. ~An Annual MDS assessment, dated 2/2/23, indicated R16 was rarely/never understood. A staff assessment indicated R16 had moderately impaired cognition. A psychosocial note, dated 8/8/23, indicated an assessment was completed on 8/3/23 and R16's BIMS score was 7 (out of 15) (which indicated R16 had severely impaired cognition). R16's Quarterly MDS assessment, dated 8/1/23, also indicated R16 had a physical restraint of a bed rail that was used daily. R16's most recent occupational therapy assessment, dated 4/27/23, indicated R16 was able to turn/roll in bed using enabler bars (U-bars). R16's most recent therapy service screen, dated 7/24/23, indicated R16 was able to feed self, use enabler bars for positioning, and had no reported concerns of decreased range of motion since the last assessment. A bed rail assessment, dated 8/8/23, indicated R16 was not at risk for entrapment. On 8/30/23 at 9:32 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who indicated R16 is independent with bed mobility and can use the bed remote control to raise and lower the head of the bed. LPN-G also indicated R16 lifts R16's legs and is able to pull R16's body side-to-side using the bed rails. LPN-G indicated R16 requests to stay in bed for other health reasons, but is not immobile or bed bound. On 8/30/23 at 9:54 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who stated R16 is weak and does not walk, but is able to move in bed independently. CNA-H indicated R16 helps with care, but needs assistance from staff. R16 can activate the call light and communicate R16's needs to staff. On 8/30/23 at 12:38 PM, Surveyor interviewed LPN-J who verified R16 is interviewable. 2. R8 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, and dementia. R8's Quarterly MDS assessment, dated 7/7/23, indicated R8's BIMS was not assessed. On 8/28/23, Surveyor interviewed R8 who was able to communicate with Surveyor and make R8's needs known. During the interview, R8 was eating independently in a wheelchair. From 8/28/23 through 8/30/23, Surveyor reviewed R8's medical record and noted the following: ~A Quarterly MDS assessment, dated 4/7/23, contained a BIMS score of 5 out of 15 which indicated R8 had severely impaired cognition. 47248 3. On 8/30/23, Surveyor reviewed R1's medical record. R1 had to diagnoses including dementia, seizure disorder, anxiety, depression, and schizophrenia. R1's Quarterly MDS assessment, 6/13/23, contained a BIMS score of 4 out of 15 which indicated R1 was severely cognitively impaired. R1's medical record contained the following MDS assessments: ~Quarterly MDS assessments, dated 9/12/22 and 12/12/22, and an Annual MDS assessment, dated 3/13/23, indicated R1 was rarely/never understood. Staff assessment indicated R1 had moderately impaired cognition. The MDS' also indicated there was not an acute change in R1's baseline mental status. A progress note, dated 6/20/23, indicated the following: BIMS score of 4 out of 15. (R1) repeated all three words and recalled none. (R1) stated the correct day of the week, however, was incorrect on the month and year. PHQ-9 (Patient Health Questionnaire) (used to diagnose and monitor the severity of depression) score of 5 (which indicates either no or subthreshold depression). (R1) stated (R1) sometimes feels down/depressed, has trouble sleeping, feels tired, feels bad about (R1's) self, and has trouble concentrating. The MDS indicated R1 had verbal aggression, delusions, hallucinations and insomnia, refused care, screamed (not at others), and was agitated, and anxious R1's medical record did not contain a Significant Change assessment that indicated a change in cognition or ability to communicate. 4. On 8/30/23, Surveyor reviewed R2's medical record. R2 had diagnoses including anxiety, depression, schizophrenia, and renal insufficiency. R2's Annual MDS assessment, dated 5/25/23, indicated R2 was rarely/never understood. A staff assessment indicated R2 had moderately impaired cognition. The MDS did not indicate there was an acute change in R2's baseline mental status and R2 is able to communicate. R2's medical record contained the following MDS assessments: ~Quarterly MDS assessments, dated 2/22/23, and 11/23/22, contained BIMS scores of 12 out of 15 which indicated R2 had moderately impaired cognition. 5. On 8/28/23 at 10:13 AM, Surveyor interviewed R14 who indicated R14 used a side rail on R14's bed to assist with sitting up, rolling, and for stability during cares and transfers. R14 stated R14 used the bed rail daily and required the bed rail to remain independent. On 8/28/23, Surveyor reviewed R14's medical record. R14 had diagnoses including diabetes type 2 with diabetic neuropathy, contracture of muscle, right hand and left hands, difficulty in walking, and non-pressure ulcer of left heel and midfoot limited to breakdown of skin. R14's Quarterly MDS assessment, dated 6/16/23, contained a BIMS score of 15 out of 15 which indicated R14 had intact cognition. The MDS also indicated R14 had a bed rail that was used daily and considered a physical restraint. R14's medical record contained the following information: ~An occupational therapy Enabler Bar Assessment, dated 7/25/23, indicated R14 utilized the left U bar bed rail independently, and refused other options such as raising the head of the bed, and a lipped mattress or trapeze. Education was provided to R14 on the risks of the enabler bar, including the risk of entrapment. R14 declined to have the enabler bar removed. ~A Side Rail Informed Consent indicated an assessment was completed to determine the appropriateness of the grab bar/side rail, and the risks and benefits of use. The document was signed by R14 on 8/22/23. R14's medical record did not contain a Physical Restraint Assessment. 6. On 8/29/23, Surveyor reviewed R20's medical record. R20 had diagnoses including Huntington's disease. R20's Quarterly MDS assessment, dated 6/14/23, indicated R20 was rarely/never understood. A staff assessment indicated R20 had severely impaired cognition. R20 was admitted to Hospice services on 1/6/20. R20's medical also included the following: ~Quarterly MDS assessments, dated 3/16/23 and 6/14/23, indicated R20 was not enrolled in Hospice services. ~A skilled nursing compliance physician note, dated 3/28/23, indicated R20 was enrolled in Hospice services. ~An Annual MDS assessment, dated 12/14/22, indicated R20 was enrolled in Hospice services. 32768 7. On 8/30/23, Surveyor reviewed R53's medical record. R53 was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, transient ischemic attack, psychoactive substance induced mood disorder, frontal lobe and executive functional deficit. On 8/28/23, Surveyor toured the facility and interviewed R53 who indicated things are going well and staff treat R53 well. R53 was able to make R53's needs known and ambulated on the unit independently. R53's Admission MDS assessment, dated 4/25/23, contained a BIMS score of 8 out of 15 which indicated R53 had moderately impaired cognition. Surveyor reviewed R53's Quarterly MDS assessment, dated 7/26/23, and noted R53's BIMS was not assessed. On 8/30/23 at 10:30 AM, Surveyor interviewed MDS Coordinator (MDSC)-E who stated MDSC-E was under the impression side rails should be coded as physical restraints. MDSC-E indicated most of the resident who use half side rails use them to get up to the bathroom, assist themselves out of bed, and for bed mobility. MDSC-E did not feel the side rails met the description of a physical restraint. On 8/30/23 at 11:15 AM, Surveyor interviewed Social Services Director (SSD)-I who stated SSD-I was trained that if a resident's BIMS assessment takes place after the MDS ARD (assessment reference date), SSD-I should mark Not Assessed and make sure the assessment is entered in the resident's medical record for reference. When Surveyor asked SSD-I to provide BIMS assessments for all sampled residents marked as Not Assessed on their MDS', SSD-I was unable to provide BIMS assessments for those marked as Not Assessed. On 8/30/23 at 1:22 PM, Surveyor again interviewed SSD-I regarding why residents' BIMS are documented inconsistently from quarter to quarter such as a BIMS of 15 one quarter, rarely/never understood the next quarter and then a BIMS of 7 or not assessed the next quarter. SSD-I indicated some residents refuse the assessment depending on their mood, and SSD-I completes the BIMS assessment after completion of the MDS. SSD-I then documents the BIMS score in a progress note in the resident's medical record. SSD-I was unclear why rarely/never understood was selected when residents refused an assessment rather than not assessed as the resident was not assessed due to refusal or inability of the resident to participate in the assessment at that time.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R259) and their Guardian of 20 sampled residents were offered care conferences and involved in continued care planning. R259's last care conference was completed in March of 2023. Staff verified a care conference should be offered every 3 months or more frequently if needed. Findings include: The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, history and preferences and information required by the resident assessment instrument (RAI) using the Minimum Data Set 3.0 (MDS) and evidence-based, discipline specific assessment tools. The information will be used to develop, with the input and participation of the resident and resident representative, a comprehensive person-centered care plan. Procedure: Upon admission, with a significant change in the resident's status, and annually, the interdisciplinary team (IDT) will complete a comprehensive assessment in accordance with timeframes per regulatory requirements. In addition, a quarterly review assessment is completed. A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently then once every 3 months .Quarterly care conferences will be held with invitations to resident and resident representative(s) .The resident and resident representative will be encouraged to review the care plan and provide input after each review and/or revision .The resident/resident representative has the right to participate in the development and implementation of his or her person-centered plan of care including, but not limited to: the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care .The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must: facilitate the inclusion of the resident/resident representative .the facility will assist residents/resident representatives with understanding the assessment and care planning process and will hold care plan review conferences at the time of day most advantageous for a resident/resident representative to be able to attend, if they so desire. Care review conferences will be held following admission, quarterly, with change of condition, prior to planned discharges and at other intervals as needed. On 8/29/23, Surveyor reviewed R259's medical record. R259 had diagnoses including schizophrenia, dementia, anxiety disorder, polydipsia (a disorder that causes extreme thirst), AEB (as evidenced by) hallucinations, excessive fluid seeking including drinking out of faucets and toilets, as well as delusional/paranoid statements. In addition, R259's MDS assessment, dated 2/10/23, indicated R259 required the assistance of one staff for ambulation and extensive assistance for all other activities of daily living, including toileting and catheter care. The MDS assessment contained a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R259 had moderately impaired cognition. R259 had a court-ordered Guardian and was protectively placed in the facility. R259's medical record also indicated the following: ~An Annual MDS assessment was due on 6/10/23, but was not completed. A Quarterly MDS assessment was due on 8/10/23, but was not completed. A care conferences was also not completed between March and August of 2023. On 8/30/23 at 12:31 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated it is the facility's policy to complete all assessments and care conferences quarterly, annually, and as needed. NHA-A also indicated R259's last care conference was in March of 2023. NHA-A verified Social Services Director (SSD)-I is responsible for scheduling care conferences with residents and resident representatives. On 8/30/23 at 12:33 PM, Surveyor interviewed SSD-I who indicated the practice for completing and scheduling assessments and care conferences occurs when department staff are alerted that assessments are due through a monthly report provided by MDS Coordinator (MDSC)-E. SSD-I indicated after the report is received, SSD-completes sections of the assessments and schedules care conferences with residents and/or their representative(s). SSD-I confirmed R259's last care conference was in March of 2023. SSD-I could not provide an explanation why R259's most recent Quarterly and Annual MDS assessments were not completed, and why a care conference was not scheduled.

Based on staff interview and record review, the facility did not ensure the medical record of 2 Residents (R) (R54 and R42) of 7 residents reviewed for code status contained an advance directive/code status that was consistent with the residents' wishes. R54 had a code status of do not resuscitate (DNR). R54's care plan identified R54 as a full code. R42 had a code status of DNR. R42's care plan identified R42 as a full code. Findings include: The facility's Code ER, Medical Emergencies, Cardiopulmonary Resuscitation and Defibrillator Use Policy, revised ,d+[DATE], contained the following information: Code Status is verified by observing the legal document in the client/resident chart or electronic medical record prior to performing CPR (cardiopulmonary resuscitation). The code status is reviewed upon admission, quarterly and with a significant change in condition. If the resident/resident representative indicates/signs No CPR in the advanced directives, as defined in Wisconsin State Statute 154.17 (2), a DNR order directs emergency medical technicians, first responders, and emergency health care facility's personnel, not to attempt CPR on the person for whom the order is issued if that person suffers cardiac or respiratory arrest. 1. On [DATE], Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance and adult failure to thrive. R54 was cognitively impaired and required assistance with activities of daily living (ADLs). R54 was under Guardianship. R54's medical record contained a document titled Emergency Care Do Not Resuscitate (DNR) signed by R54's physician on [DATE]. A progress note, dated [DATE] at 2:11 PM, stated, State advanced directive form sent to guardian. A progress note, dated [DATE] at 11:14 AM, stated, State DNR form received from representative. This was given to APNP (Advanced Practice Nurse Prescriber) and signed. Code status changed to DNR. R54's care plan, dated [DATE], indicated R54 was FULL CODE STATUS and contained the following interventions: - Resident/Resident Representative's request will be honored while in this facility. - Nursing staff will initiate CPR and transfer Resident to the hospital of choice. - Resident/Resident Representative will be notified with any change in condition. - Staff will review with Resident/Resident Representative any changes in code status at each care conference and PRN (as needed). 2. On [DATE], Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of bladder and adult failure to thrive. R42 was not cognitively impaired, but required set-up assistance with ADLs. R42's medical record contained a document titled Emergency Care Do Not Resuscitate (DNR) signed by R42 on [DATE] and by R42's physician on [DATE]. R42's care plan, dated [DATE], indicated R42 was FULL CODE STATUS and contained the following interventions: - Nursing staff will initiate CPR and transfer Resident to the hospital of choice. - Resident/Resident Representative will be notified with any change in condition. - Staff will review with Resident/Resident Representative any changes in code status at each care conference and PRN. On [DATE] at 9:56 AM, Surveyor interviewed Registered Nurse (RN)-C and Licensed Practical Nurse (LPN)-D who indicated if they came upon a pulseless and non-breathing resident, RN-C and LPN-D would confirm the resident's code status in the paper chart or would check the resident's code status on the face sheet in the electronic medical record. On [DATE] at 9:50 AM, Surveyor interviewed RN-C who indicated both R54 and R42 were DNR status. RN-C verified both R54 and R42's care plans indicated R54 and R42 were full code status, but should reflect DNR status. On [DATE] at 10:00 AM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-E who indicated MDSC-E should be notified of a change in code status by the staff member who receives the change.

Based on staff interview and record review, the facility did not complete a comprehensive Annual Minimum Data Set (MDS) assessment within the required timeframe for 1 Resident (R) (R259) of 20 sampled residents. R259's Annual MDS assessment, due on 8/11/23, was marked in process. The Annual assessment was not completed and was 17 days overdue. Findings include: The Resident Assessment Instrument (RAI) Manual, revised October 2019, indicates: The annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days .Assuming the resident did not experience a significant change in status, was not discharged , and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment. The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, history and preferences and information required by the resident assessment instrument (RAI) using the Minimum Data Set 3.0 (MDS) and evidence-based, discipline specific assessment tools. The information will be used to develop, with the input and participation of the resident and resident representative, a comprehensive person-centered care plan. Procedure: Upon admission, with a significant change in the resident's status, and annually, the interdisciplinary team (IDT) will complete a comprehensive assessment in accordance with timeframes per regulatory requirements . On 8/28/23, Surveyor reviewed R259's medical record. R259 had diagnoses including schizophrenia, dementia, anxiety disorder, polydipsia (a disorder that causes extreme thirst), AEB (as evidenced by) hallucinations, excessive fluid seeking including drinking out of faucets and toilets, as well as delusional/paranoid statements. In addition, R259 had a court-ordered Guardian and was protectively placed in the facility. R259's medical record indicated R259's last Quarterly MDS assessment was completed on 2/10/23. An Annual MDS assessment was due on 8/11/23. Surveyor noted an Annual MDS assessment, dated 8/28/23, was in progress, but was not completed. On 8/30/23 at 11:57 AM, Surveyor interviewed MDS Coordinator (MDSC)-E regarding R259's last MDS assessment (dated 2/10/23) and indicated an Annual MDS assessment was due on 8/11/23, but not yet completed. MDSC-E confirmed R259's Annual MDS assessment was overdue and stated, We missed (R259). MDSC-E did not provide an explanation why the Annual assessment was not completed. On 8/30/23 at 12:31 PM, Surveyor interviewed Nursing Home Administrator(NHA)-A who indicated it is the facility's policy to complete all MDS assessments quarterly, annually, and as needed. NHA-A was not aware R259's last MDS assessment was completed in February of 2023 and that R259's Annual MDS assessment was not completed and was overdue. On 8/30/23 at 12:33 PM, Surveyor interviewed Social Services Director (SSD)-I who indicated the practice for completing and scheduling MDS assessments occurs when department staff are alerted through a monthly report provided by MDSC-E that assessments are due. SSD-I confirmed an Annual MDS assessment for R259 was not completed by 8/11/23 as required.

Based on staff interview and record review, the facility did not complete a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for 1 Resident (R) (R259) of 20 sampled residents. R259's last Quarterly MDS assessment was completed on 2/10/23. R259's next Quarterly MDS assessment (due in May of 2023) was not completed. Findings include: The Resident Assessment Instrument (RAI) Manual, revised October 2019, indicates: .Assuming the resident did not experience a significant change in status, was not discharged , and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment. The facility's Resident Assessment, Baseline Care Plan and Care Plan Policy, last reviewed 8/2023, indicated: The facility shall prepare an interdisciplinary comprehensive assessment of the resident's needs, strengths, goals, history and preferences and information required by the resident assessment instrument (RAI) using the Minimum Data Set 3.0 (MDS) and evidence-based, discipline specific assessment tools. The information will be used to develop, with the input and participation of the resident and resident representative, a comprehensive person-centered care plan. Procedure: Upon admission, with a significant change in the resident's status, and annually, the interdisciplinary team (IDT) will complete a comprehensive assessment in accordance with timeframes per regulatory requirements. In addition, a quarterly review assessment is completed. A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently then once every 3 months . On 8/28/23, Surveyor reviewed R259's medical record. R259 had diagnoses including schizophrenia, dementia, anxiety disorder, polydipsia (a disorder that causes extreme thirst), AEB (as evidenced by) hallucinations, excessive fluid seeking including drinking out of faucets and toilets, as well as delusional/paranoid statements. In addition, R259 had a court-ordered Guardian and was protectively placed in the facility. R259's medical record indicated R259's last Quarterly MDS assessment was completed on 2/10/23. Surveyor noted a Quarterly MDS assessment (due 5/10/23) was not completed within three months and was overdue. On 8/30/23 at 11:57 AM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-E regarding R259's MDS assessment (dated 2/10/23) and indicated a Quarterly assessment was not completed since that date. MDSC-E confirmed R259's Quarterly MDS assessment was overdue and stated, We missed (R259). MDSC-E did not provide an explanation why the assessment was not completed. On 8/30/23 at 12:31 PM, Surveyor interviewed Nursing Home Administrator(NHA)-A who indicated it is the facility's policy to complete all quarterly assessments as needed. NHA-A was not aware R259's last Quarterly MDS assessment was completed in February of 2023 and that R259's next Quarterly MDS assessment was not completed and was overdue. On 8/30/23 at 12:33 PM, Surveyor interviewed Social Services Director (SSD)-I who indicated the practice for completing and scheduling assessments occurs when department staff are alerted that assessments are due through a monthly report provided by MDSC-E. SSD-I confirmed a Quarterly MDS assessment for R259 was not completed in May of 2023 as required. SSD-D was unsure why the Quarterly assessment was not completed.

Based on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, and administered for 3 Residents (R) (R18, R8, and R26) of 5 residents reviewed for vaccines. The facility did not review R18's vaccination history or offer R18 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20(R)) vaccine. The facility did not review R8's vaccination history or offer R8 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20(R)) vaccine. The facility did not review R26's vaccination history or offer R26 the PCV20: 20-valent pneumococcal conjugate (Prevnar 20(R)) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The most recent CDC (Centers for Disease Control and Prevention) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. The facility's Resident Immunizations Policy, last revised 8/2019, included the following: .2. Pneumonia Vaccine a. Upon admission .residents [AGE] years and older and residents designated as high risk for pneumonia who have not received the pneumonia vaccine will be offered the vaccination. b. Pneumococcal vaccination will be offered and administered per the Prevnar 13/pneumococcal vaccine policy following the CDC guidelines . 1. R18 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease. R18 received the PPSV23 vaccine on 12/19/03 and the PCV13 vaccine on 5/18/15. R18's medical record did not indicate R18 was offered or administered the PVC20 vaccine. 2. R8 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, and dementia. R8 received the PPSV23 vaccine on 10/26/15 and the PCV13 vaccine on 3/4/17. R8's medical record did not indicated R8 was offered or administered the PCV20 vaccine. 3. R26 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, and peripheral vascular disease. R26 received the PPSV23 vaccine on 1/31/14 and the PCV13 vaccine on 6/23/15. R26's medical did not indicate R26 was offered or administered the PCV20 vaccine. On 8/29/23 at 11:16 AM, Surveyor interviewed Infection Preventionist (IP)-K who indicated IP-K completed an audit on residents for the PCV20 vaccine, but was also focused on Respiratory Syncytial Virus (RSV) vaccination. IP-K stated IP-K would review the audit tool to see if anything was completed for R18, R8, and R26. On 8/30/23, Surveyor confirmed with IP-K and Director of Health Services (DHS)-F that there was no documented information regarding the PCV20 vaccine for R18, R8, and R26.

Based on observation, staff interview, and record review, the facility did not ensure food was prepared, stored, and served under sanitary conditions. Outdated and undated products were stored for 5 Residents (R) (R15, R27, R35, R54, and R157) of 60 residents. Staff did not date or did not discard food and beverages after seven days of constitution or opening for community use beverages and R15, R27, R35, R54, and R157's individually labeled items. Kitchenette ovens had baked food debris, in varying amounts, in the interior of oven. Findings include: On 9/6/22 at 8:36 AM, Surveyor interviewed Dietary Manager (DM)-I who indicated the facility used the Food and Drug Administration (FDA) Food Code as its standard of practice. Undated and Outdated Beverages FDA Food Code 2017 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 On 9/6/22, following initial tour of main kitchen beginning at 8:36 AM, Surveyor and DM-I entered [NAME] Way unit where Surveyor observed and DM-I verified the refrigerator held one 64 ounce (oz) container of cranberry juice cocktail was open and undated. DM-I expressed uncertainty regarding how quickly the unit used a container of cranberry juice cocktail, verified cranberry juice cocktail should have been dated upon opening, and directed a staff member to discard cocktail. Refrigerator also contained approximately a quarter of a sandwich labeled for R54 with no date. DM-I verified the sandwich required a date. On 9/6/22 at 9:24 AM, Surveyor and DM-I proceeded to Clover unit where Surveyor observed and DM-I verified a 64 oz container of orange juice was open and undated in the refrigerator. Surveyor and DM-I proceeded to [NAME] unit which where Surveyor observed and DM-I verified the refrigerator contained an open, undated 64 oz container of orange juice. On 9/6/22 at 9:37 AM, Surveyor and DM-I entered Stony unit where Surveyor observed and DM-I verified the refrigerator held a container of nectar thickened flavored water labeled as constituted for R35's use on 8/28/22, a container of nectar thickened coffee labeled as constituted for R35's use on 8/29/22, a container of honey thickened chocolate milk labeled as constituted for R15's use on 8/28/22, a container of pudding thickened chocolate milk labeled as constituted for R27's use on 8/29/22, and a container of soy milk, open and undated, labeled for R157's use. DM-I verified all alternate thickness beverages should have been discarded after day 7 from date of constitution and R157's soy milk should have been open dated. Soiled Ovens FDA Food Code 2017 documents at 4-601.11(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 9/6/22 from 8:36 AM through 9:37 AM, Surveyor observed and DM-I toured unit kitchenettes. Surveyor and DM-I entered Clover unit. Surveyor observed black, baked on food in bottom of unit oven. DM-I confirmed the oven was not clean and explained the oven was seldom used and kitchenette ovens were not on a cleaning schedule. Surveyor and DM-I entered [NAME] unit. Surveyor proceeded to open oven and felt handle was sticky to touch. DM-I then touched handle and confirmed handle was sticky. Surveyor observed crumbs in bottom of oven. DM-I confirmed oven was not clean and identified activities department as the only oven user. Surveyor and DM-I entered Stony unit. Surveyor observed Stony unit oven had aluminum foil stuck to the racks with what DM-I described as pizza drippings hanging from racks; black baked food residue was in bottom of oven. Surveyor and DM-I entered Willow unit. Surveyor observed and DM-I verified the oven bottom was soiled.

Based on Observations, record review and staff interview, the facility did not ensure 2 Residents (R) (R16 and R34) of 5 sampled residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers (injuries) from developing. R16 was observed sitting in chair with cushion and towel over cushion for two days of survey. R34 was observed sitting in recliner without cushion in recliner for 2 of the survey days. Findings include: Facility follows AHRQ (Agency for Healthcare Research and Quality) as a guide for Pressure Injury (PI) prevention. R34 was admitted to facility on 6/18/22 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's MDS (Minimum Data Set) assessment dated [DATE] indicated that R34 required extensive assistance with bed mobility, transfers, dressing and hygiene. R34's skin condition record dated 6/18/22 indicated that R34 had an opening on left buttock measuring 9 cm (Centimeters) long and 0.5 cm wide. Opening was resolved on 6/29/22. R34's Braden Risk Assessment scale dated 6/18/22 indicated R34 had moderate risk for the development of PI and the Braden Risk assessment dated [DATE] indicated R34 was at risk for the development of PI. R34's care plan dated 7/15/22 indicated pressure relieving cushion in wheelchair or recliner to protect skin in wheelchair or recliner. On 8/7/22 at 9:26 AM Surveyor observed R34 in recliner sitting on a cloth pad with no cushion in chair. On 8/7/22 at 10:22 AM Surveyor observed R34 sitting in recliner on a cloth pad with no cushion in recliner. On 8/8/22 at 9:22 AM Surveyor observed R34 sitting in recliner on a cloth pad with no cushion in chair. On 8/8/22 at 10: 02 AM Surveyor observed R34 sitting in recliner on a cloth pad with no cushion in chair. On 8/8/22 at 10:06 AM Surveyor interviewed R34 and R34 indicated they sit in recliner most of the day and also sleeps in recliner at night. R34 was not aware whether there was a cushion under them. On 8/8/22 at 10:52 AM Surveyor and the DON (Director of Nursing)-B went into R34's room to observe R34. DON-B verified there was no cushion in R34's recliner and only a cloth pad. DON-B verified that R34 should have a cushion in the recliner where R34 is sitting. 2. R16 was admitted to facility on 7/28/15 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's MDS assessment dated [DATE] indicated that R16 required extensive assistance with bed mobility, transfers, toileting, dressing and hygiene and R16 was at risk for the development of PI. The most recent care plan for R16 documented the following interventions: pressure reducing device in chair (cushion), pressure reducing device in bed, turn and reposition program On 09/06/22 at 10:57 AM Surveyor observed R16 sitting in wheelchair on a cushion with towel over cushion. On 09/06/22 at 12:19 PM Surveyor observed R16 sitting in wheelchair on a cushion with towel over cushion. On 09/07/22 at 08:32 AM Surveyor observed R16 sitting in wheelchair on a cushion with towel over cushion. On 09/07/22 at 09:52 AM Surveyor observed R16 sitting in wheelchair on a cushion with towel over cushion. On 9/8/22 at 10:42 AM Surveyor interviewed DON-B. DON-B verified that a towel should not be over cushion in R16's wheelchair.

Based on staff interview and record review, the facility did not implement the abuse prevention policy requiring background checks for 1 (Facility Worker (FW)-F) of 8 sampled staff. Facility did not obtain a response from Department of Health Services (DHS) Integrated Background Information System (IBIS) information prior to hiring FW-F. Findings include: Wisconsin (WI) Caregiver Program Manual, revision dated January 2020, documents At a minimum, a complete caregiver background check completed for a caregiver consists of the following three documents: .3. A 'Response to the Caregiver Background Check' letter from DHS that reports the person's status, including administrative finding or licensing restrictions. Facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Resident and Client Property Policy, revision dated 3/2022, Employee Screening and Training. B. Prospective employees will need to have a successful completion of criminal background checks. On 9/6/22 and 9/8/22, Surveyor observed FW-F working in facility. On 9/7/22, Surveyor selected sample of 8 staff to review for background checks. Surveyor noted FW-F did not have a DHS response with paperwork and payment receipt which usually documents $7.00 for Department of Justice (DOJ) check and $3.00 for DHS check ($10.00 total) documented $7.00 instead of $10.00 paid. On 9/7/22 at 11:25 AM, Director of Nursing (DON)-B verified DHS response was not with FW-F's background check paperwork. DON-B indicated background checks were completed by off-site Human Resources (HR) department. On 9/7/22 at 11:30 AM, Surveyor interviewed HR-G, a generalist at the HR office, via telephone. HR-G indicated another person typically runs background checks for employees with FW-F's work classification. At 1:07 PM, HR-G explained to Surveyor via telephone that FW-F's file was reviewed by HR on 9/7/22 and FW-F's DHS check was not run. FW-F indicated an oversight must have occurred.

Based on staff interviews and record review, the facility did not ensure a Resident (R) prescribed a high risk medication had a care plan developed to monitor for possible side effects for 3 (R19, R42, and R47) of 18 sampled residents. The facility did not develop a care plan to monitor for possible side effects of R19's opioid (narcotic pain relief) and diuretic (commonly referred to as a water pill) medications. The facility did not develop a care plan to monitor for possible side effects of R42's antidepressant and opioid medications. The facility did not develop a care plan to monitor for possible side effects of R47's antipsychotic medication. 1. From 9/6/22 through 9/8/22, Surveyor reviewed R19's medical record which documented R19's prescriptions included [MEDICATION(S)] (opioid medication) twice per day and up to two additional times per day as needed. R19's prescriptions also included [MEDICATION(S)] (diuretic medication) daily. Surveyor noted R19's medical record did not contain monitoring for possible negative side effects for opioid (such as respiratory depression) and diuretic use (such as dehydration). On 9/8/22 at 11:22 AM, Surveyor interviewed Registered Nurse (RN)-H, who verified being responsible for minimum data set information and contributing to nursing care plan development. RN-H confirmed side effect monitoring was not in place for R19's opioid and diuretic medications. 2. From 9/6/22 through 9/8/22, Surveyor reviewed R42's medical record which documented R42's prescriptions included [MEDICATION(S)] (antidepressant medication) daily and [MEDICATION(S)] (opioid medication) four times per day and up to four additional times per day as needed. Surveyor noted R42's medical record did not contain monitoring for possible negative side effects for antidepressant (such as dizziness and [CONDITION(S)]) and opioid medications. On 9/8/22 at 11:08 AM, Director of Nursing (DON)-B verified to Surveyor that R42 did not have a care plan to monitor for possible negative side effects related to R42's opioid and antidepressant medication use. 3. From 9/6/22 through 9/8/22, Surveyor reviewed R47's medical record which documented R47's prescriptions included [MEDICATION(S)] (antipsychotic medication) daily. Surveyor noted Tardive Dyskinesia (TD) monitoring was completed every six months and no other monitoring for possible negative side effects for antipsychotic medication (such as dizziness and sedation) was in place. On 9/8/22 at 10:06 AM, DON-B indicated to Surveyor that DON-B would review R47's medical record for monitoring plans. Only TD monitoring was submitted to survey team.

Based on record review, staff interview and resident representative interview, the facility did not document or make prompt efforts to resolve grievance for 1 Resident (R) (R306) of 18 sampled residents. Social Worker (SW)-J and Registered Nurse (RN)-L heard R306's Power of Attorney (POA)-M's verbal grievance regarding lack of activities and request for activity calendar but did not document, resolve or report the grievance to grievance official, SW-J. Findings include: The facility's Policy titled Grievance Policy-Bayshore Village revised on 09/2022. Policy: . each Resident has the right to voice grievances to the facility. Definitions: Voice grievances are not limited to a formal, written grievance process but may include a Resident's verbalized complaint to facility staff. Prompt efforts to resolve include facility acknowledgment of complaint/grievances and actively working toward resolution of that complaint/grievances. Grievance Official is an individual who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions. Procedures: H. Response 1. Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate the complaint to their supervisor and the facility Grievance Official. 1.On 09/07/22 at 11:05 a.m., Surveyor interviewed POA-M, who expressed R306's psychosocial needs are not being met due to lack of activities and desired to see what activities are being offered. POA-M verbalized POA-M had requested an activity calendar on two different occasions. First occasion from Social Worker (SW)-J via e-mail on 8/22/22. and second occasion from Registered Nurse (RN)-L via telephone on 8/29/22. POA-M has not received any further follow-up from the facility. Surveyor reviewed the facility's Grievance Notebook and noted R306's Representative's request for activity calendar grievance was not documented. 2. On 09/08/22 8:01 a.m., Surveyor interviewed SW-J who confirmed the e-mail dated 8/22/22 from POA-M with the following message R306 says there is nothing to do activity-wise. I am wondering if there is an activity calendar or anything like that or an activity director so we can give him/find him things to do. SW-J's replied to POA-M did not address the activity calendar. SW-J verbalized the e-mail was not clear in requesting an activity calendar. 3. On 09/08/22 at 2:26 p.m., Surveyor interviewed RN-L, who confirmed speaking with POA-M regarding activity calendars. RN-L did not realize POA-M wanted a copy of the activity calendar. RN-L confirmed RN-L did not inform POA-M where activity calendars were posted and did not offer POA-M any activity calendar. 4. On 09/08/22 at 12:06 p.m., Surveyor interviewed SW-K who confirmed role as facility Grievance Official. SW-K did not think the request for an activity calendar was considered a grievance, however SW-K would have reviewed the e-mail and would have given POA-M a more formal response. Surveyor reviewed POA-M's e-mail with SW-K and SW-K agreed the e-mail was considered a concern grievance. SW-K was not aware until 9/8/22 and verified there was no documentation regarding POA-M's grievance.

Based on observation, interview, and record review, the facility did not ensure the resident environment was free of accident hazards for 1 Resident (R) (R42) of 4 sampled residents reviewed for fall safety. R42 was not appropriately secured into R42's wheelchair with the seat belt while unsupervised as assessed and care planned. Findings Include: R42 was admitted in 2019 with [CONDITION(S)] (CHF), chronic [CONDITION(S)], diabetes mellitus type 2, unspecified displaced fracture of second cervical vertebra, major depressive disorder, and dementia without behavioral disturbance. R42's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated R42's Brief Interview for Mental Status (BIMS) was unable to be completed, indicating, No (resident is never/rarely understood.) On 9/7/22 at 7:45 AM, Surveyor interviewed R42's legal guardian (LG)-E . LG-E stated R42 had a seat belt that needed to be applied while R42 is in R42's wheelchair. LG- stated R42 had two irreparable breaks in R42's neck and is ordered to wear a cervical collar. LG-E stated when LG-E was visiting on Saturday, 9/3/22, LG-E needed to remind staff to put R42's seat belt on. R42 stated the facility does not leave R42's door opened per care plan. On 9/6/22, Surveyor reviewed R42's record which included a provider note dated 7/25/2022 3:37 PM which stated, [R42] utilizes a seatbelt while seated in [R42's] wheelchair. The seatbelt is indicated for use by the following information: Per [named clinic and provider], there is an old fracture that has not healed properly. There likely is a fibrous non union of two pieces of bone of C2 (second cervical vertebrae.) Options given were to continue in the Cervical Collar for the rest of [R42's] life, or fusion of C1/C2. It has been decided to remain wearing the Cervical Collar due to the dangers of fusion at C1/C2. Per [named provider], any injury to the neck or wrong movement of the neck could result in a devastating spinal cord injury, including death. Therefore, it is imperative that [R42] utilize the seatbelt at all times while in [R42's] wheelchair. On 9/6/22 at 4:04 PM, Surveyor observed Certified Nursing Assistants (CNA)-C and CNA-D transfer R42 from bed into R42's wheelchair. R42 was provided a call-light and staff and Surveyor exited R42's room. On 9/6/22 at 4:26 PM, Surveyor interviewed CNA-C regarding R42's seat belt. CNA-C stated R42's seat belt was on. Surveyor requested to observe and verify that R42's seat belt was properly secured. R42's door was opened approximately four to six inches, not allowing R42 to be in direct supervision. CNA-C lifted R42's blanket and the seat belt was not fastened. CNA-C fastened R42's seat belt. CNA-C stated R42's seat belt needed to be on most of the time. R42's therapy note dated 7/13/22 stated R42's wheelchair positioning included the use of a seat belt. R42's care plan related to seat belt use included: Seat belt may be removed under direct staff supervision when [R42] is up in W/C (wheelchair.) On 9/6/22 at 4:45 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R42's seat belt. DON-B stated R42's seat belt should be on while R42 is in R42's wheelchair and not under direct supervision. yes it should have been on while he was in his wheelchair and not in direct supervision.

Based on record review and staff interview, the facility did not ensure 1 of 1 allegations of abuse were reported to the State Agency as required for 1 sampled Resident (R) (R1). On 1/18/22, R1's family member reported to the facility that R1 stated a man had come into R1's room and took R1's clothes off. This allegation of abuse was not reported to the State Survey Agency. Findings include: The facility's policy entitled Abuse, Neglect, Mistreatment, and Misappropriation of Resident and Client Property Policy, revised [DATE], stated: Brown County Community Treatment Center will encourage and support all residents, staff, families, visitors, volunteers, and Resident Representatives to report any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property .The Hospital and Nursing Home Administrator (NHA) or designee will report any incidents of suspected 'abuse' to the state agency per State and Federal Requirements. R1 was admitted to the facility under Emergency Protective Placement on 1/3/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/18/22, R1's family member told Registered Nurse (RN)- E that R1 stated a man entered R1's room and took R1's clothes off. RN-D's statement, dated 1/20/22, indicated, R1 reported to a Licensed Practical Nurse (LPN), who immediately informed RN-D, that a man had come into R1's room in the dark and took off R1's clothes. These allegations were reported to DON-B and/or NHA-A. The investigation into this allegation did not include R1's family member's statement or any other resident interviews. On 2/21/22 at 1:14 P.M., the Surveyor interviewed NHA-A, who verified that these allegations were not reported to the State Survey Agency. NHA-A stated that the facility did not report these allegations of abuse because R1 regularly makes false accusations and no staff matched R1's description.

Based on record review and staff interview, the facility did not ensure 1 of 1 allegation of abuse involving 1 sampled Resident (R) (R1) was thoroughly investigated. On 1/18/22, R1's family member reported to the facility that R1 stated a man had come into R1's room and took R1's clothes off. This allegation was not thoroughly investigated by the facility to rule out abuse. Findings Include: The facility's policy entitled Abuse, Neglect, Mistreatment, and Misappropriation of Resident and Client Property Policy, revised [DATE], states: When an incident or suspected incident of 'abuse' is reported, the NHA or designee will investigate the incident with the assistance of appropriate personnel .The investigation will include: who was involved, resident/client statements, interviews with involved staff and witness statements of events (include the first staff member to arrive or respond to the incident, a description of the resident's behavior and environment at the time of the incident, an estimated time of when the resident/client was last visualized, environmental observations that could have contributed to the event, and a conclusion based on the findings. R1 was admitted to the facility under Emergency Protective Placement on 1/3/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/18/22, R1's family member told Registered Nurse (RN)- E that R1 stated a man entered R1's room and took off R1's clothes. RN-D's statement, dated 1/20/22, stated R1 reported to a Licensed Practical Nurse (LPN), who immediately informed RN-D, that a man had come into R1's room in the dark and took off R1's clothes. These allegations were reported to DON-B and/or NHA-A. The investigation into this allegation did not include R1's family member's statement or any other resident interviews. On 2/9/22, the facility submitted a Self-Report to the State Agency regarding allegations of neglect and misappropriation of property. A police report submitted with the investigation indicates R1's family member told the police about a a male entering [R1's] room and undressing [R1] without [R1's] permission. The report also states that DON-B informed officers that the facility was already investigating all alleged abuse by staff. The facility's investigation did not include any documentation or information regarding the allegation of abuse against R1.

Based on record review and staff interview the facility did not ensure all allegations of abuse were reported to the State Survey and Certification Agency (SSCA) for 1 Resident (R) (R52) of 2 residents reviewed for abuse. On 4/13/21, R52 reported to facility staff that agency Licensed Practical Nurse (LPN)-G swore at R52 and shoved pills into R52's mouth. The facility did not report this allegation of abuse to the SSCA. Findings include: The facility's Abuse, Neglect, Mistreatment, and Misappropriation of Resident and Client Property Policy, with a review date of 10/2020, states, Residents and clients will remain free from abuse, neglect, misappropriation of resident property, and exploitation. Any employee or volunteer who becomes aware of an abuse, mistreatment, neglect, exploitation or misappropriation shall report the abuse immediately to the Hospital and Nursing Home Administrator. The Hospital and Nursing Home Administrator or designee will report any incidents of suspected abuse to the state agency per State and Federal Requirements. The policy also defines verbal abuse as the use of speech, sound, writing or gestures that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Physical abuse, as defined in the facility policy, includes hitting, slapping, punching, and kicking. It also includes controlling behavior through corporal punishment. Physical abuse includes the use of physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident/client's medical symptoms. R52 admitted to the facility on [DATE]. Per R52's most recent Quarterly Minimum Data Set (MDS) assessment, dated 6/17/21, R52 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated R52 was cognitively intact. On 7/27/21 at 9:39 AM, Surveyor reviewed the facility's grievance file. Surveyor noted a grievance form, dated 7/13/21, that stated on 7/12/21 at approximately 9:00 PM, LPN-G had entered R52's room and asked R52 if R52 wanted R52's pills. R52 indicated that R52 did not hear LPN-G at that time. The grievance then documented that LPN-G swore at R52 and shoved pills in mouth. The grievance did not include documentation that the potential abuse was reported to the SSCA. On 7/27/21 at 9:58 AM, Surveyor attempted to interview R52 related to the grievance. R52 indicated that R52 did not want to speak to Surveyor about the incident with LPN-G. At 10:12 AM, Surveyor interviewed Registered Nurse (RN)-F who filled out the initial grievance form. RN-F explained that R52 came to RN-F on 7/13/21 to discuss the incident with LPN-G that occurred on 7/12/21. RN-F indicated that RN-F began filling out the grievance form as R52 doesn't usually bring stuff like that up, and the details of the incident seemed important. RN-F further explained that the facility had other issues with LPN-G, and LPN-G's contract with the facility was terminated. RN-F was unable to offer more specifics into what the other reported concerns with LPN-G included. RN-F stated that RN-F immediately brought R52's grievance to the Director of Nursing (DON)-B and the Social Worker (SW)-H. At 11:00 AM, Surveyor interviewed SW-H related to R52's grievance. When asked by Surveyor about an in-depth investigation and report into R52's allegations, SW-H explained on 7/13/21, SW-H spoke with R52 about the incident with LPN-G. SW-H indicated that R52 just wanted to tell staff about the incident and not report it. At 11:35 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about R52's allegation. NHA-A indicated that NHA-A felt the risk to residents was mitigated when LPN-G's contract with the facility was terminated. NHA-A further explained that SW-H's interview with R52 did not lead the facility to determine the allegation was significant to warrant further investigation. NHA-A indicated that allegations of abuse are reported to the SSCA and warrant further investigation per the facility policy.

Based on staff interviews and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R52) of 2 residents reviewed for abuse. On 7/13/21, R52 reported to facility staff that agency Licensed Practical Nurse (LPN)-G swore at R52 and shoved pills into R52's mouth The facility did not conduct an investigation into this allegation to include staff interview or additional resident interviews. Findings include: The facility's policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident and Client Property, with a review date of 10/2020, states: Investigation Investigation of Abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. It is the responsibility of all staff to cooperate during the investigation to assure the resident/client is fully protected. The investigation will include: -Who was involved -Resident/client statement -For non-verbal or cognitively impaired resident/clients who need to be interviewed, an evaluation of the resident/client's behavior, affect, and response to interaction must be documented. -Interviews with involved staff and witness statements of events -Include the first staff member to arrive or respond to the incident. -A description of the resident/client's behavior and environment at the time of the incident -An estimated time of when the resident/client was last visualized -Injuries present, including a resident/client physical assessment -Observation of resident/client and staff behaviors during the investigation -Environmental observations that could have contributed to the event -Conclusion based on the findings On 7/27/21 at 9:39 AM, Surveyor reviewed the facility's grievance file. Surveyor noted a grievance form, dated 7/13/21, that stated on 7/12/21 at approximately 9:00 PM, LPN-G had entered R52's room and asked R52 if R52 wanted R52's pills. R52 indicated that R52 did not hear LPN-G at that time. The grievance then documented that LPN-G swore at R52 and shoved pills in mouth. Surveyor requested facility documentation related to R52's grievance. The facility provided Surveyor with a written statement from Social Worker (SW)-H, dated 7/13/21, and a written statement from Scheduling Coordinator (SC)-J dated 7/28/21. Surveyor noted facility-provided documentation did not include interview with accused staff, additional resident interviews, or additional staff interviews. On 7/27/21 at 9:58 AM, Surveyor attempted to interview R52 related to the grievance. R52 indicated that R52 did not want to speak to Surveyor about the incident with LPN-G. At 10:12 AM, Surveyor interviewed Registered Nurse (RN)-F who filled out the initial grievance form. RN-F explained that R52 came to RN-F on 7/13/21 to discuss the incident with LPN-G that occurred on 7/12/21. RN-F indicated that RN-F began filling out the grievance form as R52 doesn't usually bring stuff like that up, and the details of the incident seemed important. RN-F further explained that the facility had other issues with LPN-G, and LPN-G's contract with the facility was terminated. RN-F was unable to offer more specifics into what the other reported concerns with LPN-G included. RN-F stated that RN-F immediately brought R52's grievance to the Director of Nursing (DON)-B and the Social Worker (SW)-H. RN-F indicated to Surveyor that RN-F did not participate in any further investigation of the allegations. At 11:00 AM, Surveyor interviewed SW-H related to R52's grievance. When asked by Surveyor about an in-depth investigation and report into R52's allegations, SW-H explained that, on 7/13/21, SW-H spoke with R52 about the incident with LPN-G. SW-H indicated that R52 just wanted to tell staff about the incident and not report it. SW-H confirmed with Surveyor that no additional resident or staff interviews had been collected. At 11:35 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about R52's allegation. NHA-A indicated that NHA-A felt the risk to residents was mitigated when LPN-G's contract with the facility was terminated. NHA-A further explained that SW-H's interview with R52 did not lead the facility to determine the allegation was significant to warrant further investigation. NHA-A confirmed with Surveyor that abuse allegations are investigated per policy, reported per regulatory timeframes and would include additional interviews and supporting documentation.

Based on interview and record review, the facility did not ensure comprehensive and quarterly review assessments included the Resident or the Resident's Representative for 2 Residents (R) (R6 and R10) of 19 Residents reviewed for comprehensive care plans. R2 was not provided the opportunity to participate in the admission and quarterly review assessments. R2's medical record did not include an explanation excluding R2 from participation. R10 was not provided the opportunity to participate in the comprehensive and quarterly review assessments. R10's medical record did not include an explanation excluding R10 from participation. Findings include: The facility document titled Resident Assessment, Baseline Care Plan and Care Plan Policy states: Person Centered Care Planning 2. The Resident/Resident Representative has the right to participate in the development and implementation of her or her person-centered plan of care including, but not limited to: a. The right to participate in the planning process . 3. The facility shall inform the Resident of the right to participate in his or her treatment and shall support the Resident in this right. The planning process must: a. Facilitate the inclusion of the Resident/Resident Representative. 1. R6 was admitted in October 2020. R6's Brief Interview for Mental Status (BIMS) (used for identifying a resident's current cognition) score was 15/15 on 11/3/2020 and 13/15 on 7/13/2021 which indicated R6 was cognitively intact. R6 had two co-guardians making R6's healthcare decisions. Surveyor reviewed R6's medical record which revealed documentation titled IDT (Interdisciplinary Team) Admission Care Conference dated 11/5/2020. R6 was not in attendance and an explanation of exclusion was not documented. R6's medical record did not contain IDT Quarterly Care Conference assessments. R6's medical record included a progress note written by Social Worker (SW)-H on 1/15/2021 which stated, Quarterly assessment completed . The progress note did not contain an explanation of resident participation or exclusion from the care conference assessment. On 07/27/21 9:59 AM, Surveyor interviewed R6 who stated R6 does not feel involved in R6's plan of care and is not involved in R6's care planning. On 7/27/2021 at 10:18 AM, Surveyor interviewed SW-H. SW-H stated care conferences are performed upon admission, a significant change in status, annually, and upon discharge. SW-H stated quarterly care conferences are offered to guardians and family if they desire. SW-H stated R6 is not involved in care conference because R6 has a guardian. SW-H stated if a resident has a guardian, the guardian is invited to attend all care conferences and that some guardians choose to only attend annual care conferences. SW-H stated most residents at the facility have a guardian, but if the resident does not have a guardian SW-H would invite the resident. 2. R10 was admitted in May 2013. R10's most recent BIMS score dated 4/23/2021 was 11/15 indicating R10 had moderate cognitive impairment. R10's BIMS score was 15/15 on 9/24/2020, indicating R10 was cognitively intact. R10 had a guardian making R10's healthcare decisions. Surveyor reviewed R10's medical record which included IDT Care Conference assessments dated 9/24/2020 (annual), 6/10/2020 (quarterly), and 2/5/2020 (quarterly). R10 was not in attendance and an explanation of exclusion was not documented. The most recent progress note discussing R10's quarterly assessment dated [DATE] stated, Quarterly Assessment completed. BIM[S] score 14/15 . The 1/27/2021 progress note was written by SW-H and does not include an explanation of resident participation or exclusion from the care conference assessment. On 7/28/2021 at 2:59 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility is required to perform annual, discharge, admission and significant change in status care conferences with the resident representative or resident. DON-B stated most residents at the facility have a guardian and some guardians find it difficult to attend quarterly care conferences. DON-B stated the IDT meets twice per week and does not include the resident or an explanation of resident participation or exclusion from the care conference assessment in the medical record.

Based on staff interviews and record review, the facility did not ensure 1 (Resident 1) of 8 sampled residents was provided an environment as free of accident hazards as possible and provided adequate supervision to prevent accidents. Resident 1 had a history of [REDACTED]. Resident 1 had a physician's orders [REDACTED]. On [DATE] staff gave the resident a cheeseburger on a bun. Resident 1 consequently choked, and despite staff efforts to save the resident, the resident expired. This deficient practice resulted in a finding of immediate jeopardy. The immediate jeopardy began on [DATE] and was removed on [DATE]. The nursing home administrator was made aware of this finding on [DATE]. The deficient practice remains at a scope/severity level of a D (isolated/potential for more than minimal harm) as the facility continues to implement its corrective action plan. Findings include: According to the facility's Diet Requisition policy, dated ,[DATE], all diets are ordered by a physician. The diet orders are verified by the dietitian and maintained on file by dietary staff. According to the facility's Dining Room Supervision policy, dated ,[DATE], staff are directed to provide nursing supervision of residents in the dining room during meals. Staff are directed to cue residents during meals, provide assistance, and monitor resident intakes. Nursing staff are to pass meals from the cook, to the resident after the cook plated the meal. Staff are to provide set up assistance when needed and follow each resident's individualized plan of care related to specific feeding techniques, behavior approaches, positioning, and adaptive equipment needs. Staff are to monitor residents and report any changes in eating patterns or behaviors to the RN (Registered Nurse). The policy did not define supervision or provide clear guidance regarding the amount of monitoring staff are to provide during meals. Resident 1's MDS (Minimum Data Set) assessment dated [DATE] documented Resident 1 has some cognitive impairment including short and long term memory problems with moderately impaired abilities to perform daily decision making. In addition, this MDS assessment documented Resident 1 requires supervision and one person assist for meals. Resident 1's Hospital history and physical note dated [DATE] documented Resident 1 was hospitalized for [REDACTED]. Documentation indicated the resident was treated for [REDACTED]. During this hospitalization a swallow study was completed and recommendations were made for the resident to have a NO BREAD diet and bite size pieces. The recommendation also included closely supervise during meals for safety. Resident 1's most recent physician's orders [REDACTED]. The diet order read Cut portions into small bite size pieces and NO BREAD. Resident 1's nutrition care plan dated [DATE] included the resident has longstanding eating habits that include eating too fast which may result in choking. The care plan directed staff to cut food into small pieces and reminded staff the resident was to have no bread. The care plan directed staff to Supervise, remind and reinforce that Resident 1 should chew his food thoroughly and eat slowly. Although the care plan directed staff to supervise and offer reminders, the care plan did not define supervision or indicate how much supervision Resident 1 required. Resident 1's progress note dated [DATE] documented Resident 1 choked during lunch and the facility's emergency response system was activated and a rescue squad was called. Resident 1 had a hamburger for lunch, choked, and became unresponsive. Attempts to clear the airway including the Heimlich maneuver and abdominal thrusts were unsuccessful. The resident had inadequate breathing and staff were unable to detect a pulse. Staff continued to attempt to save the resident, providing oxygen, compressions,and using an AED (Automated External Defibrillator). The AED was able to detect a pulse, the resident's color improved and the resident was transferred to the hospital via ambulance. The facility immediately began an investigation. According to a timeline developed by the facility dated [DATE], Resident 1 was given the noon meal tray between 12:00 p.m. and 12:05 p.m. on [DATE]. At 12:10 p.m. the resident was found slumped over in the chair. Staff was unable to arouse the resident and the facility initiated their response system and called 911. Staff attempted to assist Resident 1 and the ambulance arrived at 12:26 p.m. The timeline indicated the resident was with a pulse and had an oxygen level of 94% with 15 liters of oxygen when departing the facility with the paramedics. The facility's investigation dated [DATE] documented an interview with Resident 1's legal guardian. The legal guardian verified he was not consulted regarding if it was ok for Resident 1 to receive a hamburger with a bun. On [DATE] at 9:00 a.m. Surveyor interviewed NHA (Nursing Home Administrator)-A regarding Resident 1. NHA-A stated Resident 1 expired after a choking episode on [DATE] and the facility investigated the incident. NHA-A stated the investigation findings included staff was aware Resident 1 was not to have bread and gave it to the resident anyway. In addition, NHA-A stated Resident 1's legal guardian was interviewed and indicated the guardian was not asked or talked to about Resident 1 wanting or being given bread. On [DATE] at 3:47 p.m. Surveyor interviewed FSW (Food Service Worker)-B regarding Resident 1. FSW-B verified knowing Resident 1 was not supposed to have bread and this was not a new order for the resident. FSW-B verified plating Resident 1's food for the noon meal on [DATE] even though she knew the resident was not supposed to have bread. FSW-B stated Resident 1's diet sheet (which is used to ensure the appropriate foods were plated for each resident) included documentation that Resident 1 was not supposed to have bread and she plated a cheeseburger on a bun for Resident 1. FSW-B stated she thought this was okay since several months ago, when the resident's mother was still alive, the resident's mother told her Resident 1 could have bread. FSW-B also stated on Tuesday [DATE], Resident 1 filled out a menu for Wednesday [DATE] and indicated he wanted a cheeseburger on the menu. FSW-B stated she did not discuss or review Resident 1's request with any other staff before plating the cheeseburger for the resident. On [DATE] at 3:00 p.m. Surveyor interviewed CNA (Certified Nursing Assistant)-C regarding Resident 1. CNA-C stated he was the CNA who served Resident 1 the plated noon meal on [DATE]. CNA-C verified he was aware the resident was not supposed to have bread, but did not see Resident 1's diet card and stated he was just trying to pass trays quickly. CNA-C stated passing trays is fast paced and he just grabbed Resident 1's tray and did not think about if the food on the plate was right or not. CNA-C indicated FSW-B did not comment to him the bun was on the hamburger served to Resident 1. CNA-C stated he did not cut the cheeseburger into bite sized pieces, but cut it in fourths. CNA-C stated after giving Resident 1 the cheeseburger and putting salad dressing on the salad, he set up two other residents with their meals when the cook stated Can somebody check on Resident 1? CNA-C stated the resident was sitting in the chair with his head down and that RN-D approached Resident 1 at the same time as he did and found Resident 1 unresponsive. CNA-C stated at that time, he saw something in Resident 1's mouth and the RN started the Heimlich maneuver. On [DATE] at 12:17 p.m. Surveyor interviewed RN-D regarding Resident 1. RN-D verified finding Resident 1 unresponsive, initiating the emergency response system and performing the Heimlich maneuver on Resident 1 during the noon meal on [DATE]. RN-D stated when performing the Heimlich maneuver quite a bit of food was removed from Resident 1's mouth. RN-D was tearful as she recalled the events that occurred and stated she felt confident the staff did everything they could do to try to save Resident 1 after they became aware the resident had been choking. The failure of the facility to ensure Resident 1 physician's orders [REDACTED]. The facility removed the jeopardy on [DATE] by which time it had implemented or begun the following: 1. Daily audits immediately initiated for breakfast, lunch and dinner meals to ensure substantial compliance with the resident diet order validation process and meal delivery process. Audits also monitored that safe supervision was occurring in the dining room at all meals, as outlined in the Dining Room Supervision policy and procedure. 2. On [DATE], immediate education was provided to the nursing staff members through a Read & Sign written in-service prior to the start of his/her shift, reminding each staff member of his/her responsibility to check each resident dining tray against the dietary serving sheet for proper diet orders, prior to serving each resident meal. 3. Diet order sheets approved by the physician's that are to be served to each resident located in the diet order sheet binder. Includes an index of education which explains each type of resident diet, clarifies special diet instructions, and provides additional information for staff as a reference guide to safely serving a resident. 4. On [DATE], immediate education was provided to the nutrition services staff members through a Read & Sign written in-service prior to the start of his/her shift, of his/her responsibility to check each dining tray against the dietary serving sheet for proper diet orders, prior to serving each meal. 5. On [DATE], additional education was provided to the nutrition service food server staff members through a Read & Sign written in-service prior to the start of his/her shift, of his/her responsibility to remind the CNA on their household of any additional texture guidelines for each resident using the pink cards in the dietary manual binders. 6. On [DATE], education provided to nursing and nutrition service staff on Dining Room Supervision policy to re-ensure staff are properly supervising the dining room areas during each meal at all times. Education was provided to the nursing staff members through a Read & Sign written in-service that will be acknowledge by each staff member prior to the start of his/her shift, reminding each staff member of his/her responsibility. The education provided specific emphasis on the need to closely monitor residents at risk of choking due to consuming food too quickly or other risk-oriented behaviors. Also the importance of the CNA's job responsibility to follow the care plan accordingly for special feeding techniques such as the definition of cutting food into bite-size small pieces. 7. On [DATE], educational in-service was provided to the nursing staff on the Diet Requisition policy and procedure through a Read & Sign written in-service that will be acknowledge by each staff member prior to the start of his/her shift, reminding each staff member of his/her responsibility in this policy. 8. The Medical Director to assist the Administrator in the educational in-service facilitation and planning for further staff education, monitor the quality results of the audits at the QAPI meetings, and make further recommendations on quality improvement efforts and audits to ensure the facility remains in substantial compliance with following medical orders per each staff member's scope of practice. 9. Random audits using the Dining Room Observation Audit Tool at a minimum of five times per week to be completed until the next Quality Assurance meeting to ensure compliance is being obtained with these identified policies and procedures noted above in this removal plan.

Based on observations, staff interviews, and record reviews, the facility did not ensure adequate supervision to 1 out of 9 sampled residents to prevent injury. Resident #2 has a history of being intrusive. Resident #1 is alert and oriented and does not like others in his room. Resident #1 and Resident #2 have had a previous altercation. On 12/12/11, Resident #2 entered Resident #1's room when left unsupervised on the unit. Resident #1 struck Resident #2 in the jaw, knocking out a tooth and then hit him over the head with a walker causing a laceration. Resident #2 was sent to the hospital and received 4 staples to close the head laceration. Findings include: Resident #1's face sheet, last updated on 11/14/11, indicated that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was under guardianship and protective placement at this facility. Resident #1's MDS (minimum data set) dated 9/9/11 indicated he was alert and oriented and able to communicate well and understand well. His MDS indicated he was independent in ambulation with his walker and frequently refused his diabetic diet and medications or blood sugar testing for his diabetes. Resident #1's care area assessment dated [DATE] indicated behavior triggered due to episodes of refusing insulin and blood sugars and a long history of being non-compliant with diabetic management. Resident #2's face sheet, last updated 8/29/11, indicated that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was under guardianship and protective placement at this facility. Resident #2's MDS dated [DATE] indicated he was cognitively impaired and only sometimes could make self understood or sometimes understood others. The MDS also indicated that resident #2 had behaviors of daily wandering about the unit in his wheelchair with attempts at elopement, wandering into others rooms, being disruptive to others, and significantly intruding on the privacy and activities of others. The Care Area Assessment for resident #2 dated 11/2/11 indicated he had episodes of wandering and was difficult to re-direct. "He also at times has done things to annoy peers such as moving a personal item of a peer. He was moved in the past year to a different household. " Under "nature of behaviors" resident #2's assessment indicated that he would agitate peers. Surveyor # reviewed the facility's incident report dated 10/20/11. The report indicated that on 10/20/11 at 3:30 p.m., resident #2 wheeled himself in to resident #1's room. CNA (Certified Nursing Assistant)-A then witnessed resident #1 hit resident #2 twice with his walker about the hand and shoulder. Residents immediately separated. Resident #2 was placed on 1 to 1 supervision for safety. Injuries to resident #2 from resident #1 were a reddened area to left cheek/neck and a 2.5 cm (centimeter) by .3 cm scrape to his outer right wrist. Resident #1 told staff he thought resident #2 was going to take his candy that he kept in his room. (Nurses notes indicated that resident #1 would keep candy and snacks in his room.) Interventions to resident #2's care plan dated 10/20/11 were 1:1's, then 15 minute checks as needed, diversional activities, monitor resident #2's whereabouts before and after going into another resident's room. Interventions to resident #1's care plan dated 10/20/11 were 15 minute checks as warranted, monitor for stressors/triggers that could lead to an aggressive response and intervene early. Make assurances to resident #1 that his belongings are safe and that he should report any concerns he has to staff. Surveyor # reviewed a second facility self-report dated 12/15/11. The report indicated that on 12/12/11 at approximately 3:25 p.m. resident #2 wandered into resident #1's room. Resident #1 then punched resident #2 in the face knocking out a tooth and then hit him over the head with his walker as staff were removing resident #2 from the room. Resident #2 required a trip to the emergency room and 4 staples to the top of his scalp. The ER (emergency room ) report dated 12/12/11 showed resident #2 had been hit in the head during an altercation with another resident. "He had no loss of consciousness. He presents to the emergency department with scalp lacerations. He also reportedly broke off a tooth that was now brought here to the emergency department." Final assessment indicated four staples were placed, closed head injury with scalp laceration. On 12/20/11 at 8:15 a.m., surveyor # spoke with WC (Ward Clerk)-B. WC-B stated that on 12/12/11 she came onto the Clover Lane Unit and heard yelling from the far end of the unit. WC-B indicated she ran down to the room and saw resident #1 yelling at resident #2, had his hand/fist cocked and he hit resident #2 in the jaw despite her yelling at him to stop. WC-B indicated she tried to get resident #2 out of harms way by pulling him backwards in his wheelchair as he wouldn't lift his feet. WC-B indicated resident #1 then picked up his walker over his head and struck resident #2 on the top of his head with it as she was pulling resident #2 out of the room and yelling for resident #1 to "stop, don't hit." WC-B indicated that resident #2 made no comments during the altercation of any sort. WC-B indicated that as she was pulling resident #2 out of the room and right before he was struck by the walker, a CNA arrived and helped. She indicated this staff person saw the second hit with the walker and assisted her in getting resident #2 to safety. On 12/20/11 at 8:25 a.m., surveyor # spoke with CNA-C indicated she was the nurse aide that came in and saw the second hit by resident #1 to resident #2 with the walker on 12/12/11. CNA-C indicated she was helping another resident on the unit in their room with the door closed and that another CNA (CNA-D) and the Licensed Practical Nurse (LPN-E) were off the unit. CNA-C indicated she heard yelling when she came out of a resident's room and ran to help. CNA-C indicated WC-B was telling resident #1 to "stop" but she saw resident #1 raise his walker and hit resident #2 on the top of his head with it. CNA -C indicated resident #2 was bleeding and was quickly removed by herself and WC-B. CNA-C indicated she took resident #2 to the nurse managers and called for help immediately. She indicated that management went to check on resident #1 but she didn't know what happened after that. CNA-C indicated resident #1 would yell at staff who entered his room and she thought he tried to hit resident #2 once before when he entered his room. On 12/20/11 at 8:50 a.m., surveyor # spoke with LPN-E who indicated that she was passing medications on the opposite unit, Robin Way. She heard on her walkie talkie that there was an incident going on in Clover Lane. She indicated that when she got there, staff were bringing resident #2 to the nurse management team and they were cleaning him up as he was bleeding. LPN-E indicated she called the county rescue squad to transport resident #2 to the ER. LPN-E indicated CNA-D was with resident #1 providing 1 to 1 supervision. The police were called and removed resident #1 from the building. LPN-E indicated resident #1 had a history of [REDACTED]. She indicated he mostly stayed in his room but would come out for meals. LPN-E indicated resident #2 had significant dementia and would wander about the unit in his wheelchair. On 12/20/11 at 10:40 a.m., surveyor # spoke with CNA-D who indicated that on 12/12/11 he was with a resident in the tub room at the opposite end of the unit from resident #1's room. He indicated he was walking a resident out of the tub room when he heard yelling from the end of the hall and heard WC-B say, "Oh my God!" as she was pulling resident #2 out of resident #1's room with CNA-C. CNA-D indicated resident #2 was, "full of blood." He indicated he called RN (Registered Nurse)-G who came right away to help resident #2. CNA-D indicated that all the managers then came running to help and he was ordered to go sit with resident #1 to provide 1 to 1 supervision. CNA-D indicated that everything happened very quickly with the police coming and removing resident #1 from the building. CNA-D verified that resident #2 wandered the unit and would go in and out of others rooms. He indicated they would give him puzzles or movies and try to keep him busy. Observation of resident #2 by surveyor # on 12/20/11 at 11:00 a.m. showed he was up in his wheelchair with a suture line to the top of his scalp. Resident #2 did not answer any questions from surveyor # , only stared. Resident #2 later was given his noon meal which he ate independently. At 2:00 p.m. resident #1 was noted in a group activity with a 1:1 staff. On 12/20/11 at 10:05 a.m., surveyor # spoke with CNA-F who indicated that resident #2 was on 1 to 1's for awhile after the October incident when resident #1 hit him with his walker. She indicated these were removed because there didn't seem to be any further problems and verified that resident #2 still propelled himself about the unit in and out of other's rooms. She indicated resident #2 was very confused and was on 15 minute checks because of his wandering. CNA-F indicated resident #1 continued to yell at others when agitated. She also verified that resident #2 continued to wander the unit in his wheelchair going into others rooms. On 12/20/11 at 10:55 a.m., surveyor # spoke with LPN-H. LPN-H indicated that resident #1 liked to be left alone in his room. He didn't like to be approached about his diet, blood sugars, etc. and staff would re-approach later if agitated and yelling at them. LPN-H indicated resident #1 didn't like people in his room. He indicated resident #2 wandered about the unit and would go in and out of others rooms and still did so. During an interview with surveyor # on 12/20/11 at 12:00 p.m., SW (Social Worker)-I indicated that interventions were put into place to try and keep resident #2 busy such as going out to the town center in the afternoon, going outside with staff, giving an earlier supper tray. She verified that after the 10/20/11 incident with resident #1 hitting resident #2 after he entered his room, discussion was not held about moving either resident to a different unit because resident #2 had already been moved once because of his wandering behaviors. During an interview with surveyors # on 12/20/11 at 1:15 p.m., SW - I and DON (Director of Nursing)-J verified resident #2 and resident #1 had no significant changes to their care plans to prevent resident #2 from wandering into other's rooms which had been a known source of aggression by resident #1 to resident #2 since 10/20/11 when he first hit him with his walker. DON-J indicated that some medication changes had been made to resident #2's care plan with a psych consult but verified he continued to wander into other's rooms. DON-J indicated the only other thing they could do for resident #2 was 1 to 1 supervision and verified that was not being done. During an interview with DON-J at 2:00 p.m., she indicated that the facility now put resident #2 on 1 to 1 supervision.