Every finding on record at Care & Rehab - Ladysmith 1

Based on interview and record review, the facility did not ensure a resident representative did not make decisions outside the scope of their role for 1 of 3 residents (R1) reviewed for Power of Attorney for finances from a sample of 5 residents.-No Power of Attorney for finances was listed prior to R1's incapacitation and due to a joint checking account with R1 and R1's Power of Attorney for health care, the facility imposed the financial duties on the Power of Attorney for healthcare.Findings include:According to 2026 Legal Clarity Wisconsin: Wisconsin Power of Attorney for Health Care Requirements, Once activated, your agent steps into your shoes for healthcare decisions. They can consent to or refuse treatments, approve surgeries, and direct the use of life-sustaining procedures, all based on the wishes you expressed in the document or communicated directly. Your agent has priority over any other person - including family members - to make these decisions, as long as providers know the agent is available. The authority is limited to healthcare. Your agent cannot manage your finances, access your bank accounts, or make legal decisions outside of medical care. If you need someone to handle financial matters during incapacity, that requires a separate financial power of attorney under Chapter 244. https://legalclarity.org/wisconsin-power-of-attorney-for-health-care-what-you-need-to-know/R1 was admitted to the facility on [DATE]. Upon admission, R1 signed an admission agreement in which R1 indicated they would be making all financial decisions, and no other representative was listed in case of incapacitation. R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] documents a score of 4/15 indicating severe cognitive impairment.On 12/30/25 at 2:35 PM, R1's medical record documents a progress note written by Social Services Designee (SSD) F which states: Writer spoke to R1 regarding payor source. R1 has not been enrolled with institutional Medicaid, discussed private pay. R1 asked if writer could call Family Member (FM) C to discuss R1's finances. Writer placed call to FM C regarding private pay beginning 12/12/25, discussed Medicaid, R1 will have to spend down before applying to Medicaid.On 06/24/26 at 11:29 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about the admission agreement for R1. NHA A acknowledged upon admission, R1 was their own person and did not document anyone to take responsibility for finances in case R1 was unable to.SSD F was unavailable for interview.On 01/15/26, R1 was incapacitated by way of 2 physician signatures and R1's POA for healthcare was activated. FM C was listed as R1's POA for healthcare. R1's BIMS score dated 01/22/26 documented a lower score of 3/15 indicating severe cognitive impairment.On 05/05/26, a letter was sent to FM C from NHA A regarding the outstanding balance for R1's stay at the facility. It states in part: If the balance is not brought up at the current timely, we will take additional steps; which may include a 30-day discharge notice.On 06/24/26 at 9:17 AM, Surveyor interviewed FM C about spending down R1's assets and applying for Medicaid. FM C stated FM C is not qualified and not the Power of Attorney (POA) for finances, only healthcare. FM C stated FM C was instructed to apply for Medicaid for R1 by SSD F.On 05/22/26, a letter was sent to FM C from NHA A regarding the continued outstanding balance. NHA A thanked FM C for submitting some payment but stated it had not significantly affected the balance. The letter states FM C has not made a meaningful attempt to resolve the issue, and this would be the 30-day notice. NHA A wrote the county social services would be contacted in regard to FM C's lack of payment and unwillingness to complete the Medicaid application with appropriate information.On 06/24/26 at 9:17 AM, Surveyor interviewed FM C about receiving this letter, FM C stated FM C was getting the runaround with getting help for applying for Medicaid, and FM C wasn't sure at the time what to do. FM C stated they even used some of their own money to try and help with R1's bill.On 06/24/26 at 11:29 AM, Surveyor interviewed NHA A regarding the letter sent to FM C on 05/22/26. NHA A stated the facility was having a difficult time getting FM C to complete the Medicaid application and make payments.On 05/26/26, a letter was sent to FM C from NHA A regarding the 30-day discharge notice. It reads in part: If the payment is not resolved, you may find yourself providing the care, because it will be impossible to find some other facility to take R1 without your cooperation for payment of services.On 06/24/26 at 11:29 AM, Surveyor interviewed NHA A about the letter sent to FM C on 05/26/26. NHA A stated NHA A was aware the facility could not discharge R1 without a safe place to go and the letter was sent mainly to get FM C to make payments on the bill. NHA A acknowledged NHA A should have worded the letter differently.On 05/29/26, FM C reported a complaint to the State which indicated FM C has been trying to get R1 signed up for Medicaid since November 2025 and has gone through the steps as directed by SSD F but feels like FM C has been left on FM C's own. FM C reported SSD F has not been helping much and has left FM C hanging. FM C stated in the complaint that FM C has used FM C's own money toward the bill. SSD F told FM C when Medicaid gets approved it will be backdated. FM C stated R1 has no assets. FM C reported the facility sent FM C a discharge notice for lack of payment, and FM C does not know what to do.SSD F was unavailable for interview.On 06/24/26 at 9:17 AM, Surveyor interviewed FM C about Medicaid and the discharge notice. FM C stated Medicaid has since been approved and backdated to 03/01/26. FM C stated FM C felt better knowing R1 would be able to stay and there was a payment source in place and a plan for the remaining bill prior to the Medicaid activation. FM C reported to Surveyor that the concern remained regarding why FM C was instructed to do these things as FM C was not the POA for finances.On 06/24/26 at 11:29 AM, Surveyor interviewed NHA A regarding the POA for Finances process. NHA A stated upon admission, the agreement is filled out and there is a place on the form to indicate who will be responsible for finances. If a resident is deemed incapacitated, the person listed on the form would be activated. If there is no one listed, usually a family member would take over. If no family or friends want the responsibility, the facility would reach out to the local resource center or proceed with obtaining guardianship. When asked if FM C was asked about taking on the role, NHA A stated the facility just assumed because FM C has a joint checking account with R1, and has written checks before, that FM C would be the responsible party. When asked if the facility felt FM C was not performing the duties as expected, if it would warrant an alternative responsible party for Finances, NHA A reported yes, the facility should have taken alternate routes.On 05/24/26, Surveyor determined the facility did not take appropriate steps to ensure appropriate responsible party for R1's finances and forced the responsibility upon FM C who was not legally required or qualified to perform the duties.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 40 residents (R).-The facility did not complete surveillance of the onset of symptoms for resident infections. (R28, R1, and R27)-Certified Nurse Assistant (CNA) did not perform hand hygiene during water pass for R1, R6, R17, R20, and R27. -No Enhanced Barrier precautions (EBP) in place for R6 related to open wounds.-Improper PPE utilized with wound care for R6. Findings include: Example 1 Surveyor reviewed infection control line lists from January 2025-present. Surveyor reviewed line lists for months of December 2025-January 2026, which stated in part, .- On 01/06/26, Site of infection: Cold symptoms. [R28] was placed on respiratory precaution monitoring for 3 days. [R28] has cough. No fever at this time. On 01/08/26 [R28] has flu-like symptoms. Nonproductive cough noted. Sneezing noted. Closed. -On 01/09/26, Site of infection: Cold symptoms. [R1] was noted to have wheezing and congestion at 0710. Afebrile, blood pressure and heart rate within resident baseline. Low saturations. Facility tested for COVID with negative results. [R1] was sent to hospital 01/11/26 and returned on antibiotics with possible pneumonia. Closed. -On 01/14/26, Site of infection: Cold symptoms. [R27] noted to have sore throat this shift. Noted to be weak and unsteady on her feet. [R27] has scratchy gravelly voice, occasionally dry cough, loose stools. On 01/18/26 [R27] continues to have nonproductive loose cough. On 01/21/26, cold resolved. Isolation ended. Closed. Surveyor did not find line lists thoroughly completed to show what type of isolation was used, when isolation was placed, what tests were performed for infectious residents, and did not find well dates consistently documented in line lists. Examples: Surveyor did not find documentation for R28 on when or if R28 was placed on isolation precautions. Surveyor did not find any testing completed for R28 to rule out COVID, influenza, or RSV despite the connecting building having an active influenza outbreak in the facility. Surveyor did not find that any other action was taken to protect infection from spreading. Surveyor did not find R28's well date or outcome of infection. Surveyor did not find documentation for R1 on when or if R1 was placed on isolation precautions Surveyor did not find any testing completed for R1 to rule out influenza and/or RSV despite the connecting building having an active Influenza outbreak in the facility. Surveyor did not find that any other action was taken to protect infection from spreading. Surveyor did not find R1's well date. Surveyor did not find documentation for R27 on when or if R37 was placed on isolation precautions Surveyor did not find any testing completed for R27 to rule out COVID, influenza, or RSV despite the connecting building having an active Influenza outbreak in the facility. Surveyor did not find that any other action was taken to protect infection from spreading. On 02/10/26 at 9:04 AM, Surveyor interviewed Infection Preventionist (IP) C regarding the process for tracking infections and documenting on infection control line lists. IP C reported to Surveyor that IP C is newer at this line list and has been IP C for almost a year but is trying to work out process. Surveyor asked if it is IP C's expectation to document what type of isolation precautions certain residents should be placed on and documentation of when isolation ended for the infection. IP C reported that type of infection and when isolation precautions start and end should be placed on resident line lists and has not been consistently documented in that fashion over the last year. IP C stated, I am following the process from previous on how I was trained in by the former DON. Surveyor reviewed infection control line lists from January 2025-present with IP C and pointed out several different examples such as R28's, R1's, and R27's which are just a few records reviewed for possible infections and noted that IP C did not document what tests were performed to rule out certain infections. IP C reported to Surveyor that IP C didn't know the facility needed to test for more than just COVID for respiratory like symptoms in the residents with respiratory infections such as R28 and R27. IP C stated, Not everyone was even tested for COVID if they had symptoms, it is mostly up to the digression of the provider and the resident. Surveyor asked IP C what guidelines IP C follows to ensure that infection is not spread. IP C stated, I really follow the facility policies, but I see here that the Isolation and PPE policy needs to be updated as there are different processes that need to take place when residents have an active infection. IP C reported to Surveyor that IP C needs to follow the CDC guidelines and make sure the process for tracking active infections is handled according to the guidelines from the state, which has not been done consistently across the board. Example 2 The facility policy, titled Hydration Water Pass, revised February 2020, states: .Infection Control and Prevention: Perform hand hygiene using sanitizer or hand washing after removing dirty mug/glass. On 02/09/2026 at 8:54 AM, Surveyor observed Certified Nurse Assistant (CNA) K enter R17's room with clean water pitcher, and CNA K grabbed contaminated water pitcher and set the contaminated water pitcher on the water pitcher cart. CNA K then grabbed another clean water pitcher, entered R1's room and placed the clean water pitcher down on R1's table. Surveyor did not observe CNA K sanitize hands upon exiting R17's room nor did CNA K sanitize hands before entering R1's room. CNA K grabbed contaminated water pitcher, exited R1's room and placed contaminated water pitcher on water cart. Surveyor did not observe CNA K sanitize hands upon exiting R1's room. Surveyor observed CNA K enter R20's room without sanitizing hands with clean water pitcher. CNA K grabbed contaminated water pitcher, exited R20's room and placed contaminated water pitcher on water cart. Surveyor did not observe CNA K sanitize hands upon exiting R20's room. Surveyor observed CNA K enter R27's room with clean water pitcher without sanitizing hands. CNA K grabbed contaminated water pitcher, exited R27's room and placed contaminated water pitcher on water cart. Surveyor then observed CNA K go into R6's room to continue passing water. Surveyor did not observe CNA K complete hand hygiene. On 02/09/26 at 9:01 AM, Surveyor interviewed CNA K and asked what CNA K's process is for delivering clean water pitchers during water pass. CNA K reported that CNA K should be sanitizing hands in between each resident room especially if grabbing contaminated water pitchers and going into the next resident room. Surveyor asked if CNA K sanitized hands in between resident rooms. CNA K looked at Surveyor and stated, I did or maybe forgot one room, but I am unsure. On 02/10/26 at 9:24 AM, Surveyor interviewed IP C regarding process for sanitizing hands during water pass. IP C reported that all staff should be using hand hygiene such as sanitizing or washing hands between resident rooms and especially if taking out contaminated water pitchers and going into other resident rooms with clean water pitchers. IP C reported to Surveyor that CNA K should have washed or sanitized hands. Example 3 The facility policy, titled Enhanced Barrier Precautions (EBP), revised July 2025, states: .Implementation of Precautions: Wear gloves and gown when in High Contact Activity with the individual, surfaces, objects within his/her environment. PPE, including gown and gloves before or upon entering the room or cubicle. Prior to leaving the residents room, the PPE removed, and hand hygiene is performed. High Contact Activities Include: -Wound Care: any skin issue requiring a dressing. R6 was admitted to the facility on [DATE]. On 01/08/2026 R6's Brief Interview for Mental Status score was 15/15, indicating cognitively intact. On 02/10/26 at 9:25 AM, Surveyor observed wound care for R6. R6 has open wounds to buttocks stage 3. Registered Nurse (RN) L and Certified Nursing Assistant (CNA) P were present. Both staff donned gloves. R6 has an Enhanced Barrier Precautions (EBP) sign on door frame but no Personal Protective Equipment (PPE) was present. Neither staff member wore gowns. On 02/10/26 at 10:41 AM, Surveyor interviewed RN L. RN L stated Infection Preventionist (IP) C is responsible for who gets placed on precautions. RN L stated it would be appropriate for residents with catheters to be on EBP but did not mention any other reasons. RN L stated they would use droplet precautions for respiratory concerns. Once advised, the nurses will put the signs and PPE up. RN L stated they have signs and instructions at the desk. RN L showed Surveyor the guides at the desk after asking RN D where to find them.On 02/10/26 at 10:47 AM, Surveyor interviewed CNA P. CNA P stated CNA P knows when stuff is on the outside of the door that is when a resident is on precautions. CNA P is unaware of who is responsible for putting signs and PPE on resident doors. CNA P was also unaware of what kind of things require the use of PPE and states CNA P just follows the signs. CNA P stated PPE education might be part of the monthly training.On 02/10/26 at 10:53 AM, Surveyor interviewed IP C. IP C stated she is responsible for putting residents on precautions if she is here. IP C stated if she is not here and someone else catches it, they will initiate it and then follow up when she returns. IP C stated sometimes IP C will also sometimes have the cleaning lady put it up. IP C stated it would be appropriate to initiate EBP for residents with a catheter, history of certain infections, indwelling lines, or something is open. IP C stated the nurses will enter the vitals and a progress note, and IP C will complete the assessment form in the computer and add the resident to the line list. IP C stated it depends on what kind of wounds the resident has and if they felt the wound was taking a certain course they would initiate EBP. IP C asked, What do you mean? when Surveyor asked when to utilize EBP versus contact precautions. IP C stated, EBP is a part of contact precautions, isn't it? IP C stated they initiate EBP if wounds have an infection. IP C stated, Maybe I don't know enough. IP C stated IP C is new to this role and started in March of 2025. IP C stated she had some training by Minimum Data Set (MDS) coordinator/Director of Nursing (DON) B. IP C stated it was mostly from her IP training online. IP C stated the staff use an online education platform when they first start and the rest is mostly on paper. IP C stated, It's been kind of wishy-washy in some respects. IP C stated IP C was just following the education/training the staff had been provided with the year prior.

Based on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure only authorized personnel had access to medication cabinets on 100 unit and 200 unit. This occurred for 6 of the 26 medication cabinets outside residents' rooms observed. -During the three-day survey, 6 of 26 observations were made of individual resident (R6, R27, R17, R28, R31, and R11) medication cabinets left unlocked when unattended and out of view of staff with prescribed medications in cabinets. Findings include: The facility policy, titled Medication Administration, revised August 2025, states: .#2. Storage of Medications: b. Only licensed nurses, med techs, the consultant pharmacist and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked when unattended, or attended by persons with authorized access only . On 02/10/26 at 12:04 PM, Surveyor observed medication cabinet outside R6's room unlocked. Surveyor observed Trimacolone ointment labeled with R6's identifying information and dispersed on 04/14/24. Surveyor observed R6's calcium alginate dressing also located in unlocked medication cabinet. On 02/10/26 at 12:05 PM, Surveyor observed medication cabinet outside R27's room unlocked. Surveyor observed unknown white powder in a medicine cup located in unlocked medication cabinet. On 02/10/26 at 12:06 PM, Surveyor observed medication cabinet outside R17's room unlocked. Surveyor observed arthritis cream labeled with R17's identifying information located in unlocked medication cabinet. On 02/10/26 at 12:07 PM, Surveyor observed medication cabinet outside R28's room unlocked. Surveyor observed Difloneac cream labeled with R28's identifying information in unlocked medication cabinet. On 02/10/2026 at 12:17 PM, Surveyor observed medication cabinet outside R31's room unlocked. Surveyor observed prescription bottle of Hibiclens and Aspercreme tube in R31's unlocked medication cabinet. On 02/10/2026 at 12:19 PM, Surveyor observed medication cabinet outside R11's room unlocked. Surveyor observed Equate arthritic cream and Trolamine Salicylate medication in R11's unlocked medication cabinet. On 02/10/26 at 12:25 PM, Surveyor interviewed Registered Nurse (RN) L and asked if medication cabinets outside resident rooms were supposed to be locked. RN L reported that if any prescribed medication is stored in the medication cabinets, all medication cabinets should be locked. Surveyor asked if RN L could review R6's medication cabinet. RN L stated to Surveyor, I see [R6] has Trimalicone cream that he doesn't even use anymore in the medication cabinet and that the cabinet should be locked regardless. Surveyor observed RN L trying to lock medication cabinet right away. On 02/10/26 at 1:23 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked expectation for medication cabinets locked outside resident rooms. NHA A reported that all medication cabinets located outside resident rooms should be locked if prescribed medications are in the medication cabinet and staff are out of sight.

Based on interview, observation and record review, the facility did not take action through documenting grievances, conducting a thorough investigation of the issues identified or providing resolution of the concerns brought to the attention of facility staff regarding missing golden necklace. This affected R9.This is evidenced by:The facility policy, titled Grievance Complaint Procedures, revised October 15, 2021, states: .Procedure: #10. Social Worker or designee will begin investigating the complaint in a timely manner to ascertain its validity and will keep a record of the investigation in the complaint file. #11. A plan of action to resolve the grievance/complaint shall be developed within 72 hours of the social worker's knowledge of the compliant. The person filing the complaint or grievance will be informed within reasonable amount of time of the plan of action and the social worker will complete a follow-up to determine if the plan has succeeded. The person filing the complaint or grievance will receive periodic updates throughout the process. If the plan is not successful, another plan of action will be formulated and followed.#12. All parties involved and witnesses, if any, will be interviewed and responses recorded as a part of the investigation. Written statements will be signed and dated by the person.#14. The Grievance Official will work toward a solution to the problem and consult with the staff as needed .Surveyor reviewed Grievance logs dated October 2024-present (4 pages).Surveyor observed an incomplete grievance complaint form attached to grievance log, dated 12/04/25, which states in part, .[R9's] Gold necklace with (Sister) on the necklace missing.Surveyor did not see a proper investigation or process for resolution of the missing item on the incomplete grievance form. On 02/11/26 at 8:51 AM, Surveyor interviewed Social Services J and asked how Social Services J handles complaints and who oversees investigating and finding a resolution. Social Services J reported to Surveyor that typically the staff or a resident will fill out a grievance form. Social Services J then reviews the grievance and starts the investigation and interviews potential witnesses or resources who may know more of the situation. Social Services J will interview the complainant and follow up through the investigation process. Social Services J reported that Social Services J finds a resolution and makes sure to update all parties involved. Surveyor asked how Social Services J keeps record of the steps in investigation and processes. Social Services J reported that every complaint is documented on the grievance log and then a narrative of the steps and outcome are kept in a file folder per grievance. Surveyor asked if Social Services J has the investigation file for R9 and what the disposition was for R9's missing Golden necklace. Social Services J reported to Surveyor that Social Services J was out on maternity leave from 09/17/25-12/15/25, so Social Services J is unsure what came of R9's grievance. Social Services J reported that while Social Services J was on maternity leave, Nursing Home Administrator (NHA) A was to oversee grievances.On 02/11/26 at 9:05 AM, Surveyor interviewed NHA A and asked why R9's grievance of missing Golden Necklace did not have investigation process or resolution in place. NHA A reported that NHA A didn't realize the grievance was not followed up on and that it was a mistake.

Based on observation, interview, and record review, the facility did not ensure 1 of 4 residents (R6) received adequate supervision and assistance devices to prevent accidents.R6 was left unsupervised in the bathroom.Facility staff did not provide supervision or alarm system per care plan.Findings include:Facility policy titled, Care Planning with Resident and/or Representative, effective 11/23/2016, reads in part: To provide a team approach in the planning and care of the resident as a whole and to periodically review this plan to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing.Facility Policy titled, Fall Risk Management Policy, last revised 1/26, reads in part: It is the policy of {Care and Rehab-Ladysmith} to promote resident safety by identifying resident as risk for falling.as well as implement appropriate interventions to prevent continued/repeated falls.High risk fall interventions may include.Do not leave a high risk for falls resident unattended when toileting.Facility policy titled, Standards of Care, last revised 2/26, reads in part: All employees are to follow the Standards of Care for their specific job position.Residents with alarms are not to be left unattended on the toilet.R6 was admitted to the facility on [DATE].On 01/08/26, R6 had a Brief Interview for Mental Status score of 15/15 indicating cognitively intact.Surveyor reviewed most recent falls. On 12/04/25, R6 had a fall from the toilet. On 12/12/25, R6 had a fall while trying to self-transfer from recliner to bathroom. On 01/15/26, R6 had a fall from the recliner. On 02/01/26, R6 had a fall due to sliding out of his wheelchair. Interventions in place on 12/05/25 after the fall on 12/04/25. No new interventions or revisions for most recent 3 falls.R6's care plan includes in part: Focus of self-care deficit with intervention of doorbell motion alarm in bathroom (01/06/26) and do not leave me unsupervised while toileting (12/05/25). Focus of falls/injury with interventions of lessen my risk for falls/injury: Assure alarms are in place in case I attempt to self-transfer. Do not leave unsupervised during toileting (12/05/25).On 02/10/26 at 9:21 AM, Surveyor observed R6 on the toilet unsupervised with no alarms.On 02/10/26 at 9:23 AM, Surveyor observed Certified Nursing Assistant (CNA) O inform Registered Nurse (RN) L that R6 was in the bathroom if RN L wanted to look at R6's buttocks bandage. RN L informed Surveyor R6 was in the bathroom and RN L would be doing wound care shortly.On 02/11/26 at 9:57 AM, Surveyor interviewed CNA O. CNA O stated if a care plan states a resident should not be left alone while toileting or the resident has alarms, they cannot leave that resident unattended in the bathroom.On 02/11/26 at 10:08 AM, Surveyor interviewed RN D. RN D stated CNAs are expected to follow the care plans. RN D stated if the CNAs do not agree with something in the care plan, they can talk to the nurses about possible changes needing to be made.On 02/11/26 at 10:24 AM, Surveyor interviewed CNA F. CNA F stated CNA F would not leave a resident alone in the bathroom if they have alarms or the care plan stated they should not be left unsupervised in the bathroom.On 02/11/26 at 10:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated NHA A would hope CNAs would follow the care plan. NHA A stated the care plans are available to the CNAs on the computer and they should know what their tasks are. NHA A stated CNAs have shift-to-shift reports and the floor nurses should be monitoring the CNAs for compliance.

Based on interview and record review, the facility did not have a comprehensive system for ensuring residents received and/or were offered pneumococcal immunizations for 1 of 5 sampled residents (R) (R6).The facility did not have any documentation R6 was offered the pneumococcal vaccine, was educated on the risk and benefits of the vaccine, or that R6 declined the vaccination. Findings include:On 2/10/26, Surveyor reviewed Pneumococcal vaccination for R6 and noted: R6 had no Pneumococcal vaccination on record and Wisconsin Immunization Registry (WIR) stated, Recommended and overdue 08/17/86. Facility did not have any documentation of R6 declining the vaccination, nor documentation of follow-up regarding educating R6 on the risks and benefits of the vaccination.On 02/10/26 at 9:04 AM, Surveyor interviewed Infection Preventionist (IP) C and asked what the expectation is for providing pneumococcal vaccination to residents in the facility. IP C reported to Surveyor that the facility no longer offers pneumococcal vaccinations. Surveyor asked IP C to explain IP C's process for making sure the facility is offering pneumococcal vaccines or educating residents on the risks and benefits of pneumococcal vaccination. IP C reported the facility does not offer the vaccination or complete education. IP C stated, If residents come to us wanting Pneumococcal vaccination, we refer them to the clinic to have that done. Surveyor asked if IP C asks or updates vaccination status per resident upon admission and annually. IP C reported to Surveyor that IP C did not realize the facility had to offer pneumococcal vaccinations or offer education, so IP C stated to Surveyor, This is not being completed, and I will talk with Nursing Home Administrator (NHA) A going forward. Surveyor asked IP C if R6 is up to date on the pneumococcal vaccinations. IP C reported R6 is not up to date on pneumococcal vaccination, and IP C does not have any declinations for R6 refusing the pneumococcal vaccination since it was not offered to R6.

Based on observation, interview and record review, the facility did not ensure pain management consistent with the comprehensive assessment and plan of care for 1 (R5) resident of 2 residents reviewed for pain management in a sample of 12 residents. R5 did not have pain assessment according to the comprehensive plan of care and physician orders documented on treatment administration record (TAR), or in medical record. This possibly resulted in R5 not attaining highest practicable level of well-being.Facility did not recognize R5's agitated and restless behaviors as possible indicators of pain through assessment and/or documentation in R5's medical record, possibly resulting in R5 not attaining highest practicable level of well-being.R5 had history of left femur fracture while residing at facility and currently has an indwelling urinary catheter for chronic urinary retention, both which have potential for causing R5 pain and distress. Findings include:The facility policy, titled Pain Management/Assessment, last revised 04/2025, states in part: All residents have the right to pain management. All residents will be evaluated for indicators of pain, or history of pain.The pain measurement scales of 0 - 10 or the Wong-Baker FACES facial pain scale will be used measuring a resident's severity of pain level. Mild pain: 1 -3; Moderate pain: 4 - 6; Severe pain: 7 - 10. In addition to an initial pain assessment.a pain assessment shall be completed.when a resident is exhibiting behaviors that may be caused by pain.The Wong-Baker FACES Foundation, originator of the Wong-Baker FACES Pain Rating Scale (a tool created and adapted for use to facilitate communication and improving assessment for pain management), date unknown, states in part: This self-assessment tool must be understood by the patient, so they are able to choose the face that best illustrates the physical pain they are experiencing. It is not a tool to be used by a third person.healthcare professionals, or caregivers, to assess the patient's pain. R5 was admitted to the facility on [DATE] and has diagnoses that include aphasia following cerebral infarction (inability to verbally communicate due to a stroke in the brain), restless leg syndrome, insomnia, repeated falls, retention of urine, fracture of unspecified part of neck of left femur, vascular dementia with behavioral disturbance. R5's Minimum Data Set (MDS) assessment, dated 11/21/2025, indicated that R5 has a Brief Interview for Mental Status (BIMS) score of 8/15 which means moderate cognitive impairment. R5 has an activated power of attorney for healthcare decisions. R5's care plan, initiated on 09/09/2025 with a target date of 02/20/2026, states in part: Potential for Pain. Interventions include.monitor physical symptoms - use the same assessment tool consistently - use 0/10 pain scale or use verbal description (mild, moderate, severe, very severe/horrible) - [NAME] FACE scale. R5's care plan, initiated on 09/09/2025 with a target date of 02/20/2026, states in part: The resident has a communication problem related to expressive aphasia, stroke, weak or absent voice. Interventions include.monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. On 02/09/2026 at 8:45 AM, Surveyor observed R5 sitting in a wheelchair in the hallway, propelling self with his legs down corridor. R5 had an indwelling urinary catheter located beneath wheelchair. During Surveyor's observation, R5 made attempt to stand while in wheelchair, which activated a chair alarm. Staff assisted R5 to sit back down in wheelchair. Surveyor attempted to interview R5; however, R5 did not verbally respond to questions. On 02/09/2026 at 10:45 AM, Surveyor observed R5 attempting to stand from wheelchair while in hallway. Certified Nursing Assistant (CNA) F assisted R5 back to a sitting position. Surveyor interviewed CNA F regarding staff interventions for maintaining R5's safety, CNA F stated staff keep R5 in the hallway, and not allowed alone in room, because R5 often attempts to stand up, activating chair alarm. CNA F stated staff can monitor R5's safety if kept in hallway and within staff's view. CNA F was unsure why R5 attempted to stand from wheelchair, or causes of R5's restless behavior. On 02/09/2026 at 11:54 AM, Surveyor interviewed R5's wife, who was visiting R5 in his room. R5's wife stated R5 does not sleep well at night and makes several attempts to get out of bed. R5's wife stated R5 is frequently restless and makes repeated attempts to stand while in wheelchair. Surveyor observed R5 attempt to stand from wheelchair and incoherently verbalize to wife during interview with R5's wife. R5's wife stated R5 does not verbalize needs very well due to having had a stroke and is difficult to understand. R5's wife stated it is difficult to interpret R5's needs, including if having pain. R5's wife stated R5 must have a permanent indwelling urinary catheter because of chronic urinary retention, a condition diagnosed by a provider prior to R5's admission to the facility. R5's wife feels the catheter causes discomfort for R5 because of frequent pulling on catheter tubing, at times completely dislodging catheter. R5's wife stated, I think it hurts around his penis and that is why he pulls on it. R5's wife informed Surveyor of R5's history of falls, one which resulted in fracture of left femur. R5's wife was unable to interpret if R5 was having pain during interview. On 02/10/2026 at 7:44 AM, during interview with Registered Nurse (RN) D, RN D stated R5 is up all night most nights and repeatedly attempts to exit the bed. RN D stated it is unclear to cause of R5's restlessness. Record review of R5's medical record indicated the following: R5 suffered falls while residing at facility on 09/21/2025, 11/12/2025 and 10/15/2025. The fall R5 had on 10/15/2025 resulted in a left femur fracture, requiring surgical intervention. On 09/09/2025, physician orders state: Ask resident if having presence of pain, aches or discomfort OR non-verbal indicators of pain (facial expressions, protective body movements, posture etc.) using the pain measurement scale of 0 -10 or FACES pain rating scale. Document appropriate number. On 11/14/2025, physician orders state: Acetaminophen (medication for pain/fever) tablet 325mg, give 2 tablets one time a day for chronic pain. On 01/30/2026, order was discontinued. R5's TAR for January 2026 and February 2026 include directions that state: Ask resident if having presence of pain, aches or discomfort OR non-verbal indicators of pain (facial expressions, protective body movements, posture etc.) using the pain measurement scale of 0 -10 or FACES pain rating scale. Document appropriate number. R5's TARs indicate pain assessment was done twice daily. R5's TARs have no time of day documented when assessments were done. R5's TARs do not have number indicators of R5's pain levels documented. Daily pain assessment include check marks with initials of staff. On 12/03/2025 at 4:35 PM, nursing documentation in R5's medical record states in part, Foley catheter placed causes discomfort to resident, resident attempts to pull catheter out frequently. R5's medical record for December 2025, January 2026 and February 2026 showed several chart entries by nursing staff for behavior/mood of R5 exhibiting restless behaviors at night with attempts to get self out of bed. R5's frequently pulled at catheter tubing and at times pulled it entirely out. No documentation for pain assessment found in R5's record. On 12/10/2025 at 12:00 PM, interdisciplinary team charting stated in part: Resident throughout the month of November continued to have daily behaviors of pulling at lines (i.e. catheter), attempting to get out of chair or bed. Resident's wife visits nearly every day and aids with behaviors and reorienting resident. On 01/17/2026 at 6:49 AM, R5's medication administration record (MAR) indicates Acetaminophen 325mg 2 tablets was administered. No pain level or reason for administration of pain medication was documented. On 02/11/2026 at 8:35 AM, Surveyor interviewed MDS coordinator/Director of Nursing (DON) B regarding what staff expectations were for assessing and documenting pain on residents who are unable to communicate verbally. MDS/DON B stated nonverbal residents are assessed for pain using the FACES scale, and it is documented utilizing the number conversion in a resident's medical record.

Based on observation, interview, and record review, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents reviewed (R2).R2 was not repositioned per plan of care.Findings include:Facility policy titled, Care Planning with Resident and/or Representative, effective 11/23/2016, reads in part: To provide a team approach in the planning and care of the resident as a whole and to periodically review this plan to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing.Facility policy titled, Standards of Care, last revised 2/26, reads in part: All employees are to follow the Standards of Care for their specific job position.care plans are to be followed on all residents, at all times. Update nurse if the care plan requires changes.R2 was admitted to the facility on [DATE].On 11/18/25, R2 had a Brief Interview for Mental Status (BIMS) of 99 indicating R2 was unable to complete the interview.R2's care plan includes in part: The resident has potential for pressure ulcer development related to immobility with an intervention of assist to shift weight in wheelchair every 15 minutes and the resident needs (reminding/assistance) to turn/reposition at least every 2 hours (8-12-25).On 02/10/26 at 7:03 AM, R2 was taken to the dining room for breakfast in R2's Broda chair. Surveyor observed R2 until 9:18 AM. R2 was not repositioned or had weight shifted every 15 minutes per plan of care. R2 remained in Broda chair in dining room placed in front of the television.On 02/11/26 at 9:57 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O. CNA O stated if CNAs need to know what care residents need, they have care plans in the computer, and the care plans are updated all the time.On 02/11/26 at 10:08 AM, Surveyor interviewed Registered Nurse (RN) D. RN D stated CNAs are expected to follow the care plans. RN D stated if the CNAs do not agree with something in the care plan, they can talk to the nurses about possible changes needing to be made. RN D stated care plans get updated as changes happen. RN D stated CNAs will get verbal reports, there is a communication board, and therapy will give both nurses and CNAs any changes made by that department.On 02/11/26 at 10:24 AM, Surveyor interviewed CNA F. CNA F stated they have care plans available to know what care the residents need. CNA F stated the care plans are found in the electronic system the facility uses, and they also have daily sheets that give them a little insight.On 02/11/26 at 10:32 AM, Surveyor interviewed Minimum Data Set (MDS) coordinator/Director of Nursing (DON) B. MDS/DON B stated MDS/DON B updates care plans at a minimum quarterly when everything is checked to make sure it is correct and up to date. MDS/DON B stated care plans are also updated as needed when changes happen.On 02/11/26 at 10:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated NHA A would hope CNAs would follow the care plan. NHA A stated the care plans are available to the CNAs on the computer and they should know what their tasks are. NHA A stated CNAs have shift-to-shift reports and the floor nurses should be monitoring the CNAs for compliance. NHA A was informed about Surveyor's observation and what the care plan states.

Based on observation, interview and record review, the facility did not revise the comprehensive care plan based on the preferences and needs of the resident for 1 (R16) resident for 12 residents reviewed for care planning in a sample of 12 residents.R16's comprehensive care plan was not revised by staff regarding the placement of the torticollis orthosis (a device designed to restore proper head and neck alignment) based on changing goals and preferences of R16. Findings include:The facility's policy, titled Care Planning with Resident and/or Representative, dated 11/23/2016, states in part: A comprehensive plan of care is a systemic assessment and identification of resident problems accomplished through short- and long-term measurable goals.it includes which disciplines are responsible for the identified approaches. It is updated when changes occur.The facility's policy, titled Standards of Care, revised 2/2026, states in part: Physician orders, standing orders, MAR/TAR, care plans, CNA charting, and policies and procedures provide guidelines to follow to meet the needs of the residents. R16 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease with late onset, moyamoya disease (a progressive cerebrovascular disorder that can lead to reduced blood flow to the brain, causing strokes), hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left nondominant side, epilepsy, dysphagia (difficulty swallowing) and aphasia (impaired speaking).R16's Minimum Data Set (MDS) assessment, dated 12/30/2025, indicated R16 has a Brief Interview for Mental Status (BIMS) score of 10/15, which means moderate cognitive impairment. R16 has an activated power of attorney for healthcare. R16's care plan, last revised 12/23/2025, with a target date of 03/31/2026, states in part: Self-care deficit related to dementia, history of strokes, contractures both arms and legs. Interventions include.Torticollis Orthosis: apply during AM shift meals, padded area placed on right side of head. Strap around back with padded strap under arm and along front of chest. Secured at buckle. Encourage me to relax head back in a more upright position. Feed from left side to encourage improved positioning.From 02/09/2026 at 12:28 PM to 02/11/2026 9:13 AM, Surveyor observed R16 being assisted by staff with feeding at breakfast and lunch meals. R16 did not have torticollis orthosis cushion in place during each meal observed. On 02/10/2026 at 1:45 PM, Surveyor asked R16 if cushion was being used during meals to help with positioning of neck and R16 stated it was not. R16 stated he did not like the cushion because it hurt while in place. Surveyor observed torticollis orthosis on a desk in R16's room. On 02/10/2026 at 1:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F on proper timing and use of the torticollis orthosis cushion for R16. CNA F stated R16 is supposed to wear it when eating, however refuses to because R16 does not like it and tells staff it hurts when it is on. On 02/11/2026 at 7:20 AM, Surveyor interviewed Registered Nurse (RN) D what the expectations were for placement of R16's torticollis orthosis cushion. RN D stated, We have tried it. He didn't like it. It hurts him. On 02/11/2026 at 9:05 AM, Surveyor interviewed Occupational Therapist (OT) H about what the expectations of staff were for placement of the torticollis orthosis cushion on R16. OT H stated it is intended for R16 to wear the cushion during mealtime to assist with proper neck alignment while eating. OT H was aware R16's cushion was often not in place during meals. OT H stated R16's compliance with wearing the cushion depended on which staff person applied the cushion. OT H clarified when OT or physical therapy (PT) staff apply the cushion, R16 does not complain. When certain CNA staff apply the cushion, R16 does not want it in place due to discomfort the cushion causes him. On 02/11/2026 at 10:14 AM, Surveyor interviewed PT I about what the expectations were of staff to apply the torticollis orthosis cushion on R16. PT I stated cushion was to be worn by R16 at meals. PT I stated R16's compliance depended on the moment and which staff member was applying the cushion. PT I stated R16 was inconsistent with assessments, sometimes stating he had pain with it, then moments later denying having pain with the cushion in place. PT I stated another physical therapy evaluation for effectiveness of torticollis orthosis cushion is indicated for R16 and needs to be ordered by nursing staff. Record review of R16's medical record has following documentation: On 01/11/2026, monthly restorative/maintenance summary by nursing states: Torticollis orthosis: apply during AM shift meals. [R16] participated 10/19 AMs. On 02/08/2026, monthly restorative/maintenance summary by nursing states: Torticollis orthosis: apply during AM shift meals. [R16] participated 0/30 Ams. CNA documentation indicated R16 refused placement of torticollis cushion 5 days in January 2026, and 5 days in February 2026. To be noted: CNA documentation on R16's compliance for use of torticollis orthosis was not completed for all days in January and February. R16's care plan, last revised on 12/23/2026, does not indicate R16's resistance to wearing torticollis orthosis. R16's care plan does not have interventions in place to promote R16's compliance when having discomfort from cushion. R16's care plan does not have interventions for alternatives to maintaining neck alignment during meal time. R16's treatment administration record does not have documentation for monitoring placement of cushion. R16 does not have orders in medical record for a PT reevaluation for placement and/or effectiveness of torticollis orthosis cushion. On 02/11/2026 at 8:35 AM, Surveyor interviewed MDS Coordinator/Interim DON B on the facility's process for updating/revising care plans when changes in a resident's care routine were acknowledged. MDS/DON B stated any nurse can make changes to a resident's care plan at any time. Any staff discipline can notify MDS/DON B of changes in a resident's routine and ask for changes to be made in the care plan. All care plans are reviewed and/or updated quarterly, and as needed. MDS/DON B was aware R16 did not always wear the cushion stating, [R16] is tricky sometimes.

Based on observation, interview and review, the facility did not implement the care developed in a comprehensive care plan for 1 (R16) resident of 12 residents reviewed for care plans in a sample of 12 residents.R16's comprehensive care plan was not implemented by staff regarding the placement of the torticollis orthosis (a device designed to restore proper head and neck alignment). Findings include:The facility's policy, titled Care Planning with Resident and/or Representative, dated 11/23/2016, states in part: A comprehensive plan of care is a systemic assessment and identification of resident problems accomplished through short- and long-term measurable goals.it includes which disciplines are responsible for the identified approaches. It is updated when changes occur.The facility's policy, titled Standards of Care, revised 2/2026, states in part: Physician orders, standing orders, MAR/TAR, care plans, CNA charting, and policies and procedures provide guidelines to follow to meet the needs of the residents. R16 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease with late onset, moyamoya disease (a progressive cerebrovascular disorder that can lead to reduced blood flow to the brain, causing strokes), hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left nondominant side, epilepsy, dysphagia (difficulty swallowing) and aphasia (impaired speaking).R16's Minimum Data Set (MDS) assessment, dated 12/30/2025, indicated R16 has a Brief Interview for Mental Status (BIMS) score of 10/15, which means moderate cognitive impairment. R16 has an activated power of attorney for healthcare. R16's care plan, last revised 12/23/2025, with a target date of 03/31/2026, states in part: Self-care deficit related to dementia, history of strokes, contractures both arms and legs. Interventions include.Torticollis Orthosis: apply during AM shift meals, padded area placed on right side of head. Strap around back with padded strap under arm and along front of chest. Secured at buckle. Encourage me to relax head back in a more upright position. Feed from left side to encourage improved positioning.From 02/09/2026 at 12:28 PM to 02/11/2026 9:13 AM, Surveyor observed R16 being assisted by staff with feeding at breakfast and lunch meals. R16 was seated in Broda chair, parked with dining table to the right. R16 was assisted with feeding by staff seated on R16's right side. R16 did not have torticollis orthosis cushion in place during each meal observed. On 02/10/2026 at 1:45 PM, Surveyor observed signage on R16's closet door instructing proper use and application of torticollis orthosis cushion. Cushion was lying on desk in R16's room. Surveyor asked R16 if cushion was being used during meals to help with positioning of neck and R16 stated it was not. Surveyor asked R16 if assistance with feeding was required and R16 stated he could not feed himself. R16 stated it was hard to swallow foods because of neck flexion to the right. On 02/10/2026 at 1:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F on proper timing and use of the torticollis orthosis cushion for R16. CNA F stated R16 is supposed to wear it however refuses to because he does not like it and says it hurts when it is on. Record review includes the following: On 11/01/2026, a physical therapy evaluation on R16 indicated reason for referral was in part. contracture of the cervical spine. He is rotated and side bending severely to the right. On 12/08/2026, physical therapy documentation states in part: Response to treatment - actively participates with skilled interventions.patient would benefit from torticollis orthosis for positioning while eating as well as other times of the day. Education provided to DON [director of nursing] regarding torticollis orthosis for positioning. On 12/10/2026, physical therapy documentation states in part: patient was provided education about orthosis and is in agreement to wear.On 02/11/2026 at 9:05 AM, Surveyor interviewed Occupational Therapist (OT) H about what the expectations of staff were for placement of the torticollis orthosis cushion on R16. OT H stated it is intended for R16 to wear the cushion during mealtime to assist with proper neck alignment while eating. OT H was aware R16's cushion was often not in place during meals. OT H stated R16's compliance with wearing the cushion depended on which staff person applied the cushion. OT H clarified when OT or physical therapy (PT) staff apply the cushion, R16 does not complain. When certain CNA staff apply the cushion, R16 does not want it in place due to discomfort the cushion causes him. On 02/11/2026 at 10:14 AM, Surveyor interviewed PT I about what the expectations were of staff to apply the torticollis orthosis cushion on R16. PT I stated cushion was to be worn by R16 at meals. PT I stated R16's compliance depended on which staff member was applying the cushion. PT I stated education had been provided to staff as a whole group. PT I stated individual staff training was also provided when requested to promote R16's compliance in wearing the cushion.

Based on interview and record review, the facility did not have evidence that all injuries of unknown origin and allegations of misappropriation of property are thoroughly investigated for 2 of 2 residents reviewed (R7, R9).R7's injury of known origin was not thoroughly investigated.R9's allegation of misappropriation of property was not thoroughly investigated.Findings include: Facility policy titled, Abuse -Alleged Incidents of Caregiver Misconduct and Injuries of Unknown Origin, last revised 05/25, reads in part: Immediately upon learning of an incident of resident mistreatment or discovering an injury of unknown source, nursing staff must take the necessary steps to protect all residents from possible subsequent incidents of mistreatment, neglect, exploitation, or injury by removing the individual under suspicion from duty until the investigation is completed, or any suspected causative factors in the environment.In addition to Federal and State reporting requirements, The Elder Justice Act requires notification of local law enforcement authorities.A thorough investigation may include.interviewing staff who worked previous shifts to determine if they were aware of an injury.A thorough investigation may include.Interviewing other residents to determine if they have been abused or mistreated, interviewing staff worked the same shift, interviewing staff that worked the previous shift, and involving other regulatory authorities that may assist. Example 1 R7 was admitted to facility on 11/01/23. R7's diagnoses in part include Alzheimer's disease, dementia with psychotic disturbance, and mild neurocognitive disorder. On 12/30/25, R7's Brief Interview for Mental Status (BIMS) score was 7/15 indication moderate cognitive impairment. On 02/02/26 at 5:50 AM, CNA O went to assist CNA Q get R7 out of bed and when pulling back the covers discovered two skin tears to the right forearm near the elbow. Both CNAs denied knowing what caused the skin tears. CNA O got Licensed Practical Nurse (LPN) N to come assess R7. LPN N stated upon arrival to R7's room there was dried blood on the blanket and two skin tears to the right forearm. Skin tears measured 2 centimeters (cm) by 1.9cm and 9.5cm by 6.7cm. LPN N provided first aid to skin tears. CNA Q was not allowed back in R7's room but was allowed to remain on the unit and finish the shift. CNA Q left at 6:45 AM. LPN N questioned CNA O and CNA Q. Both denied having any knowledge of how the skin tears happened. LPN N talked to both CNAs about how to care for resistive residents. The facility determined this could possibly be an abuse situation or an injury of unknown origin. Director of Nursing (DON) M was notified upon arrival to work after 8:00 AM. DON M then informed Nursing Home Administrator (NHA) A. MDS Coordinator/DON B interviewed 2 residents from the same unit with severely impaired cognition and were not good historians. Education was initiated and CNA Q was removed from the schedule. On 02/02/26 at 1:19 PM, night shift Registered Nurse (RN) R stated RN R was assisting another resident to the bathroom when CNA Q called on the walkie talkie for assistance stating R7 was getting physically and verbally aggressive. RN R stated CNA Q reported R7 threatened to bite CNA Q in the arm and take a chunk of skin off. RN R stated there was no report of a skin tear at that time. RN R stated, Multiple residents were awake, confused and causing problems. RN R did not respond to R7's room. LPN N filled out a resident abuse form which indicated R7 does not have side rails and does not have the ability to reach the headboard to cause the injury to R7's arm. On 02/02/26, DON M completed a form titled, Abuse-Alleged Incident of Caregiver Misconduct Checklist. The line stating, If there is a reasonable suspicion of a crime against a resident, law enforcement will be contacted immediately, was marked as not applicable. On 02/03/26, Nursing Home Administrator (NHA) A and MDS/DON B interviewed CNA Q. CNA Q stated CNA Q washed R7 up and saw no skin tears to R7's arms until CNA Q and CNA O went to get R7 out of bed. CNA Q stated R7 was not resistive to cares earlier in the shift, CNA Q did not hold R7's arm, R7 did not yell or hit CNA Q, and CNA Q did not have long fingernails, a watch, or rings that would have caused the skin tears. It was reported that CNA Q was wearing a hoodie with a zipper during the incident. CNA Q stated that no one else took care of R7 that night. On 02/05/26, NHA A terminated CNA Q. The report included in part: Following the investigation, it was determined there was cause for termination of employment. The investigation did not find concrete evidence of abuse but lack of knowledge of the injury was concerning and neglectful. On 02/10/26, Surveyor reviewed provided education. 50% of staff had been educated on abuse and reporting. On 02/11/26 at 10:08 AM, Surveyor interviewed RN D. RN D stated if RN D was made aware or witnessed potential abuse RN D would remove the perpetrator, ensure the resident is safe and notify management immediately. On 02/11/26 at 10:37 AM, Surveyor interviewed LPN N. LPN N stated LPN N sent CNA Q out of R7's room but allowed her to stay and finish CNA Q's shift on the unit. LPN N stated LPN N reported the incident to DON M after 8:00 AM when DON M arrived for work. LPN N stated LPN N did not have an RN complete a follow up assessment of R7 and acknowledged there were RNs in the building at the time of the incident. LPN N stated the expectation would be to remove the accused staff member from the building and report to management immediately. On 02/11/26 at 10:45 AM, Surveyor interviewed NHA A. NHA A acknowledged further interviews should have been conducted with residents with higher cognition possibly on the other unit, as CNA Q had previously worked both units. Example 2 The facility policy, titled Grievance Complaint Procedures, revised October 15, 2021, states: .Procedure: #10. Social Worker or designee will begin investigating the complaint in a timely manner to ascertain its validity and will keep a record of the investigation in the complaint file. #11. A plan of action to resolve the grievance/complaint shall be developed within 72 hours of the social worker's knowledge of the compliant. The person filing the complaint or grievance will be informed within reasonable amount of time of the plan of action and the social worker will complete a follow-up to determine if the plan has succeeded. The person filing the complaint or grievance will receive periodic updates throughout the process. If the plan is not successful, another plan of action will be formulated and followed. #12. All parties involved and witnesses, if any, will be interviewed and responses recorded as a part of the investigation. Written statements will be signed and dated by the person. #14. The Grievance Official will work toward a solution to the problem and consult with the staff as needed . Surveyor reviewed Grievance logs dated October 2024-present (4 pages): Surveyor observed an incomplete grievance complaint form attached to grievance log, dated 12/04/25, which states in part, .[R9's] Gold necklace with (Sister) on the necklace missing. Surveyor did not see a proper investigation or process for resolution of the missing item on the incomplete grievance form. On 02/11/26 at 8:51 AM, Surveyor interviewed Social Services J and asked what the process is for how Social Services J handles complaints and who oversees investigating and finding a resolution. Social Services J reported to Surveyor that typically the staff or a resident will fill out a grievance form. Social Services J then reviews the grievance and starts the investigation and interviews potential witnesses or resources who may know more of the situation. Social Services J will interview the complainant and follow up through the investigation process. Social Services J reported that Social Services J finds a resolution and makes sure to update all parties involved. Surveyor asked how Social Services J keeps record of the steps in investigation and processes. Social Services J reported that every complaint is documented on the grievance log and then a narrative of the steps and outcome are kept in a file folder per grievance. Surveyor asked if Social Services J has the investigation file for R9 and what the disposition was for R9's missing Golden necklace. Social Services J reported to Surveyor that Social Services J was out on maternity leave from 09/17/25-12/15/25, so Social Services J is unsure what came of R9's grievance. Social Services J reported that while Social Services J was on maternity leave, Nursing Home Administrator (NHA) A was to oversee grievances. On 02/11/26 at 9:05 AM, Surveyor interviewed NHA A and asked why R9's grievance of missing Golden Necklace did not have investigation process or resolution in place. NHA A reported that NHA A didn't realize the grievance was not followed up on and that it was a mistake.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported/reported timely for 3 of 3 residents reviewed (R7, R26, R9) to the State Agency (SA) or to law enforcement.The facility did not report R7's injury of unknown origin to the State Agency (SA) or to law enforcement.The facility did not report R26's injury of unknown origin to the SA or to law enforcement.The facility did not report misappropriation of R9's personal property to the SA or to law enforcement. Findings include: Facility policy titled, Abuse -Alleged Incidents of Caregiver Misconduct and Injuries of Unknown Origin, last revised 05/25, reads in part: Immediately upon learning of an incident of resident mistreatment or discovering an injury of unknown source, nursing staff must take the necessary steps to protect all residents from possible subsequent incidents of mistreatment, neglect, exploitation, or injury by removing the individual under suspicion from duty until the investigation is completed, or any suspected causative factors in the environment.In addition to Federal and State reporting requirements, The Elder Justice Act requires notification of local law enforcement authorities.A thorough investigation may include.interviewing staff who worked previous shifts to determine if they were aware of an injury. Example 1 On 02/02/26 at 5:50 AM, Certified Nursing Assistant (CNA) O went to assist CNA Q get R7 out of bed and when pulling back the covers discovered two skin tears to the right forearm near the elbow. CNA O asked CNA Q what happened, and CNA Q stated CNA Q did not know. CNA Q had been taking care of R7 at 4:30 AM that morning and had called for assistance as R7 was reportedly combative with cares. No one went to assist CNA Q at the time. CNA Q stated there were no skin tears when CNA Q left R7's room the first time. CNA O got Licensed Practical Nurse (LPN) N to come assess. LPN N stated upon arrival to R7's room there was dried blood on the blanket and two skin tears to the right forearm. LPN N provided first aid to skin tears. CNA Q was not allowed back in R7's room but was allowed to remain in the building and finish the shift. CNA Q left at 6:45 AM. R7 does not have side rails or the ability to reach the headboard of the bed that R7 could have hit with R7's forearm. The facility initiated an alleged abuse investigation related to CNA Q. The initial incident report was not submitted within 2 hours to the State. The initial report was submitted on 02/04/26. Law enforcement was not contacted regarding allegation of abuse. On 02/11/26 at 10:37 AM, Surveyor interviewed LPN N. LPN N stated LPN N did not report the incident to Director of Nursing (DON) B until after 8:00 AM when DON M arrived at work. LPN N stated DON M then reported the incident to Nursing Home Administrator (NHA) A. On 02/11/26 at 10:45 AM, Surveyor interviewed NHA A. NHA A stated the facility did not call law enforcement because the facility could not prove abuse. NHA A acknowledged the facility should have contacted law enforcement due to the allegation of abuse. NHA A stated the initial report was completed on 02/02/26 at 12:00 PM but had not been completely submitted to the State. NHA A acknowledged the report would still have been beyond the 2-hour reporting time. NHA A reported it is an expectation for CNAs to report any allegations of abuse immediately to a nurse, or if it involves a nurse, to management immediately. NHA A stated it is an expectation for nurses to report an incident within 2 hours. NHA A stated it would be appropriate to report to law enforcement if the incident was aggressive including physical abuse. Example 2 Surveyor reviewed Grievance logs dated October 2024-present (4 pages). On 02/10/26 at 2:31 PM, Surveyor received grievance logs and an attached stack of papers paperclipped together pertaining to R26's ankle fracture. Surveyor reviewed a narrative note dated 08/25/25, which states in part, .[R26's] left ankle fracture resulted from most likely during one of the transferring events per provider. Writer received a text message from night nurse to update findings of bruising and swelling to [R26's] left ankle. Nurse reported that CNA was pivot transferring [R26] to toilet from bed and back to bed. Upon returning back to bed [R26] complained of left ankle pain. Nurse assessed and found scattered bruising 7cmx4.5cm and swelling to the left ankle area and lighter colored bruising above and around the outer area of the ankle bone. On 08/26/25 [R26] was seen for acute visit and had received x-rays that showed acute oblique nondisplaced distal fibular ankle fracture and [R26] is to be non-weight bearing and cast placed. Per nursing charting on 08/25/25, nurse documented R26 complained of left ankle pain for the last week . Surveyor reviewed R26's progress notes that state in part, .-On 08/18/25, [R26] complained of pain to the left ankle top/ or left foot. Increased swelling noted. Lift used due to difficulty transferring. Will continue to monitor . Surveyor reviewed all notes and did not find that facility reported R26's unknown injury to state agency. On 12/11/26 at 9:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) and asked what the expectation is for reporting R26's unknown injury to state officials. NHA A reported that NHA A did not realize that R26's injury should have been reported, therefore did not get reported to the state within the allotted time frame. Example 3 The facility policy, titled Grievance Complaint Procedures, revised October 15, 2021, states: .Procedure: #9. Consistent with CMS regulation 483.13 (c) (2), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property to the administrator and any other officials as required by State law (including the state survey and certification agency) . Surveyor reviewed Grievance logs dated October 2024-present (4 pages): Surveyor observed an incomplete grievance complaint form attached to grievance log, dated 12/04/25, which states in part, .[R9's] Gold necklace with (Sister) on the necklace missing. Surveyor did not see a proper investigation, process for resolution, or reporting of the missing item on the incomplete grievance form. On 02/11/26 at 8:51 AM, Surveyor interviewed Social Services J and asked how Social Services J handles complaints. On 02/11/26 at 9:05 AM, Surveyor interviewed NHA A and asked why R9's grievance of missing Golden Necklace wasn't reported to law enforcement or to the state agency. NHA A reported that NHA A didn't realize the grievance was not followed up on and that it was a mistake.

Based on record review and interview, the facility did not ensure each resident is free from unnecessary drugs as evidenced by not completing adequate drug monitoring for 1 of 5 residents (R) R9 reviewed for unnecessary medication reviews.The facility failed to accurately monitor resident-specific targeted behaviors for R9's psychotropic medication use. The facility policy, titled Antipsychotic use in residents with dementia and discus requirements, dated 08/24, states: Procedure: 1. Upon admission of a resident who has a diagnosis of dementia and is ordered an antipsychotic medication, the nursing staff will obtain from the physician an approved diagnosis for the antipsychotic medication and a specific targeted behavior/indication for it use.The facility policy further states under Procedure: 3. The nursing department will monitor specific behavior(s) for which the antipsychotic medication was prescribed for.*Of note, the policy does not address all psychotropic medication use.R9 was admitted to facility on 10/16/25 with diagnoses that include vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and major depressive disorder.R9's physician orders include the following psychotropic medications:-Buspirone HCl Oral Tablet 15 mg. Give 1 tablet by mouth two times a day for depression (anti-anxiety)-Trazodone HCl Oral Tablet 50 mg. Give 1 tablet by mouth one time a day for Insomnia. (anti-depressant).-12/10/25 Paroxetine HC oral tablet 20 mg. Give 1 tablet my mouth one time a day for major depression and anxiety. Give 1 tablet (20 mg) with 1 (40mg) to equal 60 mg. (anti-depressant).-12/10/25 Paroxetine HC oral tablet 40 mg. Give 1 tablet by mouth one time a day for major depression and anxiety. Give 1 tablet (40 mg) with 1 (20mg) to equal 60 mg. (anti-depressant).R9's care plan initiated on 10/28/25 and last revised on 01/22/26 states: Focus: The resident has impaired cognitive function/Alzheimer's dementia/Vascular dementia r/t Difficulty making decisions, Psychotropic drug use.R9's care plan does not include specific focus/interventions for targeted behaviors or monitoring for all 3 psychotropic medications.R26's monitoring order for targeted behaviors related to antidepressants and anti-anxiety use was not put into place until 02/10/26 when Surveyor requested supporting targeted documentation.On 02/10/2026 at 2:15 PM, Surveyor interviewed MDS/Interim Director of Nursing (DON) B regarding R9's behavior charting and monitoring for specific targeted behaviors for use of anti-anxiety and anti-depressant medication use. MDS/DON B stated was unable to find any supporting documentation. On 02/10/2026 at 4:15 PM, Surveyor made Nursing Home Administrator (NHA) A aware of concerns with no targeted specific behaviors being monitored for R9. NHA A stated was aware of concern and targeted behaviors were to be added for monitoring in R9's record.

Based on record review and interview, the facility did not ensure residents were free of misappropriation and/or exploitation. The facility failed to investigate and report to the State of Wisconsin or local authorities when alleged misappropriation was first reported by resident (R) R9 on 12/04/25. This led to no resolution of R9's missing golden necklace.This is evidenced by:The facility policy, titled Grievance Complaint Procedures, revised October 15, 2021, states:.Procedure:#10. Social Worker or designee will begin investigating the complaint in a timely manner to ascertain its validity and will keep a record of the investigation in the complaint file.#9. Consistent with CMS regulation 483.13 (c) (2), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property to the administrator and any other officials as required by State law (including the state survey and certification agency) .#11. A plan of action to resolve the grievance/complaint shall be developed within 72 hours of the social worker's knowledge of the compliant. The person filing the complaint or grievance will be informed within reasonable amount of time of the plan of action and the social worker will complete a follow-up to determine if the plan has succeeded. The person filing the complaint or grievance will receive periodic updates throughout the process. If the plan is not successful, another plan of action will be formulated and followed.#12. All parties involved and witnesses, if any, will be interviewed and responses recorded as a part of the investigation. Written statements will be signed and dated by the person.#14. The Grievance Official will work toward a solution to the problem and consult with the staff as needed .Surveyor observed an incomplete grievance complaint form attached to grievance log, dated 12/04/25, which states in part, .[R9's] Gold necklace with (Sister) on the necklace missing. Surveyor did not see a proper investigation or process for resolution of the missing item on the incomplete grievance form. On 02/11/26 at 8:51 AM, Surveyor interviewed Social Services J and asked how Social Services J handles complaints and who oversees investigating and finding a resolution. Social Services J reported to Surveyor that typically the staff or a resident will fill out a grievance form. Social Services J then reviews the grievance and starts the investigation and interviews potential witnesses or resources who may know more of the situation. Social Services J will interview the complainant and follow up through the investigation process. Social Services J reported that Social Services J finds a resolution and makes sure to update all parties involved. Surveyor asked how Social Services J keeps record of the steps in investigation and processes. Social Services J reported that every complaint is documented on the grievance log and then a narrative of the steps and outcome are kept in a file folder per grievance. Surveyor asked if Social Services J has the investigation file for R9 and what the disposition was for R9's missing Golden necklace. Social Services J reported to Surveyor that Social Services J was out on maternity leave from 09/17/25-12/15/25, so Social Services J is unsure what came of R9's grievance. Social Services J reported that while Social Services J was on maternity leave, Nursing Home Administrator (NHA) A was to oversee grievances.On 02/11/26 at 9:05 AM, Surveyor interviewed NHA A and asked why R9's grievance of missing Golden Necklace did not have investigation process or resolution in place. NHA A reported that NHA A didn't realize the grievance was not followed up on and that it was a mistake.

Based on interview and record review, the facility failed to report all allegations of neglect to the State Survey Agency within 24 hours for 1 of 2 allegations of abuse, neglect or mistreatment reviewed. On 09/23/25, R1 was discovered without her oxygen on and the facility investigated this as an allegation of neglect. It was not reported to the State Survey Agency until 09/30/25.This is evidenced by:The facility policy titled, Abuse-Alleged Incidents of Caregiver Misconduct and Injuries of Unknown Origin, dated revised 10/24, states in part, all alleged violations, involving abuse neglect exploitation, mistreatment, misappropriation of a resident property or injuries of unknown source are to be reported immediately to the Administrator of the facility no later than 2 hours after the allegation is made. All alleged violations will be reported no later than 24 hours, to other officials including the State Survey Agency . R1 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary fibrosis, and Alzheimer's disease. R1 has been on hospice care since 2023. On 09/22/25, R1 was noted to have a decline in condition including confusion, weakness, increased difficulty breathing, and short jerking movements to bilateral arms and legs. R1's Minimum Data Set assessment (MDS), dated [DATE], indicated a brief interview for mental status (BIMs) was coded as 99 which means it was unable to be completed. R1 was unable to answer any of the questions. Facility documentation reveals that on 09/23/25 at 6:10 AM, morning staff saw R1 without oxygen on and diaphoretic. O2 was 71% on room air. O2 put back on. Raised O2 sats to 89 and 90% on 4 L. Upon discussion, it initially was found to be a situation where it did not rise to the allegation of neglect. On 09/25/25, staff received education on the company policy on abuse and neglect. On 09/26/25, upon further review of the situation with the regional director and after further discussion, a decision was made to report the situation in good faith.On 12/08/25 at 3:00 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated she was on leave when the investigation occurred. Surveyor interviewed NHA A about the delay or reason for no initial self-report. NHA A stated the administrator who was working at the time was new and initially it was not looked at as a situation of neglect.

Based on interview and record review, the facility did not report an alleged violation involving mistreatment/misconduct within 24 hours of the event to the State Survey Agency. This occurred for 1 of 3 residents (R) reviewed. (R1)An incident involving R1 and Registered Nurse (RN) C occurred on 07/17/25. RN C did not transcribe a physician order to discontinue an anticoagulant medication and administered the medication without a physician order. The facility did not report the misconduct to the State Survey agency until 07/24/25.The facility policy titled, Abuse - Alleged Incidents of Caregiver Misconduct and Injuries of Unknown Origin, dated May 2025, states, . All alleged violations involving, abuse, neglect, exploitation, mistreatment, misappropriation of a resident property or injuries of unknown source are to be reported immediately to the Administrator and the appropriate units DON of the facility no later than 2 hours after the allegation is made. All alleged violations will be reported, no later than 24 hours, to other officials (including the State Survey Agency .)R1 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, chronic blood clots in vein, anemia, ovarian and rectal cancer, and GI bleed. R1's most recent Minimum Data Set (MDS) dated [DATE] indicated that R1 has a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. R1 is able to eat with set up, independent with bed mobility, and requires partial moderate assistance for transfer and toileting.Misconduct occurred on 07/17/25 at 1841 (6:41 PM) and was discovered on 07/18/25. Misconduct incident report states, Resident [R1] was having some bleeding issues and was on anticoagulant medication. Nurse discussed with physician and received an order to discontinue the medication. Resident (R1) who is her own person insisted on getting the medication, per residents rights, nurse did administer the medication causing a medication error. The nurse was following resident wishes and did not follow doctor order.The initial facility reported incident was submitted to the state agency on 07/24/25 with the final report. Under the brief summary of incident, facility noted, Added this incident to the final report (submitted when did not have access to system) see follow up report. The initial report was submitted with the final report on 07/24/25 at 9:43 AM.On 08/11/25 at 12:55 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the timing of the initial report. NHA A stated they were aware the initial report was late because there were a lot of issues going on at the same time and NHA A had trouble getting into the system.

Based on observation, record review and interview, the facility did not ensure the handwashing sink in the facility kitchen maintained a minimal acceptable water temperature. The facility practice had the potential to affect all residents. The handwashing sink's water temperature in the facility kitchen reached 73 degrees Fahrenheit after being ran for 2 minutes. Culinary Staff Aide (CSA) D and Culinary Manager (CM) E indicated low water temperatures have been occurring for several months and staff continued to use the sink as their means of handwashing in the kitchen. This is evidenced by: Surveyor requested and received the facility policy titled Handwashing -Food Service which was dated as most recently revised 11/12/24 and 10/18/22, prior to the current survey. The policy in part read: How to wash hands: ~Wet hands and forearms with warm water (minimum 100 degrees Fahrenheit) and apply an antibacterial soap . Surveyor requested and received the facility standard of practice titled Food Service Management-By Design published by Association of Nutrition and Food Service Professionals which was dated as revised most recently in 2015. The standard of practice indicated in part: ~Dining services personnel must be provided a sink specifically intended for washing hands. ~Must provide water at a temperature of at least 100 degrees Fahrenheit . Surveyor also reviewed the Food and Drug Administration (FDA) Food Code dated as most recently updated in 2022. The FDA Food Code in part read: 5-202.12 Handwashing Sink, Installation. (A) A Handwashing sink shall be equipped to provide water at a temperature of at least 29.4 degrees C (85 degrees F) through a mixing valve or combination faucet. On 11/12/24 at 10:54 AM, Surveyor entered kitchen to observe food service. Surveyor went to the handwashing sink in the kitchen to perform handwashing and noted the water barely lukewarm. Surveyor ran the water for 2 minutes and requested CM E take the temperature of the water from the faucet. CM E filled a glass with the water and immediately took the water temperature. Surveyor and CM E observed the water to be 73 degrees Fahrenheit. After checking the water temperature, Surveyor spoke with CSA D about handwashing at the sink and the water's temperature. CSA D expressed she has worked in the kitchen since springtime and uses the sink for handwashing. CSA D indicated the water temperature has been cool off and on since she started in the kitchen. CSA D further indicated she cannot wait for water to warm up for 2 minutes thus she proceeds with handwashing when the water is turned on. Surveyor also spoke with CM E after checking the water temperature. CM E expressed the water temperature being lukewarm is not unusual since the sink was replaced in the spring sometime around February or March of 2024. CM E confirmed staff continued to use the sink as their means of handwashing in the kitchen after the sink was replaced even though the temperature of the water was lukewarm off and on.

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). This has the potential to affect all 31 residents residing in the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they failed to have licensed nursing coverage on 6 days. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: 1 October 1 - December 31, (quarter 1) 2 January 1 - March 31, (quarter 2) 3 April 1 - June 30, (quarter 3) 4 July 1 - September 30 (quarter 4) . PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal year Quarter 3 2024 (April 1 - June 30), ran on 11/06/24 indicates the following: failed to have Licensed Nursing Coverage 24 Hours/Day Triggered = Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage. See Infraction Dates on Page 2, if triggered. Infraction Dates 04/14 (SU); 04/21 (SU); 05/25 (SA); 06/08 (SA); 06/09 (SU); 06/23 (SU). On 11/11/24 at 2:00 PM, Surveyor interviewed Nursing Home Administrator (NHA) A related to the triggered days for licensed nursing coverage. NHA A stated she was certain this was caused by a data entry error. NHA stated that they had licensed staff working and would provide the needed information. NHA A would provide scheduled staff postings, and payroll data, which proved staff worked, and would determine where the reporting errors occurred. On 11/11/24 at 3:30 PM, the facility provided evidence to show that staff had worked and where the errors in reporting occurred, which included the following information: 6.85 hours from the night shift of 04/13/24 did not show on the 4/14/24 report. 6.47 hours manually entered on 04/19/24 actually belong on 04/20/24. 6.48 hours manually entered on 04/20/24 actually belong on 04/21/24. 6.78 hours were not entered on 05/25/24 report. 8 hours on 06/08/24 and 8 hours on 06/09/24 were entered into the wrong facility's PBJ system instead of this facility's system. 7.25 hours worked by agency staff on the night shift did not carry over to the 06/23/24 report.

Based on observation, record review and interview, the facility staff did not conduct hand hygiene when warranted while providing care to 1 of 3 residents observed for cares (R7). Certified Nursing Assistant (CNA) C did not perform hand hygiene when warranted when proving morning cares to R7. This is evidenced by: Surveyor requested and received the facility policy title Hand Hygiene-Employee which was dated as most recently revised on 9/24. The policy in part read: Policy: Hand hygiene continues to be the single most important thing employees can do to prevent the transmissions of infection. Consistent proper hand hygiene practices are critical in preventing the spread of infections. It is the policy of this facility that all employees follow proper hand hygiene techniques. Below is a list of some situations that require hand hygiene: ~Before and after resident contact. ~Before and after assisting a resident with toileting. ~Before putting on gloves. ~After removing gloves. On 11/12/24 at 6:46 AM, Surveyor observed CNA C assist R7 with her morning care. CNA C assisted R7 to the bathroom to sit on the toilet. CNA C washed her hands and donned gloves to remove R7's brief. R7's brief was soiled with bowel movement. CNA C obtained a clean brief from the cupboard in R7's bathroom. CNA C obtained garbage bags and placed R7's pants and soiled brief in bags. CNA C did not remove her gloves, perform hand hygiene and don clean gloves. CNA C applied lotion to R7's legs and feet and applied her tubi-grip stockings on her legs. CNA C placed R7's clean brief and clean pants on her legs. CNA C placed R7's shoes on and proceeded to sink to wet washcloths. CNA C washed R7's face after removing R7's top and bra. CNA C again wet washcloths at sink and applied soap to cloths. CNA C washed, rinsed and dried R7's back, under arms, under her breasts and her arms. CNA C did not remove her gloves, perform hand hygiene and don clean gloves and proceeded to place R7's bra, apply deodorant under her arms and don a clean shirt on R7. CNA C proceeded to brush R7's dentures at sink which were provided to R7 to place in her mouth. CNA C did not remove her gloves, perform hand hygiene and don clean gloves after washing R7's upper body and before proceeding to handle R7's dentures. CNA C removed her gloves, performed hand hygiene and donned clean gloves to brush R7's hair. CNA C placed a gait belt around R7's waist and wet and applied soap to cloths. CNA C used a peri wipe to wipe bowel movement from R7's buttocks after R7 was assisted to stand with walker. CNA C washed, rinsed and dried R7's buttocks. CNA C removed her gloves and tossed gloves to the garbage. CNA C did not perform hand hygiene and pulled up R7's brief and pants. CNA C walked R7 from the bathroom with walker and brought over R7's wheelchair to assist R7 to sit in wheelchair. CNA C removed R7's gait belt and brought R7 her glasses. CNA C proceeded to make R7's bed with her bare hands that had not been washed. CNA C returned to the bathroom to bag dirty linens. CNA C used hand gel and preceded to take R7's dirty linens to the soiled utility room. CNA C returned to R7's room and propelled R7 in her wheelchair from her room up the hallway. On 11/12/24 at 1:25 PM, Surveyor spoke with CNA C about the observation and expectations related to hand hygiene. CNA C indicated she should have removed her gloves, performed hand hygiene and donned clean gloves whenever going from dirty task to clean. Surveyor asked CNA C why hand hygiene should be done when going from dirty task to clean task. CNA C responded for infection control. On 11/13/24 at 7:55 AM, Surveyor spoke with Director of Nursing (DON) B about the observation and the facility expectation related to hand hygiene. DON B indicated she would expect staff to remove gloves, perform hand hygiene and don clean gloves whenever going from a dirty task to a clean task for infection control practices, to prevent the transmission of infection.

Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring all allegations of abuse were reported immediately to the administrator or ensure the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act to law enforcement for 1 of 3 residents (R) reviewed. This is evidenced by: The facility policy entitled Abuse-Alleged Incidents of Caregiver Misconduct and Injuries of unknown Origin, dated 11/09/2016 last revised 10/23 states in part, All staff will be trained to immediately report to the administrator or designee, Any form of abuse, . should be reported immediately to the Administrator or Director of Nursing. The Elder Justice Act requires notification of local law enforcement authorities of any situation where there is a potential criminal offense. R1 was admitted to the facility on [DATE] and has diagnoses that include mild cognitive impairment, anxiety disorder, and chronic respiratory failure with hypoxia. R1's progress notes dated 11/21/23 at 1941 state in part that after returning to her room following supper, Certified Nursing Assistant (CNA) C was assisting R1 with her cares when R1 slapped CNA C across the face. R1 was convinced, screaming that she was inappropriately being touched. R1 stated that she wanted to call the police. R1 was wondering why no one believed her and also stated she was scared. Licensed Practical Nurse (LPN) D documented that it took some convincing that R1 was safe here and that no one here would ever try to hurt her, but R1 still remains adamant that everyone was out to get her. Surveyor interviewed Nursing Home Administrator (NHA) A on 11/30/23 at 12:45 PM. Surveyor asked when NHA A was informed of the allegation of abuse. NHA A stated that she was not informed of the allegation of abuse until the next day, after it occurred. When Surveyor asked if the police were informed of the allegation, NHA A stated that they were not notified. When asked if the facility policy includes informing the police, NHA A stated that the facility policy states to contact the police.

Based on record review and interview, the facility did not ensure that all residents were free from physical abuse and neglect for 1 of 4 residents (R1) reviewed for physical abuse. R1 sustained a subluxation of right thumb with bruising on right wrist during attempt by a licensed practical nurse and certified nursing assistant to obtain an oximetry reading. R1 sustained a bruise to the right forehead from R1's head hitting grab rail and sustained knee pain and a golf size bruise on the right knee, when a CNA neglected to get assistance for cares or use a 2 person assist for the hoyer lift transfer when R1 was agitated and combative. Findings: The facility policy titled, Abuse, Neglect, and Exploitation of Residents and Property, which is not dated, states in part: .Ladysmith Care Community expressly prohibits the abuse, neglect, mistreatment, or exploitation of a resident. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals . R1 was admitted to the facility on [DATE] with diagnoses, in part: .unspecified dementia with behavioral disturbances . R1's MDS (Minimum Data Set) assessment dated [DATE] indicates R1 requires extensive assist with 2 staff for bed mobility, toilet use, and personal hygiene. R1 requires a Hoyer lift with 2 assist for transfers. R1 was not assessed for the BIMS (Brief Interview for Mental Status) because per section C0100, R1 is rarely/never understood and section C1000 Cognitive Skills for Daily Decision Making is documented as severely impaired-never/rarely makes decisions. R1's care plan dated 10/17/21: I can't complete cares on my own. 10/17/21 Approaches: I need my aides to: offer me simple instructions, praise my progress/effort, speak slowly and clearly, give me rest periods during tasks, check my skin during care, place on mat on the side of my bed. I reposition in bed with the help of 1 person. I use an assist bar-assist of two when resident is having unmet needs. I transfer with the help of 2 doing 100% of the effort transfer me with a tilting sling. Provide a stuffed animal for me to hold onto while transferring to help reduce anxiety and decrease risk of self-harm. R1's care plan dated 09/15/21: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 09/15/21 Approaches: I need my nurses to: Allow extra time for me to respond. Ask me questions which can be answered with yes or no, or very brief expressions. I need my aides to use yes and no questions when speaking to me and try not to overwhelm me with too many questions or instructions, allow me to respond and keep in mind it may take me longer to process my thoughts. I need my aides to repeat questions for me as needed. On 11/11/21, Surveyor reviewed self-report submitted by facility on 10/19/21 regarding bruises on R1's forehead, arm, and knee. Nursing Progress Notes 10/16/21 12:27 p.m. POA notified regarding bruise to resident's forehead. Advised to call NH (Nursing Home) if she has any questions or concerns. 10/17/21 11:30 a.m. Left knee pain reported by resident. Muscle rub applied to bilateral knees and back. 10/17/21 11:44 a.m. Bruise to frontal forehead is dark blue in color today. Resident not able to indicate if bruise site is painful. 10/17/21 12:07 p.m. late entry for 10/16/21. Incident: potential for skin complications-to left knee and right forehead. Bruising to right side of forehead from hitting on grab bar of bed and having unmet needs, left knee from hitting on wall during cares and unmet needs. Resident was noted to have unmet needs with cares this morning, CNA reported to nursing that she was kicking, hitting, yelling, pinching, scratching, and screaming with morning cares, right forehead bumped on grab bar, left knee bumped on wall. Neuro checks: Pupils equal, round, and react to light and accommodation. POA-HC notified, MD notified, Actions: Continue to observe. Assist of 2 with cares when resident is having unmet needs. 10/17/21 4:17 p.m. Bruise dark purple to right frontal forehead. No c/o (complaint of) pain to site. 10/18/21 07/:07 a.m. Bruise continue to right forehead, area black/blue in color. 10/18/21 10:22 a.m. Call placed to NP to update regarding resident's increase in pain, bruising, and swelling. Awaiting return call at this time. 10/18/21 10:41 a.m. Noted dark purple/brown bruising to right inner wrist, noted faint yellow/blue circle bruising noted to left ankle, noted blue/purple bruising to right knee, noted swelling to left leg/knee. Resident noted to have unmet needs Saturday where she was striking out and resident noted to hit head/knee on wall. MD called and left message return call back r/t increase in discomfort. 10/18/21 5:29 p.m. Bruising to right forehead measures 2.7cm x 1.8cm, bruising to right inner wrist measures 4cm x 2.1 cm, left ankle bruise measures 2cm around. 10/18/21 10:42 a.m. spoke with POA regarding increase in pain and new bruise noted. Writer stated there is a call out the MD and awaiting orders for possible x-ray. 10/18/21 12:34 p.m. call placed to Nurse Practitioner (NP) at 11:40 d/t no call back regarding increase in pain. NP stated that she will call and talk to Dr. and get back to writer with orders. 10/18/21 2:22 p.m. x-ray of left hip, left knee, and CBC. Signed by NP. 10/18/21 3:24 p.m. Nurse spoke with Accurate Imaging and they stated they are unable to get her until tomorrow AM. MD notified and Ok'd imaging for 10/19/21. 10/18/21 4:20 No problems noted, muscle rub applied to bilateral hip areas, writer assisted resident with PROM to right wrist/hand. 10/18/21 4:21 p.m. Bruising continues to right forehead, area blue in color. 10/19/21 1:13 a.m. No pain. Resident is resting in bed without pain or discomfort and without changes in LOC (level of consciousness). 10/19/21 11:30 a.m. Dark purple bruise noted to right forehead. 10/19/21 2:09 p.m. Additional imaging: Right wrist x-ray, left ankle x-ray, left knee x-ray, [MEDICATION(S)] spine x-ray. 10/19/21 2:27 p.m. Bruising continues to right inner wrist., left ankle, right knee, and faint yellow bruising noted to left shin area. Bruise to forehead continues. 10/19/21 2:28 p.m. Mild resident discomfort expressed during transfers and repositioning. 10/20/21 11:19 a.m. Clinical High Risk Team reviewed current condition, current medication for potential side effects and effectiveness. Weights/intakes reviewed. Skin interventions reviewed and appropriate. Resident continues on temp and respiratory monitoring, Weight 167.8#, stable. Resident was noted to have unmet needs over the weekend causing bruising to right side of head and left knee pain. Update to provider, new orders received for x-rays for spine, ankle, left knee, left hip, all were negative for fracture, arthritis noted. Provider updated of results with no new orders received at this time. 10/20/21 2:09 p.m. Subluxation of first metacarpal right wrist. 10/20/21 4:55 p.m. Bruising continues to right inner wrist, left ankle, right knee, and faint yellow bruising noted to left shin area. Bruise to forehead continues. 10/20/21 5:04 p.m. X-ray result-arthritis of the wrist, right wrist, subluxation of the first metacarpal medially, old osteoporotic fracture of T7, ankle arthritis to the left ankle. 10/20/21 5:07 p.m. Call place to POA-HC to update of x-ray results. POA-HC concerned about resident's knee. Writer explained x-ray showed only arthritis. Writer explained about subluxation to right thumb and treatment would be splint and monitoring. 10/20/21 5:55 p.m. No problems noted. Muscle rub applied to bilateral hips. 10/20/21 5:56 p.m. Resident assisted with PROM bilateral hands/wrists, no discomfort noted. 10/21/21 1:09 p.m. Bruises fading and healing as expected. 10/22/21 1:58 p.m. No problems noted. Muscle rub applied to bilateral hip areas. Writer assisted resident with PROM to right wrist/hand. Bruise continue to right forehead, area black/blue in color. Staff Interviews On 11/11/21, at 10:58 a.m., Surveyor unable to interview DON-B. DON-B out on medical leave. On 11/11/21, at 12:05 PM, Surveyor interviewed CNA-D regarding incident with R1 October 16, 2021 that was reported to SA (State Agency) on October 18, 2021. CNA-D states that she went to R1's room and R1 was in bed. CNA-D states that she could smell BM (Bowel Movement) so she checked R1. CNA-D states that R1 was combative, which is not unusual for her. CNA-D states that R1 had BM on her hands. CNA-D states that she rolled R1 over to get the lift sling under her and during this R1 became combative, hitting and screaming at her. CNA-D states, I rolled her over to clean her backside up, I hit her knee on the wall, her left knee, it was not hard enough to hurt her, but put a small bruise. When Surveyor asked CNA-D why she did not stop when R1 became combative CNA-D stated, I did not stop due to BM being everywhere. She would have gotten BM all over. CNA-D also stated to Surveyor that she did not go and get anyone to help or turn the call light on. CNA-D stated that she cleaned R1 up, put the Hoyer sling under her, and then pushed the call button. CNA-D stated that nobody came to help, so I put her in the chair by myself and reported the incident to the nurse. CNA-D states that while reporting to nurse CNA-D had stated that R1 was in a mood and that nurse replied to her, I heard. CNA-D states to Surveyor that she was not very happy about this incident because she feels the nurse heard R1 screaming and did not come to help. CNA-D states that R1can be very aggressive and that this behavior is not out of the ordinary for her. CNA-D states that she thinks R1 hit her head on the repositioning bar on the bed, but did not see that bruise until later. On 11/11/21, at 12:25 PM, Surveyor interviewed AA-G regarding the incident involving R1 reported to SA. AA-G stated that she, Doesn't know much about it, but did notice the bruise on R1's forehead after CNA-E pointed it out. AA-G states that she could tell R1 was, in a lot of pain, she didn't want to eat and wasn't in a good mood. On 11/11/21, at 12:49 p.m., Surveyor interviewed NHA-A. Surveyor asked if NHA-A was aware of the incidents that took place on the weekend of 10/16/21 and 10/17/21 with R1. NHA-A stated she was aware. The NHA-A stated that LPN-C reported the bruises on 10/18/21 and that the DON-B talked to the NHA-A about the interactions of CNA-D with R1. NHA-A did not elaborate. The NHA-A stated when LPN-C reported the bruises, CNA-D and CNA-E were pulled off the floor for the rest of 10/18/21 and they didn't work until education had been provided. The NHA-A stated that R1's ankle bruise was an old bruise. The NHA-A stated that the bruise on the wrist was caused from LPN-F and CNA-D trying to get an oxygen reading. The NHA-A stated the bruise wasn't intentional, but the resident tenses up so much when approached with anything and it is difficult to do anything with her. Surveyor asked if NHA-A was aware that CNA-D transferred R1 alone with the Hoyer lift. The NHA-A stated she was aware. Surveyor asked the NHA-A if DON-B spoke with the aide. The NHA-A stated that she knew DON-B spoke to her. NHA-A stated that CNA-D stated that the memory care is not her type of patients to take care of. Surveyor asked the NHA-A if Dementia training and abuse training is done in the facility, and especially dementia training for the memory care area. The NHA-A stated abuse training is done and dementia training used to be, but hasn't been done for quite some time. NHA-A stated that after the incident with R1, dementia training was mandated for CNA-D, CNA-E, and LPN-F on 10/25/21. Surveyor asked the NHA-A to clarify the measurements for the right inner wrist bruise due to conflicting information in R1's record. The NHA-A stated the bruise on the inner right wrist measured 4cm x 2.1cm. The only abuse training the NHA-A provided was the abuse/Neglect/misappropriation/Exploitation statement the employees sign with a Grievance Team member on their date of hire. On 11/11/21, at 1:22 p.m., Surveyor interviewed LPN-C. Surveyor asked LPN-C to explain what was reported to DON-B regarding R1. LPN-C stated that when she came to work on Monday, 10/18/21, and was giving medications in the morning, she noticed bruising on R1 on her right wrist and forehead, and that R1 seemed to be in pain. LPN-C stated R1 is usually in a good mood in the morning and happy and she just wasn't. Surveyor asked if she ever witnessed or knew about any incidences occurring when CNA-D or CNA-E worked. LPN-C stated no and she didn't hear of anything from the weekend of 10/16/21-10/17/21. On 11/11/21, at 1:30 p.m., Surveyor interviewed LPN-F. Surveyor asked what occurred on the weekend of 10/16/21-10/17/21 with R1. LPN-F stated that she found out R1 had a goose egg and bruise on the forehead. At the time it occurred she had no idea, but was later told by CNA-D that when R1 was rolled over, R1 hit her head on the side rail. LPN-F stated she assessed R1 and knew it hadn't been there earlier when meds were passed. Surveyor asked if R1 resisted anything LPN-F did for or to her over the weekend. LPN-F stated R1 was resistive when LPN-F took her pulse oximeter reading. Surveyor asked, How so? LPN-F stated R1 tightens up arms and hands and LPN-F and CNA-D had to both hold her hands and arm in order to take the oximetry reading. LPN-F stated R1 was sitting in the chair and R1's hands were in her lap and LPN-F stated she held her hand so the pulse oximeter would stay on. Surveyor asked if R1 was still resisting. LPN-F stated she resists always. Surveyor asked why she continued when it was upsetting R1. LPN-F stated that it had to be done and nothing would ever get done because R1 resists everything. Surveyor asked if LPN-F knew R1 had a bruised wrist and subluxation of the right thumb. LPN-F stated Surveyor was the first person to tell her that. LPN- F stated she knew nothing about it. Surveyor asked about LPN-F being overheard stating to R1 that if R1 pinched her she would pinch her back. LPN-F denied making that comment and said she would never say anything like that. Surveyor made 2 attempts to interview CNA-E, who did not return the phone calls. Surveyor unable to interview Social Services (SS0, due to SS-H and SS-I no longer work at the facility.) The interview from CNA-E from the facility investigation in part on 10/18/21 at 10:45 a.m., CNA-E worked 10/17/21 and reported a golf ball sized bruise on the inner right knee to LPN-F, LPN-F looked at the knee and wanted to get R1's oxygen reading. CNA-E stated LPN-F grabbed R1's right hand and tried to open it to get the oxygen reading. CNA-E stated she was holding onto R1's left arm and R1 was pinching LPN-F. CNA-E stated LPN-F said, If you pinch me I will pinch you back. A second interview with CNA-E at 1:45 p.m., Social Worker shared information of the x-ray results of a subluxation of the thumb on the same side as the bruising. CNA-E indicated that she believed either she or LPN-F could have accidentally caused such an injury when they were trying to hold her hands to use the pulse oximeter. She indicated in hindsight she did not feel obtaining this reading should have taken their priority.

Based on observations, interviews and record reviews, the facility did not ensure 2 of 6 residents reviewed maintained an environment that was as free of accident hazards as possible. 1 of 6 residents were reviewed for falls (R15) and 1 of 1 resident for smoking (R179). R15 sustained a fall in (MONTH) 2019, in which the personal alarm was not in place and functioning. The facility implemented training of staff to check alarm placement and function at the end/beginning of each shift, through walking rounds. R15 sustained another fall one month later in which staff did not implement the plan of care as, again the alarm was not in place and functioning. Staff did not conduct alarm checks, as directed, and R15 sustained a nose fracture with this fall. R179 was not assessed for his safety and the safety of others when he was found smoking in his bathroom. It was discovered, after questioned by the survey team, that he again had smoking materials in his room. This is evidenced by: Example 1: R15 was admitted to the facility on [DATE]. Prior to this date, R15 had been living in a sister facility where she fell and fractured her pelvis 10/25/18. R15's current medical [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set Assessment), dated 8/12/19, R15 requires extensive assistance of staff for cares, she is incontinent of bladder, and had a fall with a minor injury during this assessment period. On 10/1/19 at 9:49 AM, Surveyor observed R15 seated in a wheelchair with a large hematoma to the left forehead. She had extensive bruising to her entire face, both eyes and forehead and extending down her neck. At 10:01 AM, Surveyor asked LPN- B (Licensed Practical Nurse) about R15's injury. LPN-B stated that from what she heard, R15 fell in her room, the alarm did not sound, the CNA saw her fall but could not get to her in time. She stated that R15 tripped over her walker. LPN-B stated that R15 didn't fracture any bones but did sustain a skin tear to the palm of her hand and banged up her face pretty good. Surveyor observed R15's room and noted fall interventions in place at this time included a floor mat, low bed, an air overlay rested on the bed with a bolstered mattress having bolsters at the sides of the bed and at the feet. There was a sensor alarm on the bed and an alarm on the back of R15's wheelchair. R15's historical care plan was reviewed and approaches regarding fall prevention included: -2/21/19, R15 is unsteady on her feet and cannot transfer safely without help. The facility was using an electric eye sensor alarm as well as another alarm on the bed and a raised edge mattress. There was also an alarm on the wheelchair with anti roll-back devices on the back wheels of the chair. There was also an eye alarm to the door frame of R15's room that was to be turned on when R15 was in her room. - 6/16/19: Sensor pad to the wheelchair was implemented as I remove the tab alarm and stand up on my own . Surveyor reviewed R15's fall history and noted the following: ~2/21/19, 11:25 PM - R15 fell in her room and was found on the floor mat, kneeling at bedside. The resident had stated her hand hurt and she was trying to get away from the pain. She sustained a 1 cm abrasion to the right knee. The intervention put into place was for staff to monitor more frequently for pain, instructed resident to use call light and reoriented to room, and a raised edge mattress was in place so facility had maintenance replace this with a regular mattress with a full edge overlay. Documentation on 5/22/19 indicates that the facility was also using a non-slip pad at bedside with an electric eye sensor alarm. ~7/23/19, 5:15 PM - R15 fell in her room, landing on buttocks. R15 told staff that she was fixing her blankets in preparation for bedtime. There were no injuries sustained with this fall. The surveyor reviewed the facility investigation from this fall and noted, . sensor alarm was not plugged into the alarm on back of w/c (wheelchair), thus the alarm did not sound . The facility implemented a therapy screen and re-education to staff. On 10/2/19 at 1:46 PM, Surveyor asked the NHA (Nursing Home Administrator) what re-education was completed as a result of this fall. The NHA stated the alarm was not plugged in after evening cares and training included re-education of staff for plugging in alarms. She stated, The CNAs (Certified Nursing Assistants) are to complete 'walking rounds' at the end of the shift, one from the leaving shift and one CNA from the oncoming shift, to check alarms are placed and operating. The nurse is then to sign off that this was completed. ~9/27/19, 12:40 AM - R15 was found in her room lying on her left hip with her shoulder on top of her walker. The fall was witnessed by CNA-G. CNA-G heard clicking noises, and when she investigated saw R15 walking with walker and then fall to the floor, face first. The walker had fallen on top of R15. Surveyor reviewed R15's record and the investigation completed as a result of this fall and noted R15 was sent to the emergency room for an evaluation and was found to have sustained facial lacerations (one of which required sutures), multiple contusions and a nasal bone fracture. On 10/02/19 at 12:46 PM, Surveyor interviewed the NHA regarding the 9/27/19 fall. The NHA stated the facility had completed an investigation which was going to be submitted to the state agency. NHA stated that at 12:40 AM, CNA-G heard a noise and responded. It was not R15's alarm that the CNA heard, but instead, a clicking noise. The CNA saw R15 fall to the floor but could not get to her in time. The NHA stated during the investigation it was discovered walking rounds had not been completed at shift change (staff previously educated on process following the 7/23/19 fall) and R15's alarm was not attached and functioning. Surveyor asked for the walking rounds sign off and was told those were not done. The NHA stated that initially, it was reported to her by the nurse on duty (who left the premises as was no tin the building at the time of the fall-Refer to F725), that the alarm was on and functioning, but during her investigation, learned this to not be the case. She stated that she was not able to determine why the alarm was not in place, as expected. The NHA stated that although the activation of an alarm would not necessarily prevent the fall, it was a part of R15's CP that was not followed, this fact, as well as those previously stated, were the result of the Self-Report. On 10/3/19 at 1:40 PM, Surveyor interviewed LPN-B regarding walking rounds. LPN-B stated that at the end of each shift, the two CNA staff go room-to- room and check each resident and give an abbreviated summary of what may have occurred each day with that resident. At that time, they also check the alarms. She stated I then sign-off that this was completed. The 3 CNAs involved working 9/26/19 and 9/27/19 were not available during survey for interview. Example 2: R179 has been a resident at the facility since (MONTH) of 2019. His [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 9/16/19, indicates that he scored a 12 out of 15 in his BIMS (The Brief Interview of Mental Status) score. This test found that he had some short-term recall problems and that his abilities were expected to deteriorate as [MEDICAL CONDITION] progressed. A review of his current care plan found that on 9/23/19 his preference to smoke was discussed under the issue of his declining health and the fact he may ignore/disregard/forget safety interventions. The plan states, I have an increased desire to smoke. I have already opted not to utilize a nicotine patch, which has been suggested to me . There was no evidence of a smoking assessment being completed. Review of R179 s nursing notes found that on 9/12/19 he was found smoking in his room and the SW (Social Worker) talked to him and explained the facility's no smoking policy. R179 indicated the nurse had taken the cigarettes and he had not wanted to smoke but he had done so because just having them was a temptation. He declined alternative forms of nicotine. A late entry was done in the nursing notes about the same situation. The notes states a CNA had smelled smoke in his room and at first he denied it but later admitted to doing so even though he knew he was not to smoke on the premises. The note states F179 gave the CNA his cigarettes and lighter and stated he was afraid that he would get kicked out. The note went on to state both R179 and his sister were informed of the policy of no smoking and agreed R179 needed assistance. R179 then left in the sister's car to have a cigarette. The facility's plan was to check for compliance for the next 14 days. Following this incident, there was no evidence of a smoking assessment being done. At 11:44 a.m. Surveyor interviewed R179 and asked where about storage of smoking materials and his smoking schedule and location. R179 told Surveyor it was none of your business. The CNA on the floor stated she thought the nurse had them. Surveyor interviewed RN-A (Registered Nurse) and she stated she did not have R179's cigarettes and checked the cart and they were not there. RN-A stated she thought R179's sister had them and that he only goes out with her for a smoke. At 2:02 p.m. RN-A told Surveyor R179's lighter and cigarettes were just found in a drawer in his room and removed. RN-A stated the therapy staff had been asked to do a smoking assessment in the past and she did not know when or what outcome had been determined. At 3:24 p.m. the DR (Director of Rehab) stated she did not remember doing a safety assessment. The DR stated R179 may have declined the assessment and thought the cigarettes found were brought in by the sister. At 3:57 the DR showed Surveyor a smoking assessment of another resident in order to show what was entailed in a smoking assessment. The DR stated it goes through how they can get out of the building, the resident's understanding of the terrain and the road to cross, dressing for the weather, and several other factor besides just how safely a resident can light and hold the cigarette. The RD stated the therapy department had never received an order to evaluate and assess R179's abilities. so an assessment was not done. The RD stated that staff at the facility are not able to go with R179 should he or any resident be found not safe to smoke. On 10/3/19 R179's physician had ordered a therapy smoking assessment for R179.

Based on observations, interviews, and record reviews, the facility did not provide for the necessary supervision and assistive devices to prevent 3 incidents of wandering for 3 of 5 residents reviewed for wandering. Resident #4 has been identified by the facility as being at risk for wandering and uses a code alert to alert staff to her attempts to exit the building. Resident #4 has numerous previous attempts to leave the building. On 09/24/12 at 7:30 p.m., Resident #4 was found on the ground in front of the garage doors facing East 11th Street. A passerby alerted the facility that Resident #4 was outside on the ground. Resident #4's wheelchair was found upright on the patio, not near Resident #4. No door alarms had sounded and the facility did not know she had left the facility. The facility never determined which facility door Resident #4 had left from. After checking the wanderguard at exit doors, Resident #4's wanderguard did not alarm the patio door by the main entrance dining room. Upon Surveyor # 's entrance to the facility on [DATE], Resident #4 was observed to have her code alert bracelet placed on the metal bar of her wheelchair, which is against manufacturer's instructions. On 10/18/12 on the a.m. shift, Resident #3 who the facility identified as having the potential to wander, who had numerous attempts to get out the facility doors and who uses a code alert bracelet, was found outside wheeling her wheelchair on the patio in back of the garage. Resident #3 had attempted to leave the facility earlier through the north door. Facility staff had turned the alarm off on the north door to allow construction workers to come and go through that door and had put a tabs alarm on the door. This door does not have a code alert system on it. Facility staff had observed the construction workers not reattaching the tabs alarm when they went through the door. M-I (Maintenance) found Resident #3 wheeling her wheelchair on the patio heading to the back of the garage heading in the direction of the green fence by the garage and the golf course on the north end of the building. M-I was not looking for Resident #3 but got a glimpse of her out of the corner of his eye wheeling her wheelchair. No alarms were sounding to alert the facility that Resident #3 was out of the building. It is not known for certain which door Resident #3 went out of. Upon entrance to the facility on [DATE], Surveyor # observed Resident #3 with her code alert bracelet on the metal bar of her wheelchair which is against manufacturer's instructions. On 5/13/12, Resident #5 who is a known wanderer and has a wanderguard, was found outside in the parking lot by a visitor around 2 p.m. The facility did not have an additional wanderguard to replace Resident #5's. In addition, there was no thorough investigation to identify how long the resident was missing. In addition, on 11/06/12 at 12:20 p.m., Surveyor # observed a dining room door to the outside patio on the 200 wing where Residents #3, #4 and #5 reside, (which goes to 11th Street, the golf course and to Highway 8 less than a block away) unlocked, unalarmed, with no locking device nor alarm device with a one-motion handle. Residents were observed freely coming and going in the hallway by this dining room, which had an open path to the door. No staff were in the vicinity. This door was observed again at 12:40 p.m. by Surveyors # and # to be unlocked and unalarmed. Surveyors # and # walked out the door onto the patio and proceeded to walk the length of the patio around the garage to 11th Street. Again, no staff were in the vicinity. Surveyor # observed this door again at 1:20 p.m. and at 1:45 p.m. The same conditions were noted as above, door unlocked and not alarmed, and no staff in the vicinity. Resident #5 has a history of elopement attempts and continuously wants to go home. Resident #5 wears a wanderguard bracelet but was found outside in the parking lot by a visitor at 2:00 p.m. on 5/12/12. There was no investigation to determine how Resident #5 had been able to get out of the facility without staff knowledge. The failure to ensure that residents with histories of elopement attempts were kept from getting out of the facility unbeknown to staff, led to a finding of immediate jeopardy which began on 09/24/12. The NHA (Nursing Home Administrator) was notified of the immediate jeopardy on 11/7/12 at 2:25 p.m. The facility removed the jeopardy on 11/9/12, but nonompliance remained at the lower scope and severity level of E (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility needed to fully train and implement their plan for all 7 residents identified as being at risk for elopement. This is evidenced by: On 10/15/12, the State of Wisconsin Division of Quality Assurance received an anonymous complaint which indicated Residents #3 and #4 were found outside the building. On 11/06/12, Surveyor # received from RN-G (Registered Nurse) a list of residents in which the facility had identified as having the tendency to wander and who had wanderguard (code alert) bracelets. Residents #3, #4, and #5 were identified on this list. In addition, Residents #9, #10, and #13 were on the list. On 11/06/12 at 12:30 p.m., Surveyor # observed Resident #12 seated in a wheelchair, with a wanderguard bracelet on his wheelchair frame. Resident #12 had not been identified as a wanderer on the list of residents that were known to wander. On 11/06/12, Surveyor # received a copy from the Executive Director of Nursing of User Guide (9450 system) from RF Technologies for the Code Alert System that the facility has on 3 of the doors. Instructions on page 7 of this guide indicates the following note regarding fastening an adult transmitter: "To monitor a patient in a wheelchair, attach the transmitter to the seat or the back of the chair as the metal on the chair can interfere with the transmitter's signal." On 11/06/12 at 3:05 p.m., Surveyor # spoke with TS-E (Tech Support) from RF Technologies. TS-E indicated staff should follow the manufacturer's instructions for the use of the transmitter. TS-E said there can be interference with the signal if used on metal, near radio waves, computers, etc. TS-E indicated if a bracelet fails, the facility should call the company about the failure as they could give the facility ideas on how to further test the system, bracelet and the door. TS-E indicated they do not have any record of contact with this facility regarding a possible wanderguard failure. On 11/07/12, Surveyor # received a copy of the facility floor plan from the facility Executive Director of Nursing. The floor plan indicates one door at the end of the north hall and one door at the end of south hall that have a tabs alarm and another door alarm system. The front entrance to the nursing home, the employee entrance in the hallway by the kitchen and laundry area, and the patio entrance door off the main dining room by the front entrance to the nursing home, have a code alert alarm system and a door alarm system. The door to the patio off the 200 wing dining room was noted to have a door alarm system and that is was locked as of 11/07/12. Attached to the nursing home is a RCAC (Residential Care Apartment Complex) and another nursing home, which are accessible via a connecting hallway with doors that are open. The 200 wing dining room door had no locks or alarm system upon surveyor entrance to the facility on [DATE]. It also had a one-motion door handle on it. Surveyors # and # 's observation of the patio off the main dining room and the 200 wing dining room is not enclosed and accessible to the golf course to the north and 11th Street to the west. Further observation revealed that the nursing home is located less than a block off State Highway 8, which runs east and west. On 11/07/12 at 10:00 a.m., Surveyors # and # held the group meeting with the residents. During the group meeting the residents indicated there is a resident who wanders into their rooms repeatedly. The residents at the group meeting indicated they feel that this resident is trying to get out of the building and is trying to get out the door. Example #1: Surveyor # 's review of Resident #4's medical record revealed Resident #4 was admitted to the nursing home on 05/03/06. Resident #4 has [DIAGNOSES REDACTED]. Resident #4's daughter is her activated health care agent (power of attorney for health care) as of 10/17/07. Resident #4's Minimum Data Set assessment ((MDS) dated [DATE], indicated the following: ~Wanders daily; ~Brief Interview for Mental Status (BIMS) score of 11 of 15; ~Assistive devices-walker and wheelchair; and ~Transfers and ambulation- needs extensive assistance of 1 person. Review of Resident #4's care plan with a print date of 11/07/12, indicated the following approach dated 07/24/12 on page 2: "Wanderguard on to alert staff of attempts to or wandering towards exits. Follow facility policy for monitoring, documentation, notification, and interventions. Refer to alternative intervention listed in plan of care for activity involvement and interventions for distractions. Update MD for medication review, involve psych, and family...." This same approach is on Resident #4's CNA Care Plan Card with a print date of 11/07/12. On 11/06/12 at 12:03 p.m., Surveyor # observed CNA-D with the assistance of CNA-R, put a gait belt on Resident #4 and with verbal cues assisted Resident #4 to a standing position in the bathroom where Resident #4 stood independently. Then Resident #4 pivot transferred to the bathroom stool and sat down. At 12:21 p.m., Surveyor # spoke with CNA-D. CNA-D was asked if Resident #4 had a wanderguard bracelet. CNA-D said Resident #4 had a wanderguard bracelet on her wheelchair. CNA-D said Resident #4 did not have one on her body because she always used her chair for getting around. Surveyor # observed Resident #4's wanderguard bracelet on the metal cross bars on her wheelchair many inches below the seat and near the wheel of the chair. On 11/06/12 during the supper meal from 4:25 p.m. to 4:40 p.m., Surveyor # observed Resident #4 in her wheelchair in the dining room. The wanderguard bracelet was still located on the metal cross bar on her wheelchair. On 11/06/12 at 12:20 p.m., Surveyor # observed a dining room door to the outside patio on the 200 wing, where Resident #4 resides (which goes to 11th Street, the golf course and to Highway 8 less than a block away). The door was unlocked, unalarmed, with no locking device or no alarm device with a one-motion handle. Residents were observed freely coming and going in the hallway by this dining room, which had an open path to the door. No staff were in the vicinity. This door was observed again at 12:40 p.m. by Surveyors # and # . It was unlocked and unalarmed. Surveyors # and # walked out the door onto the patio and proceeded to walk the length of the patio around the garage to 11th Street. Again, no staff were in the vicinity. Surveyor # observed this door again at 1:20 p.m. and at 1:45 p.m. with same conditions as noted previously, unlocked and unalarmed with no staff in the vicinity. Review of Resident #4's nurse's notes revealed the following entries of repeated attempts to wander and exit the facility: ~04/17/12 "staff states resident has increased wandering and noted confusion..." ~05/03/12 "...Behavior: 1140 Resident noted to be leaving out the employee door exit, staff redirected Resident back down to room, Resident stated she was looking for her room to use toilet, daughter called and updated and stated ok to place wanderguard on WC (wheelchair). Daughter updated on resident's attempt to exit building..." ~06/14/12 "...Summary Note: Discussed with MD resident's confusion/orientation. Resident wandering into residents' rooms, attempting to go outside without staff assist..." ~07/14/12 "Resident attempted to elope from west door times 2, resident did not wheel self past 1st door when alarm sounded and resident was turning self away from outer door. Resident wandered throughout nursing home easily redirected..." ~08/03/12 "...Mood Patterns: Resident continues to have confusion throughout morning, resident continues to wander..." ~08/06/12 "...Mood Patterns: Resident continues to wander throughout facility..." ~08/07/12 "...Mood Patterns: Resident continues to wander throughout the facility resident's cognition fluctuates throughout the day..." ~08/08/12 "...Mood Patterns: Resident continues to wander throughout the NH,...continues to be confused..." ~08/12/12 "...Mood Patterns: Resident continues to wander throughout nursing home..." ~08/24/12 "...Mood Patterns: Continues to wander throughout nursing home, easily redirected..." ~08/28/12 "...Mood Patterns: Resident quite sleepy this morning resident wandered throughout NH this afternoon..." ~08/29/12 "...Mood Patterns: Continues to wander throughout nursing home..." ~08/31/12 "...Mood Patterns: Noted talking to self x2. Self Transferred x4, to recliner chair x1 and attempted to walk unassisted to bathroom x3...Mood Patterns: ...Resident continues to wander throughout nursing home..." Wandering Incident: ~"09/24/12...22:52:33 (10:52 p.m.) Cond. Stability Note: Writer and CNA were informed by civilian that there was a lady outside calling out for help. Resident was noted to be on the ground by the garage entrance. When assessing resident she stated, 'I tried to get back around,' writer assessed resident, VSS (vital signs stable), no apparent injuries noted, resident did have mild pain noted to right knee, resident received scheduled Tylenol at HS to help with pain. Writer and CNA assessed wander guard alarm that was attached to resident's w/c, the alarm did not go off when resident went through patio door. When bringing the resident back in wander guard alarmed at other door but not in the dining room. Resident was cleaned up and put into bed to rest. CNA then took w/c to tray at other doors throughout facility. Wander guard sounded at all doors at that time. Writer notified nursing management of situation, falls team and maintenance to assess alarm system in a.m...." Surveyor # 's review of the investigation report written by the Executive Director of Nursing revealed the following: "Fall investigation for Resident #4 on 09/24/12. I received a call from the PM nurse supervisor notifying me that a resident was found outside the west entrance and had fallen out of her chair. She indicated that ...is a wander risk and had a wanderguard on however it had not activated when she went through the door. The PM nurse was instructed to cut that wander guard off and take it, along with the new wander guard, through all wander guarded exits to assure proper functioning. This was done separate with both wander guards and indeed the alarms sounded with each. A new wander guard was placed in the resident's chair and fall protocol was started per policy. Resident had new injury as result of the fall. Resident could not recall the incident during my inquiry with here (sic) related to the incident. Upon further investigation with all staff present, it was noted that this resident was attending an activity in the Ladysmith Living Center and was assisted by activity staff both to and from the activity. Upon return to the Ladysmith Nursing Home (through the linked hallway) the activity staff did not report to the CNAs that she had returned. ...then wandered toward and through an exit; staff were unable to determine which one. The time frame in which activity was finished and when resident was found was less than 20 minutes. The temperature outside was mild at low 60's at the time, resident was fully clothed with long sleeves, slacks and sweater. Again no physical or psychosocial injury was noted. Resident had no complaints offered. Followup plan of correction included Maintenance review of all alarmed doors. Original wander guard present at time of incident disposed of. All staff including activity staff has been instructed to alert consistent caregivers and or nurse to all residents' whereabouts upon leaving households and returning...Electronically signed Executive Director of Nursing RN." On 11/06/12 at 3:35 p.m., Surveyor # spoke with MD-F (Maintenance Director). MD-F said nurses do the checks of the resident wanderguard bracelets by taking a box and checking the bracelet. MD-F said he does monthly checks on the doors with the wanderguard system by taking a resident down to the door to check if it works. MD-F said he does not keep a record of these checks. MD-F said 3 of the 6 facility doors have the code alert (wanderguard) system and they are the mail entrance to the nursing home, the employee entrance by the kitchen area, and the main dining room patio door. MD-F said the north and south door have a system that can be turned on/off with a switch at the nurses' station. MD-F did not say what the type of system the door to the patio from the 200 wing dining room had. On 11/06/12 at 3:55 p.m., Surveyor # spoke with RN-G (Registered Nurse). RN-G said a passerby had informed the facility that Resident #4 was outside. RN-G said her understanding from the fall report completed on Resident #4, was that Resident #4 may have gone out the employee entrance, but when staff took Resident #4's wheelchair around to the doors to check the alarm it did not work at the main dining room patio door. RN-G said Resident #4 has her wanderguard on her wheelchair. At 4:10 p.m., Surveyor # asked RN-G about the door to the patio off the 200 wing dining room. Surveyor # and RN-G went to look at the door. RN-G said after looking at the door that there wasn't any alarm system on the door and the chord was there for the door but it had not yet been hooked up. RN-G opened the door. RN-G told Surveyor # they had just started using the 200 wing dining room. At 4:20 p.m., Surveyor # observed MD-F (Maintenance Director) blocking the outside of the 200 wing door to the patio to prevent it from opening to the outside. This was after Surveyor # brought the open unsecured door to RN-G's attention at 4:10 p.m. This exit is not an emergency exit. On 11/07/12 at 7:25 a.m., Surveyor # spoke with the EDON (Executive Director of Nursing). The EDON said she had been called at home and told Resident #4 had been found outside the building by the garage. The EDON said the facility had been alerted by a passerby that Resident #4 was outside. The EDON said no one saw Resident #4 leave the building and they did not think the wanderguard door alarm was functioning. The EDON said it appeared that Resident #4 may have gone out the West door, which would have been the employee entrance because of the time frame she was gone and Resident #4's ability to get to the garage, as Resident #4 was found on the south side of the garage and the employee entrance. The EDON said Resident #4 had been at an activity with activity staff in the new building and there was less than a 15-minute time span from the time the activity ended to when the passerby had alerted the facility of Resident #4 being outside. The EDON said nursing checks the wanderguard functioning and expiration date with a box and maintenance does the check of the doors, but was not sure of the frequency. The EDON said Resident #4 has her wanderguard on her wheelchair because she is non ambulatory and has her wheelchair all of the time, and to also prevent skin breakdown if placed on the ankle. The EDON was shown the manufacturer's instructions for the code alert bracelets on wheelchairs (page 7) . The EDON said maintenance looks at that. The EDON said she did not know if anyone spoke to the company about the possible failure of the wanderguard system. On 11/07/12 at 8:05 a.m., Surveyor # spoke with MD-F. MD-F was shown the manufacturer's instructions for the code alert bracelets and its use on wheelchairs (page 7). MD-F said he did not contact the code alert company after the incident with Resident #4. On 11/07/12 at 3:10 p.m., Surveyor # spoke with Resident #4's daughter and power of attorney for health care. Resident #4's daughter indicated she was called and told that Resident #4 had been found outside on the ground by the garage. Resident #4's daughter said the incident happened on the p.m. shift and she was told that the facility wasn't aware which door Resident #4 went out of or how long she was gone. Resident #4's daughter said she was told that someone had called the facility and stated there was a resident outside crying. Resident #4's daughter said the p.m. nurse had told her they had not seen resident since supper time, which was between 4-5 p.m. Resident #4's daughter said she had seen her mother the next day and her mother told her she had been crying and waving for help from someone in the cars that were going by. Resident #4's daughter said she did not understand how Resident #4 got outside when she has a wanderguard bracelet on and she was very upset this had happened. On 11/07/12 at 3:50 p.m., Surveyor # spoke with RN-J. RN-J said she was working the afternoon shift on the day Resident #4 had left the facility and was found on the ground by the garage. RN-J said the activity staff had taken the residents to the new part of the building for an activity and she had been on her med pass when she saw the activity staff bringing the residents back around 6:30 p.m. RN-J said she was on the floor with her med pass when someone came and told her that an older lady was calling for help outside. RN-J said she went outside and found Resident #4 on the ground in front of the garage doors by the parking lot (on 11th Street side). RN-J said Resident #4 complained of knee pain and about being dizzy. RN-J said Resident #4's wheelchair was found upright on the patio. RN-J said Resident #4 had to have walked over the rocks from the patio to get to where she was found on the ground. RN-J said no alarms had gone off alerting them to the fact that Resident #4 had left the building. RN-J said she thought it was about 7:15 p.m. when they found Resident #4. RN-J said when they went back in the building, the employee entrance alarm was delayed and the wanderguard alarm went off. RN-J said the main dining room patio door wanderguard alarm did not go off when they checked it. RN-J said they were not certain which door Resident #4 went through and how long for sure she had been out of the building because the activity staff did not let anyone know when the residents were back. RN-J said they had put Resident #4 on 15-minute checks and put a new wanderguard on her wheelchair. On 11/08/12 at 7:33 a.m., Surveyor # spoke a second time with EDON. The EDON said she felt Resident #4's whereabouts was not known for just shy of 15 minutes. The EDON was asked where Resident #4's wheelchair was located when they found Resident #4 on the ground. The EDON said the wheelchair was found just behind Resident #4. Surveyor # said that she had been told Resident #4's wheelchair was found on the patio. The EDON said she was never told Resident #4 was away from her wheelchair. The EDON then stated there was no way Resident #4 could have gone that far from her wheelchair. The EDON said her investigation did not show that the wheelchair was away from Resident #4. On 11/08/12 at 7:00 a.m., Surveyor # observed Resident #4 in her wheelchair sitting in the 200 wing dining room. The code alert (wanderguard) was now on Resident #4's right ankle and not on her wheelchair. At 7:15 a.m., Surveyor # observed Resident #4 wheeling herself in her wheelchair down the 100 wing hallway where she went into another resident's room at the far end of the hallway. Staff redirected Resident #4 out of this room. At 7:30 a.m., Surveyor # observed Resident #4 in her wheelchair by the double doors going to the new building. Resident #4 was observed to set off her wheelchair sensor pad alarm. On 11/13/12 at 2:10 p.m., Surveyor # spoke with A-S (Anonymous). A-S indicated there were two incidents where Resident #3 and Resident #4 got out of the building because the alarm system failed. A-S said the alarms did not go off and Resident #4 was found outside by a passerby. Example #2: Surveyor # 's review of Resident #3's medical record revealed Resident #3 was admitted to the nursing home on 07/29/06. Resident #3 has [DIAGNOSES REDACTED]. Resident #3's daughter is her activated health care agent (power of attorney for health care) as of 07/23/10. Resident #3's most recent Minimum Data Set assessment ((MDS) dated [DATE], indicated the following: ~BIMS score of 7/15; ~Wanders daily. Review of Resident #3's care plan and CNA care plan card with a print date of 11/07/12, indicated the following approach on page 1: "07/24/12 Wanderguard Wander guard on to alert staff of attempts to or wandering towards exits. Follow facility policy for monitoring, documentation, notification, and interventions. Refer to alternate intervention listed in plan of care for activity involvement and interventions for distractions. Update MD for medication review, involve psych, and family..." On 11/06/12 at 12:20 p.m., Surveyor # observed a dining room door to the outside patio on the 200 wing, where Resident #3 resides, (which goes to 11th Street, the golf course and to Highway 8 less than a block away) unlocked, unalarmed, with no locking device or no alarm device with a one-motion handle. Residents were observed freely coming and going in the hallway by this dining room, which had an open path to the door. No staff were in the vicinity. This door was observed again at 12:40 p.m. by Surveyors # and # as being unlocked and unalarmed. Surveyors # and # walked out the door onto the patio and proceeded to walk the length of the patio around the garage to 11th Street. Again, no staff were in the vicinity. Surveyor # observed this door again at 1:20 p.m. and at 1:45 p.m. with the same conditions noted above, unlocked and unalarmed, with no staff in the vicinity. Review of Resident #3's nurse's notes revealed the following notes where Resident #3 was wandering or attempting to leave the building through multiple different exits: ~11/20/11 "Exited Door: 19:40 (7:40 p.m.) out north entrance on PM shift on 11/19/11. Wanderguard in place and functional staff intervened while resident remained at doorway..." ~12/25/11 "Exited Door: 19:00 (7:00 p.m.) out north entrance writer intervened when resident was between outer doors. Wanderguard in place and functional staff intervened when resident was between doorways. Staff observed resident wandering toward exit and intervened by redirecting resident back into the facility..." ~01/06/12 "...Exited Door: 18:12 (6:12 p.m.) Alarm sounded to alert staff of resident exiting facility. out employee entrance dressed inappropriately, CNA... redirected resident. Made it between the doors..." ~02/06/12 "...Wandering: Resident was exiting the north side of the building; the alarm was going off, and writer ran to the other end to catch resident. By the time writer got to that exit, resident was already outside. Resident stated that she wanted to go outside, and writer brought resident back in without any difficulties..." ~03/06/12 "...Wandering: wandering is easily altered, wanders throughout nursing home. Exited door: 12:07 resident was attempting to exit out employee entrance this afternoon; writer was preparing to clock back in when resident observed self propelling towards doorway. Writer continued to watch and asked resident where she was heading, resident replied, 'out this door.' Writer reminded resident that it was winter out and she was not properly dressed with a hat, coat, or warm boots. Resident stated, 'I guess you're right.' Writer wheeled resident back up towards nurses' station. Staff continues to monitor resident's movements..." ~03/12/12 "...Attempt to exit 12:21 (attempt) out employee entrance dressed inappropriately. Wanderguard in place and functional; alarm did not sound as writer was able to redirect. Resident was viewed self propelling towards employee entrance, asked resident where she was going and she replied 'outside' stated it was raining out and there was still snow on the ground, resident 'oh.' Writer was able to wheel resident back up towards nurses' station facing 200 wing..." ~05/11/12 "...18:15 (6:15 p.m.) alarm sounded to alert staff of resident exiting facility, out main entrance dressed appropriately Wanderguard in place and functional out of second door Staff observed resident wandering toward exit and intervened by redirecting resident back into the facility..." ~08/07/12 "...Wandering: wanders throughout nursing home wanders into other resident rooms behavior occurred daily wandering impact: no wandering significantly intrudes on privacy or activity of others? yes. Exited door; approx. 1500 (3:00 p.m.) out main entrance dressed appropriately. Wanderguard in place and functional staff intervened while resident remained at doorway Resident did not make it out first per report from staff..." ~08/11/12 "...Wandering: wandering is not easily altered. Exited door: 16:53 (4:53 p.m.) alarm sounded to alert staff of resident exiting facility, out main entrance dressed appropriately..." ~08/18/12 "...Wandering: Wanders throughout nursing home Wandering impact: Wandering put resident at significant risk of getting to a potentially dangerous place? yes. Wandering significantly intrudes on privacy or activity of others? yes. Exited door: Resident exited facility at 1540 (3:40 .pm.) out main entrance alarm sounded to alert staff of resident exiting facility dressed appropriately wanderguard in place and functional to parking lot. Staff observed resident wandering toward exit and intervened by redirecting resident back into the facility..." ~08/19/12 "... Continues with wanderguard d/t (due to) attempts to leave facility at times. Resident attempted to exit facility times 2 in last week..." ~09/03/12 "...Continues with wander guard d/t multiple attempts to leave facility at times..." ~09/12/12 "...Wandering: wandering is not easily altered. Exited door: out south entrance out main entrance attempted out north entrance dressed inappropriately for weather, stating she intended to visit/go to her parent's house...wandering is not easily altered, moves with no purpose, movement oblivious to needs movement oblivious to safety, wanders throughout nursing home..." ~09/23/12"...continues to attempt leave building, redirected, but as above, very sweet and congenial when attempting to leave..." ~10/28/12 "...Wandering: Late entry for 10/27/12 resident exited rehab unit door on pm shift and was redirected back inside-without difficulty. RN notified..." Wandering Incident: ~"10/18/12 15:14:49 (3:49 p.m.) Wanders: Resident exited the building this morning. Wanderguard systems were turned off due to construction workers coming in and out of doors. Tabs alarms were applied to both doors. Resident had tried to exit north door previously and resident was redirected. (Emphasis added.) CNA was observed placing tabs alarm back on door. Construction workers were entering and exiting building after this time. Resident was found outside with no alarm sounding, clip alarm not on door. Resident was assisted back in building. Wanderguard system turned back on for safety..." On 11/06/12, Surveyor # received a copy of the facility investigation of this incident from RN-G. The following is noted: "Alarm system and CP (care plan) reviewed with administration and